The role of arthroscopy for treatment of perilunate injuries

Arthroscopic Volar Capsuloligamentous Reattachment and Reinforcement to Bone

Background:  Injuries of the volar ligaments of the wrist are not uncommon, but their arthroscopic treatment presents a significant challenge. The objective of this paper is to introduce a technique for reattaching (in acute injuries) or reinforcing (in chronic injuries) various volar wrist ligaments to the bone, using standard wrist arthroscopic dorsal and volar portals. Methods:  There are three common steps for all the arthroscopic volar capsuloligamentous reattachments or reinforcements Step 1 - Volar Portal Establishment: volar radial, volar ulnar and volar central portals are used depending on which structure needs to be reattached or reinforced. Step 2 - Anchor Placement: the anchor is positioned at the site where the ligament has been detached. Step 3 - Capsuloligamentous Suture and Knotting: a knot pusher is introduced inside the joint from the dorsal portal and advanced inside the volar portal where the threads of the anchor are located. The knot pusher is loaded with the threads and retrieved to the dorsal portal. A 16G Abbocath, loaded with a loop is used to pierce the volar ligaments. The loop of the Abbocath is captured from the dorsal portal and loaded with the threads. Both threads are taken to the volar portal and knotted after releasing the traction. This way the knot is placed out of the wrist and the ligaments are reattached or reinforced to the bone. Result:  This technique has been used to reinforce and reattach the scapholunate and lunotriquetral ligaments and to reattach the radiocarpal ligaments and the Poirier space. Since this procedure has been performed in various conditions and in conjunction with other ligament treatments (such as perilunate injuries, carpal bone fractures, distal radius fractures, and reinforcement or reattachment of the dorsal portions of intrinsic ligaments), specific results are not presented. Conclusions:  The described technique enables the reattachment and reinforcement of most volar ligaments to the bone using standard wrist arthroscopic portals. It can be performed in conjunction with the treatment of the dorsal portion of intrinsic ligaments or other wrist injuries.

A Comparison of Outcomes in Acute Perilunate Injuries: Systematic Review and Meta-Analysis of Treatment Approaches

BACKGROUND

Perilunate dislocations (PLD) and fracture-dislocations (PLFD) comprise a spectrum of high-energy wrist injuries. The purpose of this review was to review operative strategies for perilunate injuries based on approach and compare outcomes.

METHODS

A systematic review of literature on PLD and fracture-dislocations was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed and EMBASE databases were queried for literature. Inclusion criteria included English studies reporting clinical or functional outcomes of acute PLD and PLFD.

RESULTS

Twenty-nine full-text articles (604 PLD and PLFD injuries) were included. The most common method of PLD and PLFD fixation is through an open approach with combined volar and dorsal exposure. There were no differences between approaches with regard to total arc range of motion, grip strength, Mayo Wrist Score, or mean scapholunate angle. Similarly, there was no difference between approaches and postoperative radiographic arthritis or complications. Most patients were able to return to their prior level of function and work. The incidence of postoperative complications ranged from 0% to 22.5%.

CONCLUSION

Current evidence shows no difference in postoperative total wrist arc range of motion, grip strength (as compared to contralateral), or Mayo Wrist Score with regard to surgical approach. The most common method of PLD and PLFD fixation in the literature is through an open approach with combined volar and dorsal exposure. There is a large difference in reported rates of radiographic arthritis, although this finding does not appear to correlate with postoperative pain or disability.

LEVEL OF EVIDENCE

I, Systematic Review.

Palmar Trans-scaphoid Perilunar Dislocation: A Case Report and a Literature Review of Clinicodemographic Characteristics and Management Options

Palmar trans-scaphoid perilunar dislocation is a rare finding in clinical practice. Herein, we report a case of a young right-handed male hairdresser brought to the emergency room after a heavy blow to his right hand. An X-ray showed a palmar dislocation of the capitate, carpus, and distal scaphoid relative to the lunate, which remains in normal alignment with the radius, with the proximal scaphoid maintaining attachment to the lunate. Open reduction and internal fixation were done in the first week after trauma.

Carpal dislocations

Carpal dislocations result from sequential disruption of the complex relationship between the bones and ligaments of the wrist. Injuries to the carpus occur via predictable mechanisms, an understanding of which is critical to identify and treat these frequently missed patterns of injury and to avoid the sequela of chronic instability. Lunate dislocations are by far the most common, but isolated dislocation of other carpal bones can also occur. Open reduction and internal fixation still remains the gold standard for treatment regardless of the debate around the specific approaches. These high-energy injuries are associated with significant long-term morbidity even when identified promptly and appropriately treated. This review will focus on the evaluation and management of common forms of carpal dislocations.

Immediate Proximal Row Carpectomy for Severe Perilunate Dislocation Injuries: A Minimum 5-Year Follow-Up

Background: In patients with perilunate injuries (PLI) with multiple ligamentous and bony injuries involving the proximal carpal row, open reduction and internal fixation (ORIF) can be difficult and lead to poor functional outcomes. Proximal row carpectomy (PRC) is an alternative procedure that has been used for severely comminuted fractures. The aim of our study is to evaluate the long-term functional outcome (minimum 5 years) of patients that underwent an emergency PRC for PLI. Methods: We conducted a retrospective study of patients who underwent PRC at our centre between 2001 and 2016. Only patients with follow-up data of more than 5 years were included in the study. We evaluated range of motion, grip strength, Mayo Modified Wrist Score (MMWS) and Quick Disabilities of Arm, Shoulder and Hand (Quick-DASH). Radiographic analyses were performed to assess the presence of radiocarpal osteoarthritis and the space between the radius and capitate. Results: Thirteen patients were included, with an average follow-up of 78.07 months (6.5 years). The MMWS was 65 points (four excellent and good, four fair and five poor results) and the Quick-DASH score was 30 points. X-ray analysis reported only 15.3% of patients with radiocarpal arthrosis and an average radio-capitate joint space of 1.92 mm. Conclusions: The outcomes of PRC in the management of PLI are comparable to the results reported in literature for conventional ORIF. PRC is a simpler procedure that minimises the need for re-intervention. Level of Evidence: Level IV (Therapeutic).

A Novel Mini-Invasive Technique of Arthroscopic-Assisted Reduction and Robot-Assisted Fixation for Trans-Scaphoid Perilunate Fracture Dislocations

OBJECTIVE

Perilunate injuries are rare but devastating carpal injuries. The treatment of perilunate injuries remains challenging and contentious. This study aims to describe a novel mini-invasive surgical technique of arthroscopic-assisted reduction and robot-assisted fixation for the treatment of trans-scaphoid perilunate fracture dislocations (PLFDs).

METHODS

We retrospectively reviewed patients with PLFDs after surgical treatment from February 2021 to March 2021. The patients underwent arthroscopic-assisted precise reduction and robot-assisted headless screw fixation. Times of guide wire placement were recorded intraoperatively. Periodic follow-up was performed until union of scaphoid fracture was confirmed. Range of motion of the wrist, grip strength, the Visual Analog Scale (VAS) score, the Mayo Wrist Score, the Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) score, the Patient-Rated Wrist Evaluation (PRWE), and osteoarthritis were evaluated at the final follow-up.

RESULTS

Two male patients presenting with PLFDs with an average age of 24.5 years old (32 and 17 years) were included in this study. Intraoperatively, anatomic reduction of the scaphoid fracture was achieved under arthroscopic guidance. A robotic-assisted single-attempt guidewire insertion was performed for scaphoid fracture and lunotriquetral interval. The CT scans at 8 and 12 weeks showed the union of the scaphoid fracture. At final mean follow-up of 13.5 months, the extension, radial-ulnar deviation, and pronation-supination were consistent with the contralateral side in both patients. One patient experienced mild limited range of motion with the flexion 46° of the injured wrist compared with 81°of the contralateral wrist. The VAS score was 0 and 2. The grip strength was 32 and 26 kg compared with 24 and 42 kg of the contralateral wrist. The PRWE score was 13 and 10 and the QuickDASH score was 2 and 7. The Mayo Wrist Score was 100 and 65. No sign of osteoarthritis was found at the last follow-up.

CONCLUSIONS

Arthroscopic-assisted reduction and robot-assisted fixation is a viable and promising alternative for the treatment of perilunate fracture dislocations. This technique allows precise reduction and accurate placement of the K-wires/screws into the carpal bones through the optimal biomechanical paths.

Complications and outcomes of operative treatment for acute perilunate injuries: a systematic review

We systematically reviewed the incidence of complications and outcomes of different surgical methods for acute perilunate injury in the MEDLINE, Scopus, Embase and Cochrane Library databases. Forty-three articles with 880 patients were included. The most common complications were arthritis (30%), carpal instability (15%), avascular necrosis of the lunate (12%), complex regional pain syndrome (11%), and nonunion or avascular necrosis of the scaphoid (9%). In the meta-analysis, the mean scapholunate gap was 1.7 mm in the closed surgery group and 2.3 mm in the open surgery group, which was a statistically significant difference. The mean flexion-extension arc of the wrist and modified Mayo wrist score were better in the closed surgery group than in the open surgery group. However, these findings may relate to different cohorts in terms of injury severity. Therefore, the causal relationship between closed surgery and better outcomes may be uncertain as less severe subluxations are more likely to be treated closed.

Perilunate dislocation and fracture dislocation of the wrist: Outcomes and long-term prognostic factors

INTRODUCTION

Perilunate dislocations and fracture-dislocations are severe injuries that often have serious functional sequelae. Our goal was to evaluate the long-term clinical and radiological results of these perilunate injuries, and to look for prognostic factors of a poor clinical outcome.

HYPOTHESIS

All patients who suffered perilunate injuries in their wrist have functional sequelae and long-term radiographic changes despite optimal treatment with anatomical surgical reduction.

MATERIALS AND METHODS

We did a single-center, retrospective study of 32 patients who had either an isolated perilunate dislocation (n=7) or fracture-dislocation (n=25) in their wrist. Pain, range of motion, strength and functional scores (MWS, PRWE, QuickDASH) were evaluated. Radiographs were analyzed to look for signs of osteoarthritis or carpal instability.

RESULTS

The mean follow-up time was 9.9years (3.5-24). The wrist joint had a mean flexion-extension of 86° (0-140), radioulnar deviation of 38° (0-65) and pronosupination of 153° (120-180). The mean grip strength was 35kg (5-56). The mean MWS, PRWE and QuickDASH scores were 65/100, 32/100 and 29/100, respectively. At the final assessment, 23 patients (79%) had radiographic signs of osteoarthritis while 5 patients (16%) had residual carpal instability. Three patients subsequently underwent palliative treatment. Opening the carpal tunnel and the magnitude of the lunate's displacement are significant predictors of a poor long-term functional outcome (p<0.05). Older age at the time of injury was a predictor for the development of osteoarthritis.

DISCUSSION

Despite optimal treatment, perilunate dislocations and fracture-dislocations at the wrist cause functional sequelae such as pain, stiffness, strength deficit and posttraumatic arthritis in nearly 80% of patients. The functional outcomes are determined by the amount of lunate displacement (stage) and the patient's age. We do not recommend opening the carpal tunnel, even when signs of median nerve compression are present; reducing the dislocation helps to relieve the neurological symptoms.

LEVEL OF EVIDENCE

IV; retrospective observational study.

Perilunate Injuries: Current Aspects of Management

Perilunate dislocations (PLD) and perilunate fracture dislocations (PLFD) are high-energy injuries which can result in long-term complications and significant disability. Early identification of these injuries, followed by prompt, appropriate management is key to optimising patient outcomes. Knowledge of the carpal anatomy is essential in order to understand the varied patterns of injury and plan appropriate definitive management. Emergent reduction and close monitoring of the median nerve, followed by prompt stabilisation or repair of the injured structures remain the mainstay of treatment. In this review, we present a summary of the current evidence regarding the identification and management of these complex injuries.

Perilunate fracture-dislocations: Clinical and functional outcomes at a mean follow-up of 3.3 years

INTRODUCTION

Perilunate lesions in the carpus are severe injuries whose functional consequences can limit patients' ability to regain their pre-injury activity levels. The aim of this study was to evaluate the outcomes of a series of patients who suffered a perilunate fracture-dislocation and to assess their ability to resume their social and professional activities.

HYPOTHESIS

After surgical management of this injury, the medium-term functional outcomes will allow patients to return to their pre-injury social and professional activities.

MATERIALS AND METHODS

This was a single center, retrospective study. Included patients were adults who had suffered a perilunate fracture-dislocation that was treated emergently. The clinical and functional assessment consisted of comparing the mobility and grip strength between the injured and contralateral wrists, determining the functional outcome scores and the resumption of social and professional activities. A radiological assessment was done to look for instability of the proximal row of the carpus, nonunion or necrosis of the carpal bones, loss of carpal height, and presence of carpal osteoarthritis.

RESULTS

Ten patients were included with a mean follow-up of 39.4 months. The mean flexion/extension arc decreased significantly to 88° (20°-150) which was 55% of the healthy contralateral side (p=0.0026) while the grip strength decreased but not significantly (40.6 Kg vs. healthy side 62.4 Kg, p=0.063). The mean MWS was 58.75 (40-100), the mean PRWE was 32.9 (4-67.5) and the mean QuickDASH was 30.2 (0-77). Six of the ten patients (60%) were able to return to work, although three required occupational reclassifications. Four patients had signs of proximal row instability. There were seven instances of radiocarpal osteoarthritis, two of which were combined with mid-carpal osteoarthritis.

DISCUSSION

This study found shorter range of motion and worse patient-reported outcomes than other published studies, which may be due to the severity of the perilunate fracture-dislocation injuries and the inclusion of polytrauma patients. Nevertheless, the subjective scores were comparable. These injuries have serious consequences on social and professional activities of manual workers.

LEVEL OF EVIDENCE

IV; retrospective study.

Mid-term clinical and radiographic outcomes of perilunate injuries treated with open reduction and internal fixation

OBJECTIVE

This study aimed to present the mid-term clinical and radiographic outcomes of patients with perilunate injuries treated with open reduction and internal fixation (ORIF).

METHODS

Patients who underwent ORIF due to perilunate injuries from 2004 to 2015 were retrospectively reviewed. Surgery was mostly performed using a standard dorsal approach. Each injury was graded as per Mayfield staging. At the final follow-up, pain intensity was evaluated using a 10-cm visual analog scale (VAS). Wrist and elbow range of motion, handgrip and pinch strength, Modified Mayo Wrist Scores, and the disabilities of the arm, shoulder, and hand (DASH) scores were measured. On plain radiographic examination, the scapholunate (SL) angle, SL interval, carpal height, and continuity of Gilula arcs were evaluated. The presence of arthritis was also assessed using the Herzberg classification.

RESULTS

In total, 26 male patients (27 wrists) who met the inclusion criteria were included in the study. The mean age was 40 years (range: 20-58); the mean follow-up was 45 months (range: 16-96). Most of the injuries were fracture-dislocations (n=20; 71.4%). According to Mayfield staging, 7 wrists were grade 3, and 20 wrists were grade 4. According to Herzberg staging, 11 (40.7%) patients were stage 2a. The mean VAS was 2.3 (range: 0-5) at rest and 3.3 (range: 0-7) during activity. The mean wrist flexion and extension were 50° (range: 21-80°; 73.5% of the unaffected side) and 45.1° (range: 20-74°; 70.9% of the unaffected side), respectively. The mean radial and ulnar deviation were 14.6° (range: 6-25°; 63.6% of the unaffected side) and 22.3° (range: 5-40°; 64.7% of the unaffected side), respectively. Grip and pinch strength were 57.6 kg (range: 15-106; 65.5% of the unaffected side) and 18.6 kg (range: 8-28; 78.2% of the unaffected side), respectively. The mean Mayo score was 63.3 (range: 20-90), and the DASH score was 24.1±25.2. The mean SL angle was 61.6° (range: 40-83). There was 1 wrist with a pathological SL interval, 11 wrists with dorsal intercalated segmental instability, and 3 wrists with fractures of the Gilula arcs. The mean carpal height was within the normal range.

CONCLUSION

In the treatment of perilunate injuries, satisfactory clinical and radiographic outcomes can be expected from ORIF at mid-term follow-up.

LEVEL OF EVIDENCE

Level IV, Therapeutic Study.

Treatment of acute perilunate dislocations: ORIF versus proximal row carpectomy

PURPOSE

Some authors have proposed performing proximal row carpectomy (PRC) as the initial treatment for perilunate dislocations.

HYPOTHESIS

The goal of this retrospective study was to compare the results of a cohort of perilunate dislocation cases that were operated by open reduction and internal fixation (ORIF) or by PRC between 2006 and 2011.

METHODS

The cohort consisted of 21 men with a mean age of 33years, who either had an isolated perilunate dislocation (7 cases) or a fracture-dislocation (14 cases). All dislocations were dorsal, with 10 stage I and 12 stage II. Thirteen patients had been treated by ORIF (group 1) a mean of 1.2days after the injury. Eight patients had been treated by PRC (group 2) a mean of 18.7days after the injury. Immobilization time was 6-12weeks in group 1 and 2weeks in group 2.

RESULTS

The mean operative time was 95minutes in group 1 and 65minutes in group 2. After a mean follow-up of 35months, the following outcomes were found for groups 1 and 2, respectively: pain 3/10 and 1/10, strength 77% and 73%, strength in supination 79% and 93%, strength in pronation 67% and 95%, QuickDASH 27/100 and 16/100, PRWE 43/150 and 15.5/150, flexion 69% and 57%, extension 84% and 58%, pronation 97% and 103%, supination 98% and 97%. There were four cases of osteoarthritis in both groups.

CONCLUSION

Treatment of acute perilunate dislocations by PRC leads to medium-term results that are at least as good as those with ORIF treatment. The surgery duration is shorter with PRC, as is the immobilization period.

TYPE OF STUDY

Retrospective comparative.

LEVEL OF EVIDENCE

III.

Arthroscopic Reduction and Stabilization of Chronic Perilunate Wrist Dislocations

An acute perilunate wrist injury that is unreduced for more than 6 weeks results in severe disability, and even open reduction with stabilization through wide dorsal and volar approaches is technically challenging. This report describes an arthroscopic technique for reduction and percutaneous wire stabilization of a chronic perilunate wrist dislocations. The technique involves initial radiocarpal and midcarpal access through the 6R and 3-4 portals, and these portals are used for synovectomy and debridement of capsular flap tears. The midcarpal joint is accessed initially through the radiocarpal joint, and additional midcarpal portals are used for sequential perilunate adhesiolysis before carpal mobilization and reduction. A percutaneous wire drilled into the lunate is used as a joystick to manipulate the lunate into its anatomic alignment along the carpal bones, and percutaneous transcarpal wire fixation is performed to stabilize the carpus. Arthroscopic and fluoroscopic guidance is used to optimize anatomic reduction and to confirm stability. The wrist is immobilized for 6 weeks; the percutaneous wires are removed thereafter, and the wrist is mobilized. Overall, the arthroscopic technique provides a safe and reproducible method for treatment of this complex chronic injury.

Primary Wrist Hemiarthroplasty for Irreparable Distal Radius Fracture in the Independent Elderly

Background Volar plating for acute distal radius fractures (DRF) in the elderly has been recommended. Some studies have suggested that open reduction with internal fixation (ORIF) in this situation results in frequent complications. Our purposes were to provide a definition of irreparable DRF in independent elderly patients and to review the results of a preliminary retrospective series of wrist hemiarthroplasty (WHA) in this patient population. Materials Between 2011 and 2014, 11 consecutive independent elderly patients (12 wrists) with irreparable intra-articular DRF were treated with primary WHA at the acute stage. A resection of the ulnar head was associated in nine wrists. A total of 11 wrists with more than 2 years of follow-up form the basis of this paper. Description of Technique The approach was dorsal longitudinal. An osteotome longitudinally entered the dorsal aspect of the fracture medial to the Lister tubercle. Two thick osteoperiosteal flaps were elevated radially and ulnarly in a fashion similar to opening a book. The distal radius articular surface was excised. The implant was pressed into the radial canal with attention to restoring distal radius length. The two osteoperiosteal flaps were brought back together and sutured so as to close, again like a book, the osseous and soft tissues around the implant. Results At mean follow-up of 30 months, average visual analog scale (VAS) pain was 1/10. Mean QuickDASH (Disabilities of the Arm, Shoulder and Hand) score was 32, and mean Patient-Rated Wrist Evaluation (PRWE) score was 24. Mean forearm rotation arc was 151°. Mean active flexion-extension arc was 60°. Mean active extension was 34°. Mean grip strength was 14 kg (64% of contralateral wrist). Mean Lyon wrist score was 73%. Bone healing around the implants was satisfactory in all but one case. Conclusions Out data suggest that treatment of irreparable DRF in the independent elderly patient with a bone-preserving WHA may be a viable option. Longer-term follow-up and comparative studies are needed to confirm the validity of this concept.