Kinematics of the wrist. II. Clinical applications

Scapholunate Ligament Injuries

Injuries to the scapholunate interosseous ligament (SLIL) complex can result in a predictable cascade of incongruous motion in the carpus that leads to radiocarpal degeneration. Both acute traumatic impact and repetitive motion can render the SLIL insufficient. A thorough understanding of SLIL anatomy is required for appropriate diagnosis and treatment. Here, we review scapholunate ligament anatomy, prevention strategies, methods of diagnosis, nonoperative and operative treatments, and outcomes. A myriad of treatment options exist for each stage of the SLIL injury, and management should be an open discussion between the patient and physician.

Normal values of scapholunate distance in Turkish children aged 5-14 years

Wrist kinematic indices and scapholunate distance play an essential role in diagnosing and treating injury and disease of the carpus. It can be challenging to measure and diagnose scapholunate ligament injury in the immature skeleton. The aim of this study was to measure the normal ranges of the carpal indices on radiographs in the Turkish population aged 5-14 years. This retrospective study examined children aged 5-14 years between 2021 and 2022. Children aged 5-14 years with a wrist anteroposterior X-ray, children admitted to the hospital for nontraumatic reasons, and children who had not had a wrist fracture before were included in the study. The distance between the scaphoid and the lunate, the distance between the lunate and the triquetrum, the carpal height, the length of the third metacarpal, and the ratio of the carpal height to the length of the third metacarpal were measured. It was found that the scapholunate distance was significantly higher in boys aged 7-8 years and 9-10 years (P = 0.001, P = 0.004). When the averages of the lunotriquetral distances were analyzed according to age groups, it was found that it was significantly higher in boys of 7-8 years old, 11-12 years old, and 13-14 years old groups compared with girls (P = 0.003, P < 0.001, P = 0.004). In this study aiming to find the average values of scapholunate distance, lunotriquetral distance, and carpal indices in children, we concluded that we should examine the wrist X-ray in terms of carpal injuries by considering age and gender.

Diagnostic performance of traditional radiographic indices in detection of carpal collapse in Kienböck's disease

Correctly identifying carpal collapse is important for adequate treatment of Kienböck's disease. This study aimed to assess the accuracy of traditional radiographic indices in detecting carpal collapse to differentiate between Lichtman stages IIIa and IIIb. In 301 patients, carpal height ratio, revised carpal height ratio, Ståhl index and radioscaphoid angle were measured on plain radiographs by two blinded observers. As a reference standard, Lichtman stages were determined by an expert radiologist using CT and MR imaging. The interobserver agreement was excellent. In the differentiation between Lichtman stages IIIa and IIIb, measurements of indices showed moderate to good sensitivity (0.60-0.95) and low specificity (0.09-0.69) using normal cut-off values from the literature, while receiver operating curve analysis revealed poor area under the curve (58-66%). Traditional radiographic indices showed poor diagnostic performance in detecting carpal collapse in Kienböck's disease and did not reach sufficient accuracy in the differentiation between Lichtman stages IIIa and IIIb.Level of evidence: III.

Long-term results of first row carpectomy with proximal capitate resurfacing using a pyrocarbon implant

The functional results of proximal row carpectomy with a proximal capitate resurfacing using a pyrocarbon implant were evaluated in a retrospective, multicentric, multi-operator study. The outcomes of patients operated on at five surgical centres between January 2005 and December 2018 were reviewed. The data were collected by an independent observer during standardized consultations. Based on 30 patients with a mean follow-up of 7 years, the median range of flexion and extension was 65° and the median radioulnar tilt was 45°. The median Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was 14 and the improvements in strength and pain were good. Compared with the preoperative values, significant improvements were seen in the flexion and extension range of motion, radioulnar tilt and pain score. No postoperative complications were recorded.Level of evidence: IV.

Arthroscopic proximal carpal row replacement by semitendinosus and gracilis graft (CArpus Row Plasty Using the Semitendinosus: CARPUS procedure). An anatomical study of 16 cases

INTRODUCTION

Post-traumatic lesions of the carpus (scapholunate rupture, scaphoid non-union) frequently evolve into disabling osteoarthritis (scapholunate advanced collapse or scaphoid non-union advanced collapse: SLAC or SNAC wrist). Proximal row carpectomy (PRC) is a reliable option but with poorer prognosis in case of osteoarthritis of the distal radius or capitate head. In such situations, radiocarpal arthrodesis may be necessary, sacrificing wrist motion. To circumvent this limitation, we propose a new procedure consisting in arthroscopic PRC and replacing the proximal row by tendon graft.

METHODS

This was a study on 16 cadaver specimens. A scapholunate pin was introduced via an approach into the anatomical snuffbox and used as a guide for a cannulated drill bit (9mm) to create a tunnel through the proximal row. The arthroscope and a reamer were introduced into the tunnel via its radial and ulnar ends. PRC was performed under arthroscopic control. The gracilis and semitendinosus tendons were harvested and folded so as to obtain a graft with the same length and diameter as the proximal row. The graft was threaded through the radial approach and fixed to the capsule.

RESULTS

Mean procedure time was 68min. There was no pre- to postoperative difference in joint motion or carpal height. On radiocinematography, the graft was stable between the radius and the second row of the carpus. The radial and ulnar sensory branches, median nerve and radial artery were intact at end of procedure.

DISCUSSION

This technique could be a solution in SLAC or SNAC wrist with osteoarthritis of the capitate head or radial glenoid. It also conserves carpal height. Being arthroscopic, the procedure avoids the major edema observed after a dorsal approach of the carpus, and also ensures graft stability, since the radiocarpal ligaments are conserved. Harvesting from a second anatomical site and the in vivo fate of the transplant are two issues that need to be discussed.

CONCLUSION

This anatomical study paves the way for clinical experimentation.

LEVEL OF EVIDENCE

IV.

Lateral Approach for Scaphoid Excision and Capitolunate Arthrodesis in the Treatment of Scapholunate Advanced Collapse and Scaphoid Nonunion Advanced Collapse Wrists: A Case Series

OBJECTIVE

The dorsal approach is commonly used in open wrist arthrodesis. However, the extensor compartments and the dorsal wrist capsule need to be opened. We propose and evaluate a lateral approach using a small incision over the scaphoid anatomical snuffbox, which could be more straightforward for performing scaphoid excision and capitolunate arthrodesis in the treatment of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC).

METHODS

Between 2016 and 2021, 10 patients were enrolled retrospectively and underwent the lateral approach for scaphoid excision and capitolunate arthrodesis. We presented the radiographic outcomes, including fusion status, capitolunate angle, and carpal height ratio. The functional outcomes of wrist range of motion, grip strength, visual analog scale (VAS) score for pain, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and Mayo wrist score were evaluated. The data obtained were analyzed and presented as the mean and standard deviation (SD).

RESULTS

All 10 patients achieved solid bone fusion, and the mean follow-up period was 20.4 (range 12-38; SD 10.1) months. Postoperatively, the mean capitolunate angle and carpal height ratio improved from 18.1° (range 8-34°; SD 8.6°) to 2.9° (range 0-5°; SD 1.9°) and 0.45 (range 0.40-0.49; SD 0.03)% to 0.50 (range 0.46-0.54; SD 0.02)%, respectively. The average preoperative and final follow-up functional results were as follows: flexion-extension arc of 76.5° (range 50-110°; SD 20.0°) and 74.0° (range 65-90°; SD 9.1°); VAS pain score of 5.8 (range 4-7; SD 1.0) and 0.9 (range 0-2; SD 0.6); QuickDASH score of 55.9 (range 40.9-79.5; SD 11.4) and 26.1 (range 18.2-36.4; SD 6.0); and Mayo wrist score of 46.5 (range 25-60; SD 13.8) and 72.5 (range 70-80; SD 3.5), respectively.

CONCLUSIONS

The lateral approach for scaphoid excision and capitolunate arthrodesis in treating SLAC and SNAC can provide a straightforward way for performance. This approach does not require disruption of the dorsal wrist capsule and extensor retinaculum. Bony healing can be achieved, and functional outcomes can be improved.

The INCA® implant to treat isolated scaphotrapeziotrapezoid osteoarthritis: Preliminary results at a minimum 2 years' follow-up

We report results with the INCA® distal scaphoid pole resurfacing implant anchored within the scaphoid for isolated scaphotrapeziotrapezoid osteoarthritis. Thirty-five implants in 27 patients (mean age, 69 years) were retrospectively included with a minimum follow-up of 2 years. Outcome criteria were pain (VAS), PROMs (QuickDASH, PRWE and MMWS), wrist motion, pinch and grip strength, and radiographic assessment. The average follow-up was 4.6 years. There was a significant improvement in pain, PROMs, grip and pinch strength. Radial deviation and wrist extension showed slight but significant postoperative decrease (-4° for both). Dorsal intercalated segment instability (DISI) was significantly improved postoperatively (7 cases versus 21 preoperatively). There were 2 cases of implant loosening (6%) within the first 10 months: 1 keel malpositioning and 1 insufficient postoperative immobilization. These findings suggest that the INCA® implant is an effective and reliable medium-term solution for isolated scaphotrapeziotrapezoid osteoarthritis. By restoring scaphoid length and gliding on the trapeziotrapezoid surface, the implant contributes to restoring normal bone alignment of the wrist.

Is DISI Deformity Related to Presence of a Medial Lunate Facet in Patients with Scapholunate Dissociation?

Background  Lunate morphology has been suggested to influence carpal kinematics. Purpose  We investigate a possible relation between presence of a medial lunate facet and dorsal intercalated segment instability (DISI) of the wrist in patients with a scapholunate (SL) dissociation. Methods  We retrospectively reviewed patients diagnosed with SL dissociation between 2000 and 2017. Lunate morphology was categorized based on radiographs and magnetic resonance imaging (MRI), as type I or II according to Viegas and Galley. DISI was defined as radiolunate angle > 15 degrees and SL instability as SL angle > 60 degrees. SL distance > 3 mm was considered as widening and carpal height ratio < 0.5 was considered as carpal collapse. We used descriptive statistics to report on SL instability and DISI in patients with Viegas type I and type II lunates. We calculated kappa to determine agreement between radiographs and MRI and to determine inter- and intraobserver agreement. Results  Of 119 patient files, 79 wrists met the inclusion criteria of which 25 were type I lunates and 54 type II. Similar spreading of the data of both groups was found regarding DISI, SL instability, and SL widening based on radiographic classification of the lunate, even after adding MRI findings. In the presence of carpal collapse, capitate-to-triquetrum distance was higher. We found a substantial inter- and intraobserver agreement for lunate classification. Conclusion  Our results suggest a similar prevalence of DISI deformity or enlarged SL angle in patients with type I or II lunate in presence of SL dissociation. The Viegas classification is a reliable and reproducible classification system. Level of evidence  This is a Level III, cross-sectional study design.

Pyrocardan Scaphotrapeziotrapezoid Joint Arthroplasty for Isolated Osteoarthritis: Results after a Mean Follow-Up of 5 Years

Background  Isolated scaphotrapeziotrapezoid (STT) osteoarthritis (OA) mainly develops in women over 50 years of age in a bilateral manner. Many surgical treatments are available, including distal scaphoid resection with or without interposition, trapeziectomy, and STT arthrodesis. However, there is a controversy about which procedure is the most effective. Purposes  The purpose of this study was to report the outcomes of the Pyrocardan implant for treating STT isolated OA at a mean follow-up of 5 years. Patients and Methods  Consecutive patients who underwent STT arthroplasty using the Pyrocardan were reviewed retrospectively by an independent examiner who performed a clinical and radiological evaluation. Results  The mean follow-up time was 5 years (range 3-8 years). Thirteen patients (76%) were followed for more than 5 years. Between the preoperative assessment and the last follow-up, pain levels decreased significantly. There was no significant difference in the mean Kapandji opposition score. Grip and pinch strengths were 88 and 91% of the contralateral side. The active range of motion in flexion-extension and radioulnar deviation was not significantly different to the contralateral side (119° vs. 121° and 58° vs. 52°, p  > 0.1). Functional scores were improved significantly. No identifiable differences were found in the radioscaphoid, capitolunate, and scapholunate angles before and after surgery. In three cases, the preoperative dorsal intercalated scapholunate instability (DISI) failed to be corrected. In one case, DISI appeared after the procedure. There was one asymptomatic dislocation of the implant. Calcification around the trapezium and/or distal scaphoid was found in four cases. The survival rate of the implant without reoperation was 95%. Conclusions  In the medium term, Pyrocardan implant is an effective treatment for STT OA as it reduces pain, increases grip strength, and maintains wrist mobility. This is consistent with the results of other published case series using pyrocarbon implants. It provides a high rate of patient satisfaction. Nevertheless, the surgical procedure must be done carefully to avoid STT ligament damage, periarticular calcifications, or dislocation.

Medium-Term Outcomes for Amandys Implant: A 5-Year Minimum Follow-Up of 63 Cases

Background  Amandys is a pyrocarbon interposition implant used as a therapeutic alternative to total wrist fusion (TWF) or total wrist arthroplasty (TWA) in painful and disabling extensive destruction of the wrist. Objective  To review mid-term outcomes in a continuous prospective series of patients who underwent wrist arthroplasty Amandys with a minimum follow-up of 5 years. Methods  Clinical evaluation included a satisfaction survey, pain, two functional scores, the short version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and the Patient-Rated Wrist Evaluation (PRWE), active wrist mobility, and grip strength compared with the contralateral side. Radiological evaluation was used to detect implant subsidence, carpal migration, bone lysis, or implant malposition. All per- and postoperative complications were collected. Results  Fifty-nine patients (63 procedures) were evaluated with a mean follow-up of 7 years; 57% of the patients were males, and the mean age was 58 years. Among the patients, 90% were satisfied or very satisfied. Pain was significantly improved, with a gain of 4/10 ( p  < 0.001). Functional outcomes also improved between the second and fifth year of follow-up. Active mobility was preserved and grip strength was significantly improved by 7 kg ( p  < 0.001). No implant subsidence or carpal migration was observed. Ten patients (11.9%) underwent revision surgery for conflict (1%), rotation (6%), or implant dislocation (5%). All complications and revisions occurred early with no new events after 1 year of follow-up. Discussion  Mid-term clinical and radiological outcomes were stable with improvement of functional scores. The survival rate was comparable to that reported for TWF with conserved mobility. We report fewer complications compared with those reported for TWA or TWF. Early instability of the implant was the main etiology of the revisions. Repositioning of the implant was successful. No conversion to TWA or TWF was necessary. Conclusions  Mid-term outcomes of the Amandys implants were encouraging. Patients conserved good wrist motion with improved strength and functional scores. The implant was well tolerated. Functional outcomes continue to improve with the follow-up. The survival rate remains stable after 2 years. The level of evidence of this study is IV (therapeutic case series).

Four-dimensional CT analysis of carpal kinematics: An explorative study on the effect of sex and hand-dominance

Wrist pathology is often diagnosed by using the contralateral wrist as a comparison of baseline motion and strength. However, recent range of motion studies suggest that females have different carpal motion patterns compared to males and that the dominant carpal bones have different motion patterns. The purpose of this study is to evaluate the effect of sex and hand dominance on in vivo kinematics of the scaphoid, lunate and capitate using four-dimensional computed tomography (4D-CT) analysis in healthy uninjured volunteers. In this prospective study, both wrist of 20 uninjured Caucasian volunteers (11 men and 9 women) were assessed using 4D-CT during active flexion-extension and radial-ulnar deviation. A linear mixed model was used to compare the carpal motion patterns. Sex had no influence on carpal kinematics. Hand-dominance in males did have a significant effect on carpal kinematics. During flexion-extension of the male wrist, more radial-ulnar deviation of the lunate, scaphoid and capitate of the non-dominant hand was seen. During radial-ulnar deviation of the male wrist, radial-ulnar deviation and pro-supination of the lunate was more in the dominant hand. This study provides a better understanding of carpal kinematics and the effect of sex and hand-dominance on the scaphoid, lunate and capitate in uninjured wrists.

Influence of carpal-ulnar translation on clinical outcome after scaphocapitate arthrodesis for the treatment of late-stage Kienböck disease

BACKGROUND

This study sought to compare postoperative outcomes after scaphocapitate arthrodesis (SCA) for the treatment of late-stage Kienböck disease according to the amount of ulnar translation of the carpus and to identify surgical factors associated with carpal-ulnar translation.

METHODS

Thirty-nine patients diagnosed with Kienböck disease (Lichtman stages III-IV) and treated with SCA were retrospectively reviewed. They were divided into the translated group (n=28) and untranslated group (n=11) according to the presence of carpal-ulnar translation. The following surgical factors in the patients were assessed: excision of the lunate, postoperative carpal height ratio, and radioscaphoid angle (RSA). Pain Visual Analog scale (VAS) score, wrist range of motion, grip strength, modified Mayo wrist score (MMWS), the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and progression of radioscaphoid osteoarthritis were also assessed.

RESULTS

All patients showed functional improvement after a mean postoperative follow-up period of 40 months (VAS: 4.1 vs. 1.1, p <0.001; grip strength, 42.3 vs. 51.2 lb., p = 0.002; MMWS, 52.6 vs. 69.5, p <0.001; QuickDASH, 33.7 vs. 21.5, p <0.001). No statistically significant differences were found between the two groups in terms of outcome measures. Among the assessed surgical factors, the mean postoperative RSA was significantly smaller in the translated group than in the untranslated group (34.8° vs. 46.8°, p = 0.008). The proportion of patients with postoperative RSA <30° was significantly higher in the translated group than in the untranslated group (54.5% vs. 0%, p<0.001).

CONCLUSION

These results suggest that sufficient pain relief and functional improvement can be achieved after SCA for the treatment of late-stage Kienböck disease disregarding the occurrence of carpal-ulnar translation. In this study, overcorrection to RSA <30° induced more frequent carpal-ulnar translation after SCA.

Clinical Outcomes of Patients with Stage II and IIIA Kienböck's Disease After Undergoing Conservative Management

PURPOSE

The current study aimed to demonstrate the outcomes of patients with Lichtman stage II and IIIA Kienböck's disease with mild pain and good range of motion (ROM) after conservative management. We hypothesized that we can conservatively manage patients with early-stage Kienböck's disease including those with stage IIIA.

PATIENTS AND METHODS

This study is a retrospective case series. Between January 2012 and December 2017, 38 patients were enrolled in this study. The mean follow-up period of conservatively managed group was 49.1 months. The flexion-extension (FE) arc, grip strength, Pain Visual Analog Scale (pVAS), Modified Mayo Wrist Score (MMWS), and disabilities of the arm, shoulder, and hand (DASH) score were determined for functional evaluation. The radiographic parameters were assessed using the Stahl's index and carpal height ratio. The morphological changes in the lunate were also evaluated with plain radiographs.

RESULTS

A total of 31 of 38 patients (81.6%) showed favorable outcomes after conservative treatment. The mean pVAS score, MMWS, and DASH score showed statistically significant improvement, as well as the morphology of lunates on the plain radiograph. The mean FE arc was slightly decreased without statistical significance. The grip strength showed improvement with statistical significance. One patient showed the same radiographic morphology, but did not manifest any pain. A total of five (13.2%) patients who experienced aggravated pain and decreased ROM underwent surgical treatment. The other patient required surgical intervention but was provided conservative treatment due to her circumstances.

CONCLUSION

Favorable outcomes can be expected in patients with Lichtman stages II and IIIA avascular necrosis of the lunate (Kienböck's disease) with mild pain and good ROM who undergo conservative management.

LEVEL OF EVIDENCE

IV.

Wrist-Spanning Fixation of Radiocarpal Dislocation: A Cadaveric Assessment of Ulnar Translation

Background: Radiocarpal dislocations represent a high-energy wrist injury that can occur with or without concomitant fractures about the wrist. Poor outcomes are often due to radiocarpal instability and secondary ulnar translation. The purpose of this cadaveric study is to determine if there is any difference in the radiographic parameters in a wrist dislocation model given the different location of distal fixation. Methods: Ten paired fresh cadaver upper extremities were fluoroscopically evaluated with posterior-anterior (PA) and lateral views. We created a radiocarpal dislocation model and applied a dorsal bridge plate to either the second or third metacarpal. Repeat PA and lateral fluoroscopic views were obtained for evaluation of radial inclination, radial height, volar tilt, ulnar variance, radiolunate angle, radioscaphoid angle, scapholunate angle, radial rotation index, and four indices for ulnar translation (Taleisnik, Gilula, McMurtry, and Chamay). Results: Bridge plate application to the second metacarpal resulted in a significantly greater incidence of ulnar translation compared to the third metacarpal. Application to either metacarpal resulted in extension of the carpus relative to the radius. Conclusions: A more anatomic radiocarpal relationship was restored more often when distal fixation of the dorsal wrist-spanning bridge plate was applied to the third metacarpal. Further investigation is warranted to determine clinical relevance of these findings in conjunction with clinical and radiographic outcomes.

Results of interposition arthroplasty with the Amandys® pyrocarbon implant in rheumatoid wrist at a mean 5 years' follow-up

Management of severe joint involvement in rheumatoid wrist is controversial. The gold-standard is total wrist fusion, but total wrist replacement offers a motion-conserving alternative. The purpose of this study was to present the results of interposition arthroplasty with the Amandys® pyrocarbon implant in rheumatoid wrist. We performed a retrospective review of 28 arthroplasties for rheumatoid wrist arthritis. Eighteen females and 5 males were included, with a mean age of 55.7 years. Mean follow-up was 64 months. We measured range of motion, grip strength, and pain (on VAS). Function was evaluated preoperatively and at last follow-up with the DASH and PRWE scores. Mean range of motion in flexion-extension was maintained while mean inclination and rotational range of motion showed significant improvement. Mean grip strength increased from 10 kg to 17 kg. Mean pain score decreased from 6/10 to 2/10. Mean PRWE and QuickDASH scores decreased from 62/100 to 25/100 and from 62/100 to 36/100, respectively. Three patients underwent early reoperation to reposition a dislocated implant. No implants had to be removed. Amandys® pyrocarbon arthroplasty is a reliable alternative to total fusion or total replacement in rheumatoid wrist. Indications must be limited to well-aligned wrists with competent capsule-ligament structures.

Clinical, functional, and radiological results of the Amandys® interposition arthroplasty in 13 cases of wrist osteoarthritis

Amandys® pyrocarbon interposition arthroplasty is intended for widespread arthritis of the wrist. The aim of this study was to assess the clinical, functional, and radiological results of this arthroplasty with a minimum follow-up of 12 months. This retrospective single-center study brought together all osteoarthritis indications that can benefit from an Amandys® arthroplasty. Twenty-one implants were used between January 2011 and October 2018. There were seven cases of distal radius malunion, eight SLAC wrists, two SNAC wrists, two cases of Kienböck's disease at Lichtman's stage 4, and two aftermaths of inflammatory arthritis. Twenty-four percent of patients had previously undergone another type of surgery for this wrist arthritis. Six implants were removed, five early for dislocation and one after 6 years for chronic pain. Thirteen patients were reviewed with an average follow-up of 40.7 months (21-90). The average pain level on a visual analog scale was 3.1/10 (0-7). The mean range motion was 36° flexion (10-60) and 33° extension (15-50). The mean grip strength at the last follow-up was 14.8 kg (2-30) (43% of contralateral). The average QuickDASH and PRWE functional scores were 37.9/100 (0-80) and 29.6/100 (0-83.5), respectively. Amandys® interposition arthroplasty is an interesting alternative to total wrist fusion or total wrist prosthesis for widespread arthritis of the wrist. For the implant to be stable, the capsulo-ligamentous systems must be intact.

Long-term radiological changes and functional outcomes after proximal row carpectomy: Retrospective study with 3 years' minimum follow-up

INTRODUCTION

The aim of this study was to analyze the radiological changes and determine the clinical and functional outcomes of proximal row carpectomy (PRC) over the long term.

HYPOTHESIS

Radiological changes after PRC occur in every patient while the clinical and functional outcomes remain stable over time.

METHODS

This was a retrospective single-center study of patients who underwent PRC between January 2004 and December 2014. A clinical assessment (range of motion, grip strength), functional assessment (Mayo Wrist score and QuickDASH) and radiographic assessment (radiocapitate osteoarthritis, radiocapitate congruency) was done in every patient at the longest follow-up.

RESULTS

Thirty-one patients were reviewed with a mean follow-up of 97.9 months. The indications for PRC were SLAC (n=10), SNAC (n=5), Kienböck disease (n=9) and other conditions (n=7). The radiocapitate index, which is the radius of curvature of the tip of the capitate divided by the mean radius of curvature of the lunate fossa, went from 0.68 immediately postoperative to 0.74 at the final assessment (p=0.035). The mean flexion/extension arc was 93°. The mean grip strength was 25 kg. The mean QuickDASH was 29 and the mean Mayo Wrist score was 69. Fifteen patients had radiocapitate osteoarthritis. Seven patients (22%) required revision surgery for wrist fusion after a mean of 18.6 months.

CONCLUSION

Radiological adaptation in the radiocapitate joint after PRC was found in this study. PRC is a reliable solution and yields stable outcomes over time for treating radiocarpal osteoarthritis, except in young adults and manual laborers who had a notable early revision rate.

LEVEL OF EVIDENCE

IV - retrospective study.

Dynamic Wrist Radiographs in Patients with and without a Ganglion Cyst

Objectives  The purpose of this study was to find out if carpal instability played a role in the etiology of ganglion cysts. Materials and Methods  Dynamic wrist radiographs of 33 patients with and without a ganglion cyst of the wrist were compared. The control group consisted of patients who had dynamic radiographs of both wrists after a traumatic event in one wrist. Measurements were performed on the contralateral uninjured side. Radiological parameters that may indicate carpal instability included: width of the scapholunate gap, scapholunate, radiolunate, and lunocapitate angles, and ulnar translocation. Results  No statistically significant difference was found between the two groups except for lunocapitate angle which was higher in wrists with ganglion cysts. However, mean lunocapitate angle was still within the normal range. Conclusions  It could be concluded that in this study we did not see a difference between scapholunate gap and radiocarpal angles with the presence or absence of a ganglion cyst.

Treatment of purely ligamentous dorsoulnar radiocarpal dislocation with ulnar translation of the carpus: A case report

RATIONALE

Radiocarpal fracture-dislocations are extremely infrequent injuries caused by high-energy trauma and involve significant osseous and ligamentous injuries. If not treated properly, it can lead to serious complications such as ulnar translation of the carpus, multidirectional instability, loss of motion, and post-traumatic arthritis. Purely ligamentous injuries are rarer than fracture-dislocation injuries. Because previous studies have reported small patient cohorts, there has been no standardized treatment strategy for purely ligamentous radiocarpal dislocation.

PATIENT CONCERNS

A 24-year-old man suffered a left wrist injury in a motorcycle accident. Plain radiographs revealed dorso-ulnar radiocarpal dislocation without radial fracture and Carpal-ulnar distance ratio (CUDR) was 0.16. MRI scans showed the disruption of the dorsal ligaments and capsules and avulsed from the proximal insertion of the volar radiocarpal ligaments.

DIAGNOSIS

Dorsoulnar radiocarpal dislocation with purely ligamentous injury.

INTERVENTION

We removed the interposing chondral fragment from the radiocarpal joint and repaired the radioscaphocapitate (RSC) and radiolunate (RL) ligaments with the Jugger Knot Soft Anchor Suture (Biomet, Inc, Warsaw, IN) and applied additional radiocarpal K-wires and an external fixator to maintain reduction and optimal ligament tension.

OUTCOMES

The patient showed good clinical results although ulnar translation of the carpus recurred in radiological follow-up.

LESSONS

Aggressive surgical management is needed earlier in the treatment of purely ligamentous radiocarpal dislocation, especially if the ulnar translation of the carpus was observed in the initial radiographs.

Normal Wrist Development in Children and Adolescents: A Geometrical Observational Analysis Based on Plain Radiographs

BACKGROUND

To investigate the geometric development of the wrist in relation to the changes in its ossification pattern. This study will help the treating surgeon to identify early deviations from normal in children with musculoskeletal disorders and provide a template for anatomic reduction after trauma scenarios.

METHODS

A retrospective multicenter analysis was carried out of radiographs of 896 children (896 posteroanterior and 896 lateral views) with normal wrists from January 1996 till April 2016. We stratified patients into different yearly age groups; these included 16 age groups from 1 to 16 years, and 2 sex groups: males and females. We evaluated, depending on the wrist ossification pattern, the ulnar variance, radial and carpal heights, carpal height ratio, radial inclination, volar tilt, together with radiocarpal, scapholunate, and capitate-lunate angles and scapholunate distance.

RESULTS

Our analysis showed that the ulna minus variance predominates in children. Radial height, radial inclination, and radiocarpal angle increase steadily during growth and reach their respective expected values at the beginning of the pubertal growth spurt. The scapholunate and capitolunate angles showed a downward trend with growth till reaching the adult values at puberty. Carpal height increased constantly, whereas the carpal height ratio was similar to that in adults. Volar tilt was not developed until the age of 12 years, when it started to increase gradually to reach the adult values by puberty. Both sexes have similar measurements.

CONCLUSIONS

Most radiologic parameters showed reproducible anatomic changes till the 12-year-old time-point. After that, there are minimal changes till adulthood.

CLINICAL RELEVANCE

The study findings offer a template of pediatric normal values guiding hand and pediatric surgeons in treatment of children with wrist pathology.

Are Vascularized Periosteal Flaps Useful for the Treatment of Difficult Scaphoid Nonunion in Adults? A Prospective Cohort Study of 32 Patients

PURPOSE

To evaluate clinical and radiological outcomes after surgical treatment of difficult scaphoid nonunion in adults with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF).

MATERIALS AND METHODS

Thirty-two patients at least 18 years old, with scaphoid nonunion and characteristics associated with a poor prognosis, who underwent a VTMPF procedure, were included in this retrospective cohort study with a mean follow-up of 17 months. Factors associated with a poor prognosis were a delay in presentation of over 5 years, the presence of avascular necrosis, and previous nonunion surgery. All patients had at least 1 poor prognostic factor and 25% had 2 or more.

RESULTS

In 30 men and 2 women, the mean age was 36 years (range, 19-56 years). There were 11 type D3 nonunions (Herbert classification) and 15 type D4. Five patients had delayed presentation of over 5 years. Fourteen patients had previously undergone an unsuccessful surgical attempt to treat their nonunion. The patients experienced no postoperative complications. Overall union rate was 97% (31 of 32 patients), with 72% cross-sectional trabecular percentage bridging at 12 weeks. Pain subsided after surgery and patients experienced improvements in both their Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Modified Mayo Wrist Score (MMWS). Overall 41% and 42% gains in strength and wrist motion, relative to the contralateral normal side, were observed. At final follow-up, there were no differences between the treated and the untreated (healthy) hands, in terms of wrist range of motion, grip, or pinch strength.

CONCLUSIONS

In this study, the use of VTMPF for difficult scaphoid nonunion in adults was associated with good general outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Functional and radiological results of partial capitate shortening osteotomy in the treatment of Kienböck's disease

This study assessed the functional and radiological results of partial capitate shortening osteotomy in the treatment of Lichtman stage 2 and 3A Kienböck's disease. Nineteen patients who underwent partial capitate shortening osteotomy between 2014 and 2017 were included. Functional and radiological parameters were assessed both pre- and postoperatively. The mean age was 35 years and the mean follow-up was 16 months. Pain scores, wrist range of motion, hand and finger strength, carpal height ratio and lunate height were significantly improved compared with their preoperative values. Sixteen patients were able to return to work. Ten of them had complete and six had partial revascularization. The mean time taken to return to work was 62 days. No vascularity was achieved in three patients who were unable to return to work. Partial capitate shortening osteotomy is effective in the treatment of stage 2 and 3A Kienböck's disease with successful results both functionally and radiologically. Level of evidence: IV.

Functional Outcomes After Sauve-Kapandji Arthrodesis

PURPOSE

The Sauve-Kapandji procedure (SK) combines a distal radioulnar joint (DRUJ) arthrodesis with the creation of an ulnar pseudarthrosis for the salvage of DRUJ instability or arthritis. Despite several published case series, there are limited data on postoperative functional outcomes. This study evaluates patient-reported outcomes of SK using a validated functional outcomes scale.

METHODS

We performed a retrospective review of patients who underwent SK in 2 health care systems over 10 years (2008-2018). Preoperative and postoperative range of motion, Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, and wrist plain film radiographic measurements were recorded. Preoperative and postoperative outcomes analyses and subgroup comparisons were performed.

RESULTS

We included 57 patients in the study. Surgical indications included posttraumatic DRUJ arthritis (n = 35), rheumatoid arthritis (n = 10), degenerative DRUJ arthritis (n = 7), Madelung deformity (n = 3), psoriatic arthritis (n = 1), and giant cell tumor of bone (n = 1). During the first postoperative year, QuickDASH scores decreased from a mean of 52 before surgery to 28 at 12 months. The QuickDASH scores at final follow-up demonstrated significant improvement in patients with osteoarthritis and inflammatory arthritis. Supination significantly improved after surgery, from 48° to 74°, whereas wrist flexion, wrist extension, and pronation remained unchanged. Radiographically, significant postoperative decreases were seen in ulnar variance and McMurtry's translation index. The postoperative complication rate was 21%, including revision osteotomy in 4 patients (7.0%) and hardware removal in 4 patients (7.0%). No DRUJ nonunions were seen.

CONCLUSIONS

The Sauve-Kapandji procedure for DRUJ salvage significantly improved patient-reported outcomes after 1 year and significantly improved supination. Similar functional improvements after SK were seen in both osteoarthritis and inflammatory arthritis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Overstuffing of Unstable Scaphoid Nonunions: A Radiographic Analysis of Carpal Parameters

PURPOSE

The purpose of this study was to radiographically evaluate scaphoid length and carpal parameters before and after reconstruction of nonunions with interposition vascularized medial femoral condyle (MFC) bone graft to determine if the scaphoid was overstuffed or if normal anatomy was restored and to determine the effect on ulnar carpal translocation when the volar radiocarpal ligaments were left unrepaired.

METHODS

Thirty-nine patients with established scaphoid nonunions with carpal collapse were reconstructed by interposition vascularized MFC bone grafts without repair of the volar radiocarpal ligaments. Pre- and postoperative radiographs and computed tomography scans of the 39 patients were reviewed. The scaphoid length, capitate-ulnar distance ratio (CUDR), modified carpal height ratio (MCHR), radiolunate (RL) and scapholunate (SL) angles were measured before and 3 months after surgery. Thirteen of these patients had contralateral wrist radiographs that were used for analysis of scaphoid length restoration.

RESULTS

No significant changes were observed for CUDR and MCHR before and after surgery. The length of the scaphoid significantly improved after reconstruction from 21.9 ± 3.3 to 23.7 ± 3.4 mm on posteroanterior x-ray views and from 24.0 ± 2.2 to 27.7 ± 2.8 mm on lateral views. The RL and SL angles also changed significantly after surgery from 19.5° ± 13.5° to 4.1° ± 16.9° and from 67.5° ± 12.5° to 56.0° ± 12.5°, respectively. Regarding the 13 patients with contralateral x-rays, no differences were seen on CUDR, MCHR, or scaphoid length on posteroanterior x-ray views. However, the scaphoid length on lateral x-ray views increased from 23.1 ± 2.40 to 27.6 ± 2.78 mm and was significantly longer than the contralateral side by 9.6%. The RL and SL angles were restored and comparable with the contralateral side.

CONCLUSIONS

The use of vascularized MFC bone graft increased scaphoid length by 9.6% and restored normal carpal alignment. Despite the increased scaphoid length compared with the contralateral side, the lack of repair of the volar radiocarpal ligaments did not cause ulnar carpal translocation in short-term follow-up.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Combined synovectomy and extensor carpi radialis longus transfer to realign and stabilise the rheumatoid wrist

BACKGROUND

In patients with rheumatoid arthritis, the surgical treatment of wrist lesions relies on synovectomy combined with stabilisation and realignment of the carpal bones. The objective of this study was to evaluate the outcomes and define the indications of extensor carpi radialis longus (ECRL) transfer to the extensor carpi ulnaris (ECU) as described by Clayton and Ferlic.

HYPOTHESIS

ECRL-to-ECU transfer combined with synovectomy can prevent the development and/or progression of rheumatoid deformities at the wrist.

MATERIAL AND METHODS

A retrospective observational study was performed in 16 wrists. The following data were collected before and after surgery: pain, synovitis, range of motion, carpal height, ulnar translocation and radial deviation of the carpal bones, and Larsen's grade of the radio-carpal and mid-carpal joints.

RESULTS

After a mean follow-up of 42.5 months after surgery, pain relief was noted in 14 cases and synovitis resolution in 10 cases. Mean mobility gains were 19.7° in extension and 5.7° in flexion. The radiographs showed a decrease in carpal height, whereas radial deviation and ulnar translocation were unchanged. No change was seen in the radio-carpal and mid-carpal joint lines. In the 3 wrists that required mid-carpal arthrodesis due to advanced disease before surgery, the radio-carpal joint line was unchanged and outcomes were the same as in the overall population.

DISCUSSION

ECRL-to-ECU transfer combined with synovectomy provides pain relief and prevents radio-carpal destabilisation. The main indication of ECRL transfer is reducible radial deviation and ulnar translocation. ECRL is also indicated in combination with mid-carpal arthrodesis in the small minority of patients who have predominant mid-carpal involvement with a Larsen grade greater than 2.

LEVEL OF EVIDENCE

IV, retrospective observational study.

Unipolar ulnar head replacement for treatment of post-Darrach procedure instability

The aim of this study was to assess distal radioulnar joint stability after unipolar ulnar head replacement for post-Darrach instability. All the patients who underwent ulnar head replacement between1999 and 2015 for post-Darrach procedure instability at our clinic were reviewed. Seven Hebert-type and two uHead (SBI/Stryker) prostheses were implanted. None of the implants were cemented. We assessed stability, pain, range of motion and strength pre- and postoperatively. The changes in the radiographic appearance between immediate postoperative and the last follow-up were determined. All patients (8 patients and 9 joint replacements) had a stable distal ulnar stump at the mean follow-up of 69 months. No complications occurred and no revisions were needed. Pain on a visual analog scale (VAS) was 0 at rest and 6 during maximum effort at the last follow-up; it was 1.5 at rest and 8.5 during effort preoperatively. Wrist flexion and extension, supination and grip strength were unchanged. Pronation increased from 45° to 70°. An area of bone resorption proximal to the ulnar head implant was found in 5 cases but no secondary displacement of the implant or increased pain was reported. Ulnar head replacement stabilizes the ulnar stump. The implant acts as a spacer to place the soft tissues under tension. Distal ulnar stump instability after the Darrach procedure can be solved by a unipolar ulnar head replacement procedure.

Combined Perihamate Peripisiform and Peritrapezium Open Axial Carpal Dislocation: Description of a New Pattern of Crush Injury

BACKGROUND

Axial carpal dislocations and fracture-dislocations remain difficult to understand and to treat. The outcome is directly related to the injury pattern and long-term results are not good in most cases.

METHODS

39-year-old male admitted to our emergency department after his left hand was caught between 2 rollers for 10 minutes. He was diagnosed of an open axial carpal dislocation type B (perihamate peripisiform) and type E (peritrapezium) of Garcia-Elias. An extensive debridement, reduction of the carpometacarpal dislocations and stabilization with Kirschner wires was performed requiring a full thickness skin graft 14 days after the trauma.

RESULTS

At 4-year follow-up, he had 70° of wrist extension, and 78° of wrist flexion, grip strength of 65% compared to the healthy side and x-ray showed mild signs of osteoarthritis. He was satisfied and returned to the same job.

CONCLUSIONS

Axial carpal dislocations continue to be difficult injuries to address but also to classify. Since the prognosis depends on the injury pattern and other associated lesions, we believe that adding a type G which include the association of different patterns to the classification of Garcia-Elias could be useful not in changing the treatment but probably indicating a worse prognosis.

Radial shortening osteotomy for treatment of Lichtman Stage IIIA Kienböck disease

We carried out a retrospective study to analyse the long-term outcome of 36 patients after radial shortening osteotomy for treatment of Lichtman Stage IIIA Kienböck disease at a mean follow-up of 12.1 years (range 5.4-17.5). At review, seven wrists had progressed to Stage IIIB, eight wrists to Stage IV and 21 remained in Stage IIIA. Motion and grip strength were significantly improved. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score at review was 12 points (range 0-52), and patient satisfaction was high. Apart from plate removals in 14 patients and one wrist denervation, no subsequent surgical procedures were done. Radial shortening yields good long-term clinical results, but does not prevent radiographic progression of disease in some patients.

LEVEL OF EVIDENCE

Therapeutic IV.

Proximal row carpectomy on manual workers: 17 patients followed for an average of 6 years

Proximal row carpectomy (PRC) is indicated for the treatment of SNAC or SLAC wrist with preservation of the midcarpal joint. Our hypothesis was that PRC is not appropriate for treating advanced wrist osteoarthritis in patients who carry out heavy manual work. Twenty-three PRCs were performed on 21 patients, 5 women and 16 men with an average age of 54 years (33-77). All patients performed manual work; 11 of them performed heavy manual work. Etiologies were: SLAC wrist in 14 cases (2 stage III, 11 stage II, and 1 stage I) and SNAC wrist in 9 cases (6 stage IIIB and 3 stage IIB). At an average 75 months' follow-up (24-153), five patients were lost to follow-up. Radiocarpal arthrodesis was performed in one patient 10 years after the PRC. In the 17 remaining patients (18 wrists), pain (VAS) averaged 2.2, with residual pain of 5. Flexion-extension range was similar to preoperative levels (67% of contralateral wrist). Wrist strength was decreased by 34% compared to preoperative. The QuickDASH score averaged 26 points and the PRWE 20 points. Radiocapitate distance decreased by 0.3mm on average with joint line narrowing in 6 patients. The carpal translation index was 0.33mm, which was unchanged relative to preoperative values. Three patients had work-related limitations that required retraining and one patient had to be reassigned. PRC preserved the preoperative range of motion and reduced pain levels. However, significant loss of strength was observed, resulting in 23% of manual workers needing retraining or reassignment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Carpal Kinematics and Kinetics

The complex interaction of the carpal bones, their intrinsic and extrinsic ligaments, and the forces in the normal wrist continue to be studied. Factors that influence kinematics, such as carpal bone morphology and clinical laxity, continue to be identified. As imaging technology improves, so does our ability to better understand and identify these factors. In this review, we describe advances in our understanding of carpal kinematics and kinetics. We use scapholunate ligament tears as an example of the disconnect that exists between our knowledge of carpal instability and limitations in current reconstruction techniques.

Radiographic Progression of Kienböck Disease: Radial Shortening Versus No Surgery

PURPOSE

The natural course of the pathophysiology of Kienböck disease is uncertain. Shortening of the radius is believed to modify the pathophysiology by addressing mechanical influences on the lunate. The aim of this study was to compare the radiographic progression of Kienböck disease among patients who had radial shortening osteotomy and patients who had no surgical treatment, with a minimum 1-year interval between radiographs.

METHODS

Among 207 patients with Kienböck disease, we included all 48 eligible patients who had either radial shortening osteotomy or nonsurgical treatment and 2 sets of wrist radiographs available a minimum of 1 year apart. We compared changes in carpal height ratio, Stahl index, and carpal angles between the 2 sets of radiographs and between radial shortening osteotomy and nonsurgical treatment.

RESULTS

We found, on average, a small decrease in the carpal height ratio and the Stahl index in patients who did and did not have surgery, with no differences between the 2 groups. Nearly half of the patients had no decrease in the carpal height ratio and/or the Stahl index.

CONCLUSIONS

Radiographic progression of Kienböck over 1 year or more seems slight on average regardless of treatment. Future research might address the probability of and factors associated with radiographic progression of Kienböck disease.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Patient-Reported Outcomes Following Surgically Managed Perilunate Dislocation: Outcomes After Perilunate Dislocation

BACKGROUND

Perilunate dislocations (PLDs) are uncommon high-energy injuries that may result in significant morbidity if inadequately treated. We report the midterm outcomes following surgical intervention and the validity of the Patient-Rated Wrist Evaluation (PRWE) score as an assessment tool post injury.

METHODS

We prospectively present outcomes in 16 patients with perilunate injuries. Definitive surgical management comprised fixation of all fractures and anatomical reconstruction of ruptured ligaments where possible. All patients completed the Disabilities of the Arm, Shoulder and Hand (DASH), 12-Item Short-Form Health Survey, and PRWE, for which internal consistency and construct validity were assessed.

RESULTS

At 24 months, the mean grip strength was 59% of the uninjured side (range 33%-85%) and the mean range of flexion was 71% and extension was 58%. Eighty-eight percent of patients returned to work within 6 months and 63% to sport within 1 year. The PRWE score was 36.2 (range 14.5-77.3) and DASH 25.2 (range 7.5-91.7). The mean visual analog scale (VAS) satisfaction score was 7.9 (range 0-10), VAS pain at rest 1.9 (range 0-6) and on activity 3.3 (range 1-6). DASH and PRWE demonstrated similar internal consistencies with Cronbach alphas of .98 and .91, respectively, and a strongly positive correlation coefficient of r = +.7 (P < .05).

CONCLUSIONS

Surgical treatment of PLDs can provide good clinical outcomes allowing patients to return to normal activities in a reasonable timescale when delays to surgery are kept to a minimum. The PRWE demonstrated high internal consistency and was found to be a valid questionnaire with advantages over the DASH for use following severe carpal injures.

Functional kinematics of the wrist

The purpose of this article is to review past and present concepts concerning functional kinematics of the healthy and injured wrist. To provide a context for students of the wrist, we describe the progression of techniques for measuring carpal kinematics over the past century and discuss how this has influenced today's understanding of functional kinematics. Next, we provide an overview of recent developments and highlight the clinical relevance of these findings. We use these findings and recent evidence that supports the importance of coupled motion in early rehabilitation of radiocarpal injuries to develop the argument that coupled motion during functional activities is a clinically relevant outcome; therefore, clinicians should develop a framework for its dynamic assessment. This should enable a tailored and individualized approach to the treatment of carpal injuries.

Radiocarpal and Midcarpal Instability in Rheumatoid Patients: A Systematic Review

Background:

This study was aimed at identifying the criteria for the diagnosis of Radiocarpal instability in rheumatoid arthritis RA).

Methods:

The main databases were searched to identify studies describing the pathophysiology of Radiocarpal instability in patients with RA. We focussed on the epidemiology, radiographic parameters, criteria for instability and on treatment options. Results. In the search 108 articles were found, of these 12 studies were included for this review. Instability occurs in at an average of 35.2% of the rheumatoid wrists. The instability was found between 8 and 13 years after onset of rheumatoid arthritis. A strong correlation was found between instability, duration of RA and Larsen score. Several radiographic methods were described to evaluate Radiocarpal instability in RA. Several treatment options for instability in patients with RA are described. All with their own indications and limitations.

Conclusion:

On a standard AP radiograph deformity can be measured using the carpal height and the ulnar translation index of Chamay. This gives an indication for instability. For describing the deterioration of the joints the Larsen score is most used. If there are more radiographs in time the Simmen classification can be used. For real assessment of instability dynamic radiographs are needed.

Level of Evidence:

Level IV.

Long-Term Natural Outcome (7–26 Years) of Lichtman Stage III Kienböck’s Lunatomalacia

Background and Aims:

The natural history of Kienböck’s disease is controversial. Only three papers report a pure natural history without treatment. We hypothesized that the natural course of Kienböck’s disease may be better than reported.

Material and Methods:

We examined eight patients with Lichtman stage III Kienböck’s disease without any treatment, evaluating clinical and radiological results (9 wrists; 7 men, mean age at onset of symptoms 34 years) over a period of 10–38 years (mean, 27.3 years) after symptom onset.

Results:

Lichtman stage remained the same in five of nine wrists. The inner structure of the lunate improved in three, remained the same in three, and deteriorated in three wrists, and its shape improved in two, remained the same in four, and deteriorated in three wrists. Pain averaged visual analog scale 3.1 at rest, 3.4 during motion, 3.6 with slight, and 5.2 with heavy exertion. The range of motion improved at extension 19% and at flexion 14%, reaching 81% and 72% of that of the contralateral wrist, and grip strength reaching 93%. The Disabilities of the Arm, Shoulder, and Hand averaged 11.3, Optional Disabilities of the Arm, Shoulder, and Hand 18.0, and Mayo Clinic score 70.0. The radiographic course did not correlate with clinical course.

Conclusions:

The long-term natural history of Lichtman stage III Kienböck’s disease is insufficiently good to suggest thoughtful observation alone as an option to treat it.

Clinical radiographic features of the wrist without osteoarthritis and its relations to age and sex in Japanese

The purpose of this study was to identify a clinical radiographic features containing the measurements of carpal alignment, configuration, and joint space width of the wrist without osteoarthritis (OA) in Japanese. We also aimed to analyse age-related correlations in these parameters with reference to the difference between men and women. A total of 184 cases were analysed to establish the following relations: (1) Sex-related differences in the morphology and joint space width of the wrist without OA; (2) correlation coefficient between these parameters and age according to sex. This study suggests that carpal height ratio (CHR) was higher in men than in women. Also the ulnar variance (UV) increased and the radial inclination (RI) decreased with age in both men and women, and the volar tilt (VT) decreased with age in women.

Scaphocapitate arthrodesis for treatment of late stage Kienbock disease

Symptomatic lunate collapse owing to Kienböck disease is difficult to treat. To define the potential role of scaphocapitate arthrodesis, we reviewed ten patients who underwent scaphocapitate arthrodesis for stage IIIB-IV Kienböck disease at a mean follow-up of 8.75 years (range 1.3-18.6). Clinical variables included ranges of motion, grip strength, pain, return to work, and QuickDASH (disabilities of the arm, shoulder and hand) scores. Radiographs were evaluated for union, carpal height, alignment, ulnar translation, and radiocarpal arthritis. The procedure resulted in functional ranges of motion and good grip strengths. Pain was substantially reduced. The mean QuickDASH score was 27 (range 9.1-56.3). Radiographic analysis showed union in nine patients, maintenance of carpal height with a corrected radioscaphoid angle, and no evidence of ulnar translation. The long-term clinical benefits of scaphocapitate arthrodesis for treatment of collapsed Kienböck disease are demonstrated. However, radiographic signs of radioscaphoid arthritis were often observed in patients with follow-up greater than 10 years.

Vascularized bone grafting and distal radius osteotomy for scaphoid nonunion advanced collapse

PURPOSE

To determine the outcome of an alternative treatment for wrists with stages I to III scaphoid nonunion advanced collapse using a closing-wedge osteotomy of the distal radius and a vascularized bone graft for scaphoid reconstruction.

METHODS

Twelve patients with scaphoid nonunion advanced collapse (stage I, 3; stage II, 7; stage III, 2) treated with a vascularized bone graft interposition for the scaphoid and a closing-wedge osteotomy for the distal radius were retrospectively reviewed. Data were obtained and analyzed from the radiographs, and we assessed the pre- and postoperative range of motion, grip strength, visual analog scale pain score, as well as the Mayo and Disabilities of the Arm, Shoulder, and Hand (DASH) functional scores.

RESULTS

Follow-up ranged from 2 to 11 years. All scaphoid nonunions united after an average of 9 weeks, and all osteotomies united after an average of 8 weeks. Although there was radiographic progression of the scaphoid nonunion advanced collapse stage in 5 of 12 cases, there was major improvement in visual analog scale pain score (from 6.1 to 0.8) and in both Mayo (from 64 to 85) and DASH (from 40 to 9) functional scores. The range of motion remained unchanged, and grip strength trended toward minor improvement. The carpal height was preserved, and the dorsal intercalated segmental instability was corrected.

CONCLUSIONS

Scaphoid reconstruction with vascularized bone graft combined with closing-wedge distal radius osteotomy preserved wrist function for scaphoid nonunion advanced collapse. The method offers pain relief and does not compromise wrist motion or grip strength.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

[Capitolunate arthrodesis: 12 patients followed-up an average of 10 years]

The aim of the study was to evaluate long-term results of capitolunate arthrodesis for the treatment of posttraumatic degenerative wrist disorders. A capitolunate arthrodesis was performed on 12 patients, three women and nine men, of 45 years on average (28-66). Ten patients were manual workers. Dominant side was involved in seven cases. Indications were nine scapholunate dissociations (SLAC) and three scaphoid non-unions (SNAC) with degenerative lesions. Fixation of the arthrodesis was performed with K-wires in seven, K-wires and staples in two, and only staples in three. Patients were reviewed at 118 months of average follow-up (72-168). One complete wrist arthrodesis was necessary one year after the capitolunate arthrodesis for an evolutive painful osteoarthritis. For the 11 remaining patients, pain on visual analogic scale (VAS) was 0.5. The flexion/extension arc was decreased of 25° and strength of 6kg compared to preoperative values. DASH score was equal to 33.7 points, Cooney score to 77.2 points and Mayo score to 82.8 points. Radiolunate and capitolunate angles were decreased of 4.9° and 6.2° respectively compared to preoperative values. Some complications occurred: evolutive osteoarthritis between triquetrum and lunate in two, non-union of the arthrodesis in one, and reflex sympathetic dystrophy in two. Nine patients were able to return to their previous professional activities. Capitolunate arthrodesis allowed restoring a pain free and functional wrist in eight out of the 11 patients reviewed. Results were maintained with follow-up. It is a satisfactory therapeutic alternative to four corners fusion for chronic instability of the wrist with osteoarthritis.

LEVEL OF EVIDENCE

IV.

Long-term clinical results and MRI changes after tendon ball arthroplasty for advanced Kienbock's disease

The purpose of this study was to assess the long-term clinical results and morphological changes after tendon ball arthroplasty for advanced Kienböck's disease. Twenty-six patients were reviewed, with a mean follow-up interval of 125 months (range 50-226). At follow-up, mean score on the Disabilities of the Arm, Shoulder, and Hand questionnaire was 7.7 and mean visual analogue scale score for pain was 1. Mean carpal height ratio was significantly reduced with respect to the pre-operative value. On magnetic resonance imaging scans, cartilage damage, synovitis, and erosive or oedematous changes in the bones were detected in most patients. Calcification in the defect filled by the tendon ball was seen in all patients. Narrowing of the radioscaphoid joint and the presence of intercarpal synovitis were negatively associated with clinical outcome. Tendon ball arthroplasty in advanced Kienböck's disease results in long-term satisfactory clinical outcomes, despite widespread changes in the bones and joints within the wrist.

Scaphocapitate arthrodesis for treatment of scapholunate instability in manual workers

PURPOSE

To assess the long-term efficacy of scaphocapitate arthrodesis for treatment of chronic scapholunate instability in high-demand patients.

METHODS

We retrospectively analyzed the clinical and radiographic results of 20 manual workers who underwent scaphocapitate arthrodesis for chronic scapholunate instability at a mean follow-up of 10 years (range, 1-23 y). We measured range of motion and grip strength; pain on a scale of 0 to 5; Quick Disabilities of the Arm, Shoulder, and Hand score; and ability to return to work. We assessed radiographs for union, carpal height and alignment, signs of ulnar translation or radiocarpal arthritis, and hardware problems.

RESULTS

At most recent follow-up, the arc of motion averaged 87° for flexion-extension and 41° for the radioulnar deviation. The postoperative average maximum grip strength was 21 kg, which was 60% of the opposite, normal wrist. Pain was significantly reduced. The average postoperative Quick Disabilities of the Arm, Shoulder, and Hand score was 19, and the return-to-work rate was 90%. Radiographic analysis showed union in all patients, improvement of carpal height and scaphoid angle, no evidence of ulnar translation, and a 30% rate of radiocarpal osteoarthritis.

CONCLUSIONS

This report of long-term results demonstrates the efficacy of scaphocapitate limited carpal arthrodesis for the treatment of chronic rotatory subluxation of the scaphoid. We conclude that continued use of this procedure is warranted.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Accurate quantitative measurement of lunate uncovering ratio--is Gilula's semiquantitative test reliable?

The Gilula's test suggests the presence of ulnocarpal translation when 50% or more of the lunate lies medial to the ulnar edge of radius. The purpose of this study was to examine the reliability of this semiquantitative test as there was inconsistency between the previous publications in regarding 50% as the cutoff value for the normal lunate uncovering ratio (LUR). We utilized the Picture Archiving and Communication System to investigate radiographs of 299 normal adult wrists and emphasized defined radiographic landmarks for accurate quantitative measurement. Our mean LUR was 35%(SD8) with a range of 8 to 49%. Therefore we re-affirmed the reliability of the Gilula's test since none of our normal wrists had a LUR of 50% or greater.

Traumatic ulnar translocation of the carpus: early recognition and treatment

This study evaluated the clinical outcomes and radiographic features of surgically treated traumatic ulnocarpal translocation in nine patients (ten cases). All ligament and fracture repairs were completed within 2 months of injury. Seven cases were examined at a mean of 6.5 years, and information in three cases was obtained from medical records at a mean of 13 months after injury. At final evaluation, the mean disabilities of the arm, shoulder, and hand score was 6 (range, 0-16), and the mean Mayo modified wrist score was 76 (range, 40-100). Ulnocarpal translocation was evident in nine of the injured wrists, six of which showed arthritis, and in four of the uninjured wrists. Ulnar variance measured negative in nine cases and neutral in one case. Pre-existing medial alignment of the carpus and ulnar minus variance may predispose to traumatic ulnocarpal translocation. Early injury repair does not assure restoration of radiocarpal alignment or prevent joint deterioration; however, these changes do not always portend a suboptimal result.

Amandys(®) implant: novel pyrocarbon arthroplasty for the wrist

OBJECTIVES

Post-traumatic, arthritic or degenerative destruction of the midcarpal and radiocarpal joints are difficult to treat. A new arthroplasty with a free interposition pyrocarbon implant, Amandys(®), is proposed for the treatment of extensive destruction of midcarpal and radiocarpal joints. Preliminary results are reported.

METHODS

The prospective series included 25 patients, 15 males and 10 females with a mean age of 60. The indications were degenerative, post-traumatic or rheumatoid destruction of the wrist. Sixty percent of the patients had already had surgery on their wrist before the operation. The mean follow-up was 24months.

RESULTS

Three patients had a reoperation: two for a repositioning of the implant and one for a styloidectomy. At the last follow-up, the mean grip strength was 16kg (51% of the contralateral side), the mean range of motion in flexion-extension was 68°. Mean strength and range of motion did not change significantly with the operation. Pain and function showed significant improvement. The mean pain score decreased from 6.7/10 to 3.7/10 postoperatively. The mean PRWE score decreased from 61/100 to 32/100.The mean QuickDash score decreased from 63/100 to 36/100. Ninety-six percent of the patients were satisfied or very satisfied. No dislocation or subsidence of the implant was noticed.

CONCLUSIONS

This minimally invasive pyrocarbon interposition increases the possibilities for the treatment of extensive articular destructions of the wrist. Indications must be limited to a well-aligned wrist with competent capsuloligamentous structure. This new arthroplasty is a reliable alternative to other surgical options, which are more radical or invasive such as total arthrodesis or total wrist prosthesis.