Limited triscaphoid intercarpal arthrodesis for rotatory subluxation of the scaphoid

Dorsal intercarpal ligament capsulodesis for chronic, static scapholunate dissociation: clinical results

The purpose of this study was to review and report the results of using a new procedure, the dorsal intercarpal ligament capsulodesis (DILC), to treat a group of patients with chronic flexible scapholunate dissociation. This was a prospective study of 21 patients (22 wrists), ranging in age from 16 to 62 years followed up for 1 to 4 years. For this study all patients returned to complete a questionnaire and have a physical examination performed by physicians and therapists independent of the treating surgeons and to obtain standardized radiographs of the wrists. Patient demographics, mechanism of injury, range of motion, and grip strength were recorded. Patients completed the Mayo wrist, Short-Form (SF)-12, and Disabilities of Arm, Shoulder and Hand (DASH) questionnaires. Results showed there were significant improvements in scapholunate angle and scapholunate gap at final follow-up examination, with minor loss of range of motion and grip strength. Patients were satisfied with the outcomes, showing an average score of 17 on the DASH and 83 on the SF-12. The DILC procedure is a reasonable option for treating chronic scapholunate dissociation. The procedure has conceptual advantages to recommend it: it avoids a tether between radius and scaphoid and keeps the proximal carpal row linked as a functional unit. It reduces the scapholunate angle and gap. Overall the results to date are quite encouraging.

Long-term results after repair and augmentation ligamentoplasty of rotatory subluxation of the scaphoid

Twenty-two patients had scapholunate ligament repairs combined with a new augmentation ligamentoplasty for chronic scapholunate dissociation. All were evaluated by physical and radiologic examination after a mean postoperative follow-up period of 63 months (range, 12-134 mo). According to Green and O'Brien and Johnson and Carrera scores 5/8 had excellent, 13/12 good, and 4/2 fair results. Thirteen were free of pain; 6 had mild pain and 3 had moderate pain. Nineteen returned to their original occupation. There was an average loss of 10 degrees of flexion, 9 degrees of extension, and 11% of grip force compared with the opposite wrist. Radiologic examination showed an average decrease of 12 degrees of the scapholunate and 10 degrees of the radiolunate angles compared with the levels before surgery. No signs of degenerative osteoarthritis were found in 16 (73%) cases. Five wrists showed a distinct pattern of midcarpal degeneration correlating with notable dorsal intercalated segment instability after surgery, and 2 cases had signs of radioscaphoid degeneration.

Bone-retinaculum-bone reconstruction of scapholunate ligament injuries

This article describes the indications for the use of a bone-retinaculum-bone autograft in soft tissue reconstruction of the torn scapholunate ligament. Specific surgical technique and postoperative management are highlighted. Initial results of a primary cohort of patients undergoing this technique are described. The technique is mainly indicated for patients with scapholunate ligament tears that are moderately easy to reduce by open methods.

Lunate excision, capitate osteotomy, and intercarpal arthrodesis for advanced Kienböck disease. Long-term follow-up

BACKGROUND

Kienböck disease is caused by aseptic necrosis of the lunate. In the advanced stages of the disease, carpal collapse, joint incongruity, and osteoarthritis develop. We performed lunate excision, capitate osteotomy, and intercarpal arthrodesis (the modified procedure of Graner et al.) on fifteen patients with stage-IIIB or IV Kienböck disease. This report is a review of the findings in these patients.

METHODS

The subjects ranged in age from twenty-six to fifty-four years (mean, 39.2 years) at the time of surgery. We evaluated the results more than five years postoperatively (range, sixty-two to 145 months postoperatively; mean, 79.3 months postoperatively). Therapeutic results were evaluated according to the scoring system of Evans et al.

RESULTS

Pain disappeared after surgery in most patients. Others had a reduction in the intensity of the pain to a mild level. The grip strength on the affected side had recovered to about 80% of that on the unaffected side twelve months after surgery. The long-term results were graded as good in eleven of the patients, as fair in two, and as poor in two. Postoperative radiographs showed that the carpal bone parameters (carpal height index and radioscaphoid angle) had improved. Radiographic osteoarthritic changes occurred in all of the patients; however, except for moderate limitation of the range of motion at the wrist joint, these findings did not affect the level of pain, grip strength, or activities of daily living.

CONCLUSIONS

Lunate excision followed by capitate osteotomy and intercarpal arthrodesis (the modified procedure of Graner et al.) is a reliable form of treatment for advanced Kienböck disease, with favorable results for at least five years postoperatively.

Examination and treatment of a patient with hypermobility syndrome

BACKGROUND AND PURPOSE

The purpose of this case report is to present the patient examination, evaluation/diagnosis/prognosis, intervention, and outcome of a patient with hypermobility syndrome (HMS). Hypermobility syndrome has been widely recognized in the rheumatology literature, but it has seldom been discussed in the orthopedic literature and has only recently been described in the physical therapy literature. The signs and symptoms of HMS are common among patients seen in orthopedic physical therapy clinics; however, the underlying HMS may be overlooked while treating individual joints or tissues causing pain. CSE DESCRIPTION: The patient was a 28-year-old woman with complaints of chronic, multiple-joint pain. After years without a diagnosis, a rheumatologist had recently diagnosed underlying HMS.

OUTCOMES

Following intervention that emphasized patient education and activity modification, the patient's complaints decreased.

DISCUSSION

Recognition of HMS underlying common orthopedic problems may facilitate appropriate patient education and management.

Constraint and material properties of the subregions of the scapholunate interosseous ligament

The material and constraint properties of the dorsal, proximal, and palmar regions of the scapholunate ligament were studied using isolated bone-ligament-bone preparations from 24 adult intact cadaver wrists. Determinations of constraint to differential rotation and translation as well as failure strength were made using a servohydraulic testing machine incorporating an additional rotatory actuator. The dorsal region of the scapholunate ligament offered the greatest constraint to differential translation, while both the dorsal and palmar regions demonstrated statistically significant combined constraints to differential rotation between the scaphoid and lunate. The greatest yield strength was found in the dorsal region (260.3 N +/- 118.1 N), followed by the palmar region (117.9 N +/- 21.3 N) and the proximal region (62.7 N +/- 32.2 N).

Blatt's capsulodesis for chronic scapholunate dissociation

We have reviewed prospectively 44 cases of chronic scapholunate dissociation treated by Blatt's dorsal capsulodesis. The diagnosis was based on clinical and arthroscopic criteria. The minimum follow-up was 2 years. The results were analysed clinically and radiologically. Postoperatively statistically significant reductions in wrist movements and grip strengths were noted. Delay in surgery and presence of compensation claims were also statistically significant factors. Patients with a high column/row index had higher overall good and excellent results. The scapholunate gap, scapholunate angle, carpal height and the type of instability as diagnosed on arthroscopy and cineradiography did not affect the outcome significantly. The scapholunate gap, scapholunate angle and the carpal height did not change significantly after operation.

Wrist instability

Hidden in the diagnosis of ‘the sprained wrist’ is the missed ligament tear. A resultant carpal instability pattern can cause persistent pain and late osteoarthritis. The carpal bones act as a link system of two rows between the forearm and hand, held together by both an intrinsic and an extrinsic ligament system. Two common patterns of carpal collapse occur, the first at the scapho-lunate joint, where a tear results in scaphoid flexion and lunate extension (dorsal intercalated segment instability - DISI). The second occurs at the luno-triquetral joint, and results in lunate flexion (volar flexed intercalated segment instability - VISI). Further instability patterns are now emerging; those at the triquetro-hamate joint producing ulnar-sided wrist pain and midcarpal laxity, and complex dislocations, with or without fracture. Careful clinical examination, plain X-rays, magnetic resonance imaging (MRI) scan and wrist arthroscopy can enable a clear diagnosis to be made for most instability patterns. Treatment consists of acute open repair, soft tissue stabilization procedures or limited intercarpal fusion, depending on the time from injury.

Dorsal intercarpal ligament capsulodesis for scapholunate dissociation: biomechanical analysis in a cadaver model

The purpose of this study was to evaluate in cadavers a new method for treating scapholunate dissociations, dorsal intercarpal ligament capsulodesis (DILC), and to compare its performance with that of a previously described soft tissue reconstruction, Blatt capsulodesis (BC). A cadaver model was used to simulate normal and abnormal wrist motions. The positions of the scaphoid and lunate and their changes with wrist motion and ligament condition were recorded using biplanar radiographs taken posteroanteriorly and laterally. The scapholunate gap was measured on the posteroanterior radiographs and the scapholunate angle was measured on the lateral view radiographs. Following scapholunate interosseous ligament sectioning, a diastasis developed between the scaphoid and lunate that was maximum in the clenched fist position 2.1 +/- 0.33 mm (mean +/- SEM) with the ligament intact versus 8.0 +/- 1.74 mm after the ligament was sectioned. Dorsal intercarpal ligament capsulodesis reduced gap formation more than BC, including when the specimens were in the clenched fist position: increased gap versus intact specimens equals 1.0 mm for DILC versus 3.7 mm for BC. The differences in diastasis were statistically significant between BC and DILC when the wrist was in extension, radial deviation, and clenched fist positions. After the scapholunate interosseous ligament was divided, the scaphoid flexed relative to the lunate. Both capsulodeses improved scapholunate alignment and there was a trend for DILC to correct the scapholunate angle more than BC. The results demonstrate that DILC is an attractive alternative to BC ex vivo. Because DILC does not tether the scaphoid to the distal radius, as BC does, improved wrist motion, especially flexion, might be possible in vivo. The use of DILC in the treatment of scapholunate dissociation warrants further investigation and clinical trials.

Limited wrist fusions: comparison of results 22 and 89 months after surgery

Limited wrist arthrodeses were performed to treat wrist diseases other than rheumatoid arthritis. The purpose of this study was to evaluate whether clinical and radiographic results noted 22 months after the procedure were maintained on re-examination an average of 89 months (range, 66-148 months) after the procedure. The study comprised 17 wrists. The average patient age was 42 years (range, 11-65 years). Two patients, both with Kienböck's disease, were lost to follow-up. Four radiocarpal and 11 intercarpal arthrodeses were performed. The range of motion between the first and second follow-up examination showed no significant difference. Grip strength likewise was nearly identical at both visits. At the last follow-up visit, progression of osteoarthrosis about the fusion area was noted in only 1 patient. These results suggest that the clinical and radiographic results at 22 months were maintained at the final follow-up visit and that the effect of limited wrist fusion does not deteriorate.

Scapholunate ligament repair and capsulodesis for the treatment of static scapholunate dissociation

Twenty-four patients were treated with scapholunate ligament repair and dorsal capsulodesis for scapholunate dissociation. Seventeen patients were available for follow-up at an average of 30 months. The average interval between injury and surgery was 3 months. At final follow-up, no patients were pain-free. Average total wrist motion was 60% and grip strength 70% of the opposite normal side. The average preoperative scapholunate angle was 78 degrees and was corrected to a normal 47 degrees at surgery. The average final scapholunate angle was 72 degrees, which was not significantly different from the preoperative value. The scapholunate gap likewise was not significantly changed postoperatively. Only two patients had an excellent or good outcome using a clinical grading system, and six out of 17 scored good or excellent using a radiographic grading system. In conclusion, repair of the scapholunate ligament with dorsal capsulodesis failed to provide consistent pain relief and maintain carpal alignment in patients with static scapholunate instability.

Scapholunate ligament reconstruction using a bone-retinaculum-bone autograft: a biomechanic and histologic study

A new surgical technique has been recently described that involves reconstruction of the dorsal aspect of the scapholunate ligament (DSLL) with a bone-retinaculum-bone (BRB) autograft preparation from Lister's tubercle. In this study, the mechanic and histologic properties of the 2 tissues were compared. The BRB and DSLL specimens were harvested from 6 fresh-frozen human cadaveric forearms. The specimens were measured and then tested in tension with an MTS 810 servohydraulic materials testing machine at a rate of 10 mm/min. The BRB autograft was significantly weaker than the DSLL. However, because the mean cross-sectional area of the DSLL was more than 3 times as large as that of the BRB autograft, the failure stress (failure force/cross-sectional area) of the BRB autograft was not significantly different from that of the DSLL. Histologically, the DSLL and BRB autograft were also similar. These findings suggest that the BRB autograft may be appropriate graft material for scapholunate ligament reconstruction, but that structural parity with DSLL will ultimately depend on remodeling and hypertrophy during healing. This also highlights the importance of using a large BRB autograft to approximate the strength of the DSLL as much as possible, and that the BRB autograft must be protected postoperatively as it heals and remodels.

Scapholunate ligament reconstruction using a bone-retinaculum-bone autograft

This study was designed to evaluate the use of a locally available bone-retinaculum-bone graft in the reconstruction of the completely torn scapholunate (SL) ligament. Nineteen consecutive patients (14 with dynamic instability and 5 with static instability) underwent SL ligament reconstruction using an autogenous bone-retinaculum-bone graft taken from the third dorsal compartment region. All patients underwent arthroscopy to document a torn SL ligament. The bone plugs on the graft were fitted into the dorsal scaphoid and lunate, respectively, with the retinaculum periosteal soft tissue intervening sleeve arching between these 2 bones. The SL interval was reduced and pinned for 8 weeks with cast immobilization. The follow-up period averaged 3.6 years (minimum, 24 months). Of the 14 patients with dynamic instability, 12 had no pain and 2 had pain with heavy activity of the wrist. Range of motion (ROM) decreased slightly from preoperative values, and grip strength improved 46%. Thirteen patients were completely satisfied and returned to their former work activities, and 1 returned to modified work activities. Of the 5 patients with static instability, 2 had no pain after surgery, 1 had pain with heavy activity, and 2 had constant pain. ROM in this group decreased moderately in extension/flexion from the preoperative values. Grip strength improved 30% from preoperative values. Satisfaction was rated as complete by 1 patient and partial by 2 patients; 2 patients were dissatisfied. Two patients returned to their former jobs, 2 returned to modified duties, and 1 is on disability. Reconstruction of the SL ligament using a bone-retinaculum-bone autograft is predictable in patients with dynamic instability. Use of this technique with static SL instability is questionable; these patients may require a stronger construct to prevent recurrence of the SL gap.

Kinematics of the scaphoid shift test

Twenty-five uninjured subjects (50 wrists) were examined clinically and fluoroscopically during performance of the scaphoid shift test. Wrists were placed into 3 groups on the basis of the degree of palpable carpal motion that occurred during the clinical examination. Kinematic parameters of rotation and displacement were calculated from digitized images of the carpals at rest and at maximum displacement. On clinical exam, 36% of normal individuals had positive findings on scaphoid shift test. Dorsal displacement of the scaphoid was not significantly associated with positive scaphoid shift test results in these subjects, while total displacement of the scaphoid (the sum of axial and dorsal displacement) was significantly associated with positive test results. The principle confounding factor appeared to be a high degree of displacement that occurred at the capitolunate joint in some individuals, termed a "midcarpal shift." The data demonstrate that despite a high prevalence of positive scaphoid shifts among uninjured individuals, the ability to accurately detect dorsal displacement of the scaphoid using the scaphoid shift test is limited. On the basis of their findings, the authors recommend that positive test results be confirmed fluoroscopically.

Normal kinematics of carpal bones: a three-dimensional analysis of carpal bone motion relative to the radius

Normal carpal kinematics were studied in 22 cadaver specimens using a biplanar radiography method. The kinematics of the trapezium, capitate, hamate, scaphoid, lunate, and triquetrum were determined during wrist motion in sagittal and coronal planes. The results were expressed using the concept of the screw displacement axis and converted to describe the magnitude of rotation about and translation along three axes (X-axis: pronation-supination axis, Y-axis: flexion-extension axis, and Z-axis: radial-ulnar deviation axis) commonly used for the wrist. The orientation of these axes is expressed relative to the radius. Within the proximal carpal row, considerable differences of carpal behavior around the Y-axis were observed during sagittal plane motion of the wrist. The scaphoid exhibited the greatest magnitude of rotation, and the lunate the least. The magnitude of rotation of the carpal bones around the X-axis during sagittal plane motion of the wrist was small. The proximal carpal bones exhibited some ulnar deviation in 60 degrees of wrist flexion. During coronal plane motion of the wrist, the magnitude of radial-ulnar deviation of the distal carpal bones was mutually similar and generally of a greater magnitude than that of the proximal carpal bones. The proximal carpal bones experienced some flexion during radial deviation of the wrist and extension during ulnar deviation of the wrist. Translation was generally minimal in all carpal bones throughout wrist motion. This study reports results from the largest cadaver wrist kinematics study completed to date. The accuracy of the current method was improved when compared to previous studies. A sufficient number of specimens to allow statistical comparison was used and minimal interspecimen variability was noted. This study enabled a precise description of quantitative analyses of normal carpal kinematics relative to the radius.

Scapholunate dissociation: an experimental kinematic study of two types of indirect soft tissue repairs

Indirect soft tissue repairs of scapholunate dissociation (SLD) address the pathophysiology but have been criticized for significantly limiting wrist flexion and altering wrist kinematics. This study was designed to analyze and compare the kinematics of a normal cadaveric wrist to those of 2 types of soft tissue repairs performed for SLD. Ten uninjured fresh cadaver arms were evaluated by cineradiography and standard x-rays. The average scapholunate (SL) gap was 0.9 mm, with a SL angle of 50 degrees. A model of SLD was produced by sectioning the SL ligaments resulting in an average SL gap of 3.9 mm and SL angle of 66 degrees. The wrists were randomized to a dorsal capsulodesis repair and a distally based split extensor carpi radialis longus (ECRL) repair. The average SL gap after repair was 1.0 mm and the average SL angle was 47 degrees. The split ECRL repair and dorsal capsulodesis reduced scaphoid flexion with only a 10 degree and 18 degree decrease in wrist flexion, respectively. Both repairs reduced the SLD and restored normal wrist kinematics.

Nonunion rates of limited carpal arthrodesis: a meta-analysis of the literature

Numerous types of limited intercarpal arthrodeses have been reported in dozens of articles in the English-language medical literature. The nonunion rate varies considerably within and between the different types of arthrodeses. This may be due in part to the small number of cases in most studies. The data on the number of good results and nonunion rates for 27 different types of limited carpal arthrodeses reported in the English-language medical literature from 1946 to 1993 were collected, and for each study, the 95% confidence intervals (95% CI) were calculated. The studies were then combined for specific types of arthrodeses and the overall nonunion rates and confidence intervals were calculated to more accurately determine the actual nonunion rate expected for limited intercarpal arthrodeses. Nonunion rates (95% CI) for the most popular types of limited arthrodeses were as follows: of 385 scaphotrapezium-trapezoid arthrodeses reported, there was a 14% nonunion rate (95% CI, 11%-18%); of 104 lunotriquetral arthrodeses, the nonunion rate was 27% (95% CI, 19%-36%); and of 17 scapholunate arthrodeses, the nonunion rate was 47% (95% CI, 26%-69%).

Dynamic scapholunate instability: results of operative treatment with dorsal capsulodesis

Nineteen patients underwent 20 dorsal capsulodesis for dynamic scapholunate instability. Seventeen patients (18 wrists) were evaluated by a questionnaire and physical examination after a mean postoperative follow-up period of 34 months (range, 12-65). The diagnosis was based on a combination of characteristic symptoms of scapholunate instability and physical findings consisting of dorsal wrist tenderness at the scapholunate interval and a positive scaphoid shift test. Following surgery, a significant decrease was noted in symptoms of pain and clunking. Functional status was improved postoperatively; the most significant gains were seen in opening jars, sweeping, shoveling, and throwing. Fifteen of 17 patients returned to their original occupations, although 7 of those who returned to their original occupations did so with some restrictions. Objective evaluation by physical examination revealed a significant improvement in wrist stability as determined by the scaphoid shift test, and an average loss of 12 degrees of flexion. Fifteen of 17 patients (16 of 18 wrists) stated that they would undergo the surgery again if faced with the same choice. Our data demonstrate that dorsal radioscaphoid capsulodesis of the wrist in patients with dynamic scapholunate instability provides substantial improvement over preoperative status.

Analysis of carpal instability: I. Description of the scheme

There is a lack of a generally agreed analysis of carpal instability that can assist in the diagnosis, give guidelines for treatment, and ensure unity when reporting results of treatment. Based on the literature and using six categories describing chronicity, constancy, etiology, location, direction, and pattern of the instability, we present a proposal for a standardized analysis. Using this analysis, an instability should be presented with information in all six categories. The analysis may be expanded and developed according to future needs.

Distal anterior radius bone graft in surgery of the hand and wrist

The distal anterior radius was used as the source of bone graft for 131 reconstructive procedures in the wrist and hand. These included curettage and bone grafting of 9 cysts, 75 arthrodeses of various joints, and 47 scaphoid nonunions. The overall healing rate was 82%. There was one donor site complication; a distal radius fracture through the graft site occurred 46 months after surgery. We conclude that the distal anterior radius provides an excellent source of bone graft for surgery of the hand, with little morbidity.

Mechanical evaluation of the scaphoid shift test

Manipulative examination of the carpal bones is an important facet of the examination of the wrist. Abnormal translation of portions of the carpus in response to applied force is a commonly used clinical indicator of ligament injury. Unilateral scaphoid hypermobility during the so-called scaphoid shift test is felt to represent traumatic instability, especially in the context of wrist injury. The test, however, is subjective, and requires considerable experience to correlate the degree of scaphoid mobility with pathologic significance. We used an instrument that quantifies the load-displacement behavior of the scaphoid and its supporting ligaments during application of a dorsally directed load at the scaphoid tubercle. We evaluated 18 uninjured (normal) wrists with clinical ligament examination and with mechanical testing. Subjects who exhibited a positive scaphoid shift had significantly increased displacement and significantly decreased stiffness when compared with subjects who did not have a shift.

Scaphoid shift in the uninjured wrist

To determine the prevalence of a positive scaphoid shift in an uninjured population, 100 patients presenting with symptoms unrelated to trauma or wrist instability underwent physical and radiographic evaluation. On physical examination, the scaphoid shift maneuver was performed bilaterally, and generalized ligamentous laxity was assessed using standard criteria. Standard x-ray films were inspected for carpal abnormalities, and the radiolunate and scapholunate angles were measured. The prevalence of a positive scaphoid shift was 32%; the shift was painless in all patients. Fourteen patients had a unilateral scaphoid shift. Patients with a positive scaphoid shift had increased generalized ligamentous laxity manifested by a decreased average thumb-to-forearm distance and an increased mean flexion-extension arc. A positive shift was not correlated with radiographic carpal malalignment.

Long-term results following proximal row carpectomy

The functional outcome, patient satisfaction, and x-ray film status for 23 wrists were examined an average of 6 years following proximal row carpectomy. Surgery was performed for Kienbock's disease, scapholunate dissociation with periscaphoid arthritis, and scaphoid nonunion not suitable for bone grafting. Twenty patients were satisfied with functional performance and pain relief. Wrist flexion-extension arc averaged 74 degrees, or 61%, of the opposite wrist at a later examination. Grip strength, corrected dor dominance, averaged 79% of the opposite side, reflecting an average improvement of 15 kg force. Radiocarpal arthritis developed in three wrists, but only one required arthrodesis for pain relief. The majority of patients experienced satisfactory pain relief, functional wrist motion, and effective grip strength following proximal row carpectomy. The results did not decline at an average of 6 years after surgery.

Complications of intercarpal arthrodesis

Fifty patients who underwent intercarpal arthrodesis were retrospectively reviewed at an average follow-up period of 34 months. Eighteen patients had a good result, 16 results were fair, and 13 were poor. Thirty-six patients experienced some complication, and 25 patients underwent further surgical therapy: The most common indication for secondary surgery was nonunion (16 patients). Good results were significantly decreased among patients who experienced nonunion, required secondary surgery, or experienced any complication. Patients with static carpal instability treated by scaphoid trapezoid trapezium arthrodesis had a significantly greater proportion of good results.

Scaphoid excision and capitolunate arthrodesis for radioscaphoid arthritis

Eighteen patients with symptomatic radioscaphoid arthritis had scaphoid excision and capitolunate arthrodesis. Eight patients also had a silicone scaphoid replacement. The follow-up period averaged 3 years. Fusion was solid in 12 cases at an average of 8 weeks, and pain was significantly less at follow-up evaluation. Six patients had a pseudarthrosis and five had persistent pain. Immobilization in the pseudarthrosis group averaged 6 weeks, which was significantly less than the group that fused. Two patients underwent successful repeat fusions. Wrist extension averaged 26 degrees, flexion 34 degrees, radial deviation 11 degrees, and ulnar deviation 24 degrees. Grip strength averaged 25 kg. Presence of an implant had no significant effect on motion or strength. Pin track infection and pseudarthrosis were the main complications. Pain relief, functional motion, good strength, and patient satisfaction can be expected after scaphoid excision and solid capitolunate arthrodesis. Kirschner wires should be buried subcutaneously to avoid infection. The addition of a scaphoid implant offered no advantage over simple scaphoid excision.

Arthroscopic categorization of intercarpal ligamentous injuries of the wrist

Recent advances in our knowledge of wrist ligamentous anatomy, as well as improvements in arthroscopic techniques, permit the diagnosis and treatment of a wide variety of wrist injuries. The authors review current concepts in wrist ligamentous anatomy, patterns of instability, and the role of the arthroscope in the evaluation and treatment of such instability. Specifically, wrist portal anatomy and techniques of arthroscopic treatment of patients with partial and complete intercarpal ligament injuries are described. Chronic complete injuries are a contraindication of arthroscopic treatment. The authors conclude that wrist arthroscopy provides a valuable method of diagnosing and treating partial and complete intercarpal ligamentous injuries.

Long-term follow-up of scaphoid-trapezium-trapezoid arthrodesis

A series of 19 consecutive patients who underwent scaphoid-trapezium-trapezoid arthrodesis for chronic scapholunate instability or isolated arthrosis was reviewed. The average follow-up of 14 patients was 62 months. Eight of these 14 patients had significant residual symptoms and/or functional limitations at follow-up, and 11 had complications, including radiocarpal arthrosis (six patients), trapeziometacarpal arthrosis (four patients), and nonunion (three patients). Fusion without reduction of the scaphoid to a normal orientation was predictive of a poor result, but normal scaphoid positioning did not preclude development of arthrosis. Development of a painful degenerative thumb carpal-metacarpal joint may occur as an isolated phenomenon after scaphoid-trapezium-trapezoid arthrodesis.

Carpal instability, the missed diagnosis in patients with clinically suspected scaphoid fracture

To determine the incidence of carpal instability and its relation to clinical findings in patients with suspected scaphoid fracture, we performed a long-term follow-up investigation in a consecutive series of 160 patients who were treated in our department of traumatology for suspected scaphoid fracture after a fall on the outstretched hand. Radiography of the carpus was obtained. Bone scintigraphy was performed in all patients with negative initial radiographs. Follow-up investigation was performed in 100 patients and consisted of history, clinical examination, including measurement of grip strength and wrist movement, synovia stress test, Watson's scaphoid test, and radiographic examination. In 22 patients, clinical or radiological signs of carpal instability were found. The incidence of complaints and a positive synovia test were significantly higher in patients with suspected carpal instability. The bone scan was not useful for the detection or exclusion of carpal instability. The three-phase bone scan gave no additional information in the diagnosis of carpal instability.

The scaphoid shift test

The scaphoid test described by Watson has generally been accepted as the definitive test for scaphoid instability and uses pressure against the scaphoid tubercle as the wrist moves from ulnar to radial deviation for the evaluation. This article describes a stress test done with the wrist in neutral position, which actively provokes scaphoid instability. Variations in stability can be used to grade scaphoid laxity.

Scaphocapitolunate arthrodesis

Since 1985 scaphocapitolunate arthrodesis has been performed on 21 patients with either chronic incompetence of the scapholunate ligament or a scaphoid nonunion. The average age was 31 years; follow-up averaged 28 months. Eighty-six percent of the injuries involved workers' compensation. The operative procedure was done through a dorsal approach, with the use of autogenous bone grafting and Kirschner wire fixation. Eight-one percent healed after the primary procedure; one patient had a major infection. Range of motion averaged 35 degrees of extension, 30 degrees of flexion, 10 degrees of radial deviation, and 20 degrees of ulnar deviation. Grip strength averaged 70% of the uninvolved side. Pain was significantly reduced in 80% of the patients. Sixteen of 20 patients were able to return to work. Radiographic examination at final follow-up showed mild degenerative changes at the radiocarpal joint in two patients.

A comparison of scaphoid-trapezium-trapezoid fusion and four-bone tendon weave for scapholunate dissociation

The contact characteristics of the radiocarpal joint (area, pressure, and ratios of scapholunate area, pressure and force transmitted) were determined with the use of pressure-sensitive film in seven normal wrists after ligament sectioning to create scapholunate instability, with reconstruction involving a scaphoid-trapezium-trapezoid fusion, and with reconstruction involving a four-bone tendon weave procedure. The results demonstrated that the scaphoid-trapezium-trapezoid fusion significantly altered the contact characteristics of the wrist, transferring load, pressure, and area to the radioscaphoid joint, thereby unloading the lunate. In contrast, the tendon weave reconstruction produced characteristics similar to those of the normal joint.

Ideal scaphoid angle for intercarpal arthrodesis

This experimental study was conducted to determine the best scaphoid position, measured as the radioscaphoid (RS) angle for optimum wrist motion after scapho-trapezio-trapezoid (STT) and scaphocapitate (SC) fusion and to assess the implications of radial styloidectomy on motion after STT fusion. STT and SC fusions were simulated in six fresh cadaver hands with the scaphoid in horizontal, neutral, and vertical positions with respect to the long axis of the radius seen on lateral x-rays. RS angle and wrist motion were measured on x-ray films before and after each simulated arthrodesis. Radial deviation and wrist extension increased as the RS angle increased (i.e., increased as the scaphoid became more nearly vertical). Ulnar deviation and flexion decreased as the scaphoid became more nearly horizontal. We found no statistically significant differences in RS angle between SST and SC fusions with respect to ulnar deviation, flexion, or extension. However, radial deviation was more sensitive to RS angle after STT fusion than after SC fusion, but the differences were not statistically significant. The ideal radioscaphoid angle (range) for maximal wrist motion when STT fusion is performed is 41 to 60 degrees; when SC fusion is performed, it is 30 to 57 degrees. Motion is not improved by radial styloidectomy after simulated STT fusion.

Scaphocapitate intercarpal arthrodesis

We reexamined 17 patients at 16 to 57 months (average, 23.4 months) after scaphocapitate arthrodesis. Surgery was performed for treatment of rotary scaphoid instability, isolated arthrosis, resistant scaphoid nonunion, and prevention of carpal collapse in Kienböck's disease. Scaphocapitate fusion with autogenous bone grafting was used to bridge carpal spaces. Two patients had nonunion of the scaphocapitate arthrodesis, which required reoperation. Seven patients experience persistent pain with heavy use; of these, two changed occupations and one remains disabled. Compared with the nonoperated side, scaphocapitate fusion reduced wrist extension an average of 28 degrees, flexion 40 degrees, radial deviation 14 degrees, and ulnar deviation 14 degrees. The greatest loss was of radial deviation. Static grip reached a average of 74% of the nonoperated side. Dynamic power regained 73%, and dynamic endurance measured 105% of the nonoperated side. Motion peaked after six months on average, and then reached a plateau. Static strength peaked at 11 months and then stabilized.

Radial styloidectomy: an anatomical study with special reference to radiocarpal intracapsular ligamentous morphology

This study determines the anatomical relationship of the radiocarpal ligaments to the radial styloid process, and the effect of three specific styloidectomies on the integrity of these ligaments. Thirty fresh cadaveric wrists were dissected. The origins, insertions, and dimensions of each ligament was determined. The thirty wrists were divided randomly into three equal groups and the ten wrists in each group had three types of styloidectomy: short oblique, vertical oblique, and horizontal. The styloid fragments and wrists were then reexamined to determine the integrity of the ligaments. All styloidectomies removed the radial collateral ligament origin. Vertical oblique styloidectomy removed additionally 92% of the radioscaphocapitate and 21% of the radiolunatotriquetral ligament. Horizontal styloidectomy removed 95% of the radioscaphocapitate, and 46% of the radiolunatotriquetral ligament. These findings indicate that the degree of radiocarpal ligament disruption that occurs after styloidectomy may be predicted accurately by correlating the amount of styloid removed, with the consistent ligamentous anatomy of this area.

Bilateral spontaneous scapho-lunate subluxation treated by limited carpal fusion

The case of a 19 year-old-girl who developed spontaneous bilateral snapping scapho-lunate subluxation is described. Her symptoms were successfully treated by bilateral triscaphoid fusion.

Wrist injuries: correlation of clinical and arthroscopic findings

Wrist arthroscopy was done for one hundred nine patients with chronic wrist pain, averaging 22.8 months in duration. History regarding mechanism of injury, painful crepitus, pain with activity or at rest, localization of tenderness, visible swelling, and instability with examination was compared with arthroscopic findings of ligament damage, articular cartilage damage, and synovitis. Both pain at rest and swelling correlated significantly with synovitis. Tenderness did not correlate with specific ligament injury. Wrist ligament injuries and/or cartilage damage were noted in 96.3% of these wrists. Ligament injuries were frequently multiple, averaging 2.6 ligament injuries per wrist. No significant association was found between the presence of chondromalacia, synovitis, or specific ligament tears and the mechanism of injury, duration of symptoms, presence of clicking, or pain with activity.

Scapholunate interosseous reconstruction and imbrication of palmar ligaments

Twenty-eight patients with scapholunate interosseous ligament disruption, carpal instability, and persistent wrist pain were treated by carpal reduction, stabilization, and palmar ligament reconstruction. In twenty-two of these patients pain was well controlled, carpal alignment was maintained, and they were able to resume their previous employment. Grip and pinch strengths averaged eighty-two percent and range of motion averaged seventy-six percent of the normal uninvolved side.

Scapholunate dissociation in the skeletally immature carpus

A case of scapholunate dissociation with a dorsal carpal instability pattern is described in a skeletally immature 13-year-old male. The malrotation of the scaphoid was treated by soft tissue reconstruction, with use of a dorsal capsulodesis to provide a dorsal restraint to excessive palmar flexion of the scaphoid. In the skeletally immature carpus, isolated ligamentous injuries are less frequently recognized than epiphyseal injuries. To avoid interference with the successful conclusion of carpal growth, soft tissue reconstruction of deranged carpal relationships is preferable to intercarpal arthrodesis in the skeletally immature patient.

Scapho-trapezio-trapezoid arthrodesis for treatment of chronic static and dynamic scapho-lunate instability: a 10-year perspective on pitfalls and complications

Goals of reducing wrist pain, allowing a stable active wrist range of motion, and retarding degenerative changes make arthrodesis of the scapho-trapezio-trapezoid joint a popular treatment for chronic static and dynamic scapho-lunate instability; however, pitfalls and complications have not been well studied. Forty-seven wrists in 46 patients over a 10-year period revealed a complication rate of 52%. Failure to attain perfect scaphoid reduction consistently resulted in persistent incapacitating pain. Radial styloid-scaphoid impingement, observed after "successful" limited wrist fusion, was effectively treated by simple styloidectomy. Carpal osteomyelitis, lunate avascular necrosis, pin-tract infection, progressive medial carpal translation, and intractable pain without arthrosis complete the spectrum of complications managed in this series. Careful preoperative patient screening and attention to detailed recommendations will assist surgeons in avoiding the many potential problems associated with this procedure.

Degenerative arthritis at the triscaphe joint

The clinical presentation of triscaphe arthritis and the results of arthrodesis are presented. Twenty-one patients had triscaphe arthrodesis for treatment of arthritis of the triscaphe joint between 1972 and 1986. Seven also had rotary subluxation of the scaphoid and one had Kienböck's disease. Twenty patients were available for examination at an average of 5 years after operation. All had relief of pain and the average flexion-extension arc was 101 degrees. One patient had a nonunion successfully treated by refusion, and in two patients a dystrophy developed, which was relieved by a stress loading program. No progression of arthritis was seen elsewhere in the wrist.

Evaluation of the biomechanical efficacy of limited intercarpal fusions for the treatment of scapho-lunate dissociation

An experimental model that uses a static positioning frame, pressure-sensitive film, and a microcomputer-based videodigitizing system was used to measure the contact areas and pressures in a group of wrists in their "normal" state, after ligament sectioning, which resulted in stage III perilunate instability and then following different types of simulated carpal fusions. Compared with a normal wrist, there is an overall decrease in load in the lunate fossa and a significant increase in load in the scaphoid fossa in the wrist with stage III perilunate instability. Scaphoid-trapezium-trapezoid and scaphoid-capitate fusions transmitted almost all load through the scaphoid fossa. Scaphoid-lunate, scaphoid-lunate-capitate, and capitate-lunate fusions all distributed load more proportionately through both scaphoid and lunate fossae. The positioning of the carpal bones within a limited carpal fusion was also found to affect the load distribution in the wrist. The scaphoid-lunate, scaphoid-lunate-capitate, or capitate-lunate fusions, with attention to the relative carpal alignment within the limited fusion seem to offer more promise for treatment of perilunate instability biomechanically than the scaphoid-trapezium-trapezoid or scaphoid-capitate fusions.

Acute scaphoid fracture with scapholunate gap

Disruptive forces from wrist trauma are thought to fracture bone or disrupt ligaments. Two cases are presented to demonstrate the simultaneous occurrence of acute scaphoid fracture and scapholunate gap. Recommended treatment in acute cases is open reduction and internal fixation of the fracture and open stabilization of the scaphoid. In chronic cases, we recommend open reduction and internal fixation with bone graft to the scaphoid nonunion combined with fusion of the scaphoid-trapezium-trapezoid joint.

Wrist kinematics after limited intercarpal arthrodesis

Two limited intercarpal fusions, scapho-trapezial-trapezoidal and scapho-capitate, were simulated in six fresh human cadaver wrists by means of two Herbert screws. By use of a biplanar radiographic measurement system, the relative kinematic behavior of selected carpal bones, before and after the simulated limited fusions could be analyzed. Both scapho-trapezial-trapezoidal and scapho-capitate fusions produced a similar reduction in global range of motion and comparable effects on the relative intracarpal motion. In both fusions, a significant reduction in relative motion at the lunocapitate joint was recorded. The scaphoid, being fused to the distal carpal row, was shown to lose its role in the adaptative mechanism that allows preservation of articular congruency to the always changing space between the distal carpal row and the radius. After both types of fusion, increased sliding motion of the lunate on the radius was found. These kinematic changes are likely to enhance shear stresses on the lunate and tension on the surrounding ligaments, potentially diminishing long-term functional results.

Long-term study of chronic scapho-lunate instability treated by scapho-trapezio-trapezoid arthrodesis

The effect of scapho-trapezio-trapezoid arthrodesis on wrist kinematics was studied in 25 patients with chronic static scapho-lunate instability and in 16 patients with dynamic instability, with follow-up ranging from 24 to 101 months (average, 56 months). Postoperative planar and cineradiographic examination in patients returning to heavy labor reveal an absence of carpal shift-influence of the scaphoid proximal pole on the lunate-triquetral unit in ulnar deviation. Scapholunate diastasis present before operation persists in ulnar deviation as the STT fusion mass, capitate, and hamate rotate with the hand into ulnar deviation; the lunate-triquetral unit is not physiologically "pulled" radially into the lunate fossa of the radius. Triquetro-hamate mechanics remain normal as active engagement along the helicoidal triquetro-hamate interface initiates proximal row dorsiflexion. Clinical postarthrodesis wrist motion is a combination of intercarpal and radiocarpal mechanics, with energy in the flexion and extension arc dissipated through the scapho-lunate interface. The paucity of arthritic changes after up to 101 months after surgery is based on the kinematic changes presented in these data.