Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries

OBJECTIVES

The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique.

METHODS

Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of "0," "5," and "10" reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of "8" or higher for 80% or more of the panelists.

RESULTS

Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds.

CONCLUSIONS

Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC.

CLINICAL RELEVANCE STATEMENT

MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries.

KEY POINTS

• Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.

Interdisciplinary consensus statements on imaging of scapholunate joint instability

Objectives

The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique.

Methods

Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors’ clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of ‘0’, ‘5’ and ‘10’ reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of ‘8’ or higher for 80% or more of the panellists.

Results

Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available.

Conclusions

Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability.

Key Points

• Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability.

• Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability.

• Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

Ulna shortening osteotomy versus arthroscopic wafer procedure in the treatment of ulnocarpal impingement syndrome

Post-traumatic or constitutional ulnar impaction syndrome can be treated by shortening the ulna. This can be achieved by diaphyseal or metaphyseal osteotomy, or by arthroscopic epiphyseal resection. The objective of this study was to compare the results of the diaphyseal shortening osteotomy (USO) and arthroscopic wafer procedure (AWP) of the ulna in this indication. This was a retrospective case series of 33 patients operated for ulnar impaction syndrome by the same surgeon between 1997 and 2017. The diagnosis was made based on pain on the ulnar edge of the wrist with positive provocative tests. Radiographs were made and CT arthrography or MRI were used to confirm the diagnosis. Per-and post-operative assessments were functional (DASH and PRWE scores), clinical (pain, range of motion and grip strength) and radiographic. Diaphyseal ulnar shortening osteotomy (USO) was performed in 9 patients using a volar plate and a cutting guide. Twenty-four patients underwent an arthroscopic wafer procedure. Mean follow-up was 103 ± 8 months in the USO group versus 55 ± 4 months in the AWP group. There was no significant difference between groups in pain levels (1.2/10 in the USO group versus 0.9/10 in the AWP group, p = 0.88), grip strength (39 Kg in the USO group versus 34 Kg in the AWP group, p = 0.27) and PRWE score (5,8/100 in the USO group versus 11,2 in the AWP group, p = 0.34), and DASH score (25/100 in the USO group versus 28 in the AWP group, p = 0.63). The time away from work was long in the USO group than in the AWP group (7.86 months versus 3.75 months) (p = 0.002). Seven patients were reoperated in the USO group (5 plate removal, 1 nonunion and 1 delayed union) versus 3 in the AWP group (1 ECU stabilization, 1 ablation for painful ulnar styloid due to nonunion and 1 wrist denervation) (p = 0.0004). The study found no clinical differences between these two techniques except the return to work time. In our series, diaphyseal USO was associated with a greater number of reoperations than the AWP.

Lunate loads following different osteotomies used to treat Kienböck's disease: A 3D finite element analysis

BACKGROUND

One of most accepted principles for treating Kienböck's disease before wrist degeneration settles in is to decompress the lunate by an osteotomy. Several osteotomies have been proposed since 1935. However, they are based on biomechanical hypotheses that are sometimes conflicting: This study compares the decompression effect of radius transverse shortening, radius lateral closing and medial closing wedge osteotomies, capitate shortening - with and without hamate shortening - and a Camembert-type radius wedge osteotomy with and without ulnar head shortening according to Sennwald.

METHODS

We built a 3D wrist model using finite elements that included the metacarpal, carpal and forearm bones. All wrist ligaments and Triangular Fibrocartilage Complex were incorporated in the simulation. Load was applied on the metacarpals with the forearm bones fixed. We then applied the different osteotomies to the model.

FINDINGS

When load was applied to the wrist, the osteotomies that best unloaded the lunate were the capitate shortening osteotomy combined with hamate shortening and the Camembert osteotomy combined with ulna shortening; the latter was the only osteotomy that completely unloaded the lunate.

INTERPRETATION

We think the association of the radius Camembert osteotomy and ulna Sennwald's shortening osteotomy is the most effective procedure to propose in Kienböck's disease.

Arthroscopic-assisted 6U approach for foveal reattachment of triangular fibrocartilage complex with an anchor: Clinical and radiographic outcomes at 4 years' mean follow-up

The main objective of this study was to evaluate the long-term clinical and radiological outcomes of arthroscopic-assisted foveal repair of proximal triangular fibrocartilage complex (TFCC) tears with an anchor. The secondary objective was to look for ligament damage associated with TFCC tears. Twenty-four patients who underwent foveal repair of the TFCC were evaluated retrospectively: 16 stage 2 and 8 stage 3 in the Atzei-EWAS classification. The TFCC was repaired with an anchor using an expanded 6U approach. Systematic testing of intrinsic and extrinsic ligaments was performed. The assessment criteria were pain on a visual analog scale (VAS), wrist joint range of motion, grip strength and pronation-supination strength, and the QuickDASH and PRWE outcome scores. X-rays were also taken to assess anchor position and to look for distal radioulnar (DRU) joint damage. The average follow-up was 44 months. After the surgical repair, pain was reduced (7.36±1.3 preoperatively vs. 0.69±1.3 postoperatively; P<0.001), the QuickDASH score improved (52.1±16 vs. 21.7±7; P<0.001), the PRWE score improved (83.7±35 vs. 9.3±12; P<0.001) as did strength (35 vs. 43kg; P<0.001). The DRU joint stability was also significantly improved. The time away from work was 2.6 months. During the arthroscopy exploration, 25% of patients had an ulnotriquetral ligament lesion and 8% had an ulnolunar ligament lesion in combination with their TFCC tear. Fifteen anchors were positioned in the anatomical fovea (62%). No DRU joint damage was noted. Six patients had neurapraxia of the dorsal branch of the ulnar nerve, although it recovered spontaneously. One patient still had hypoesthesia of the ulnar side of the fifth finger at 48 months. Arthroscopic-assisted foveal repair of the TFCC yields good results in terms of pain, strength and DRU joint stability. In one-quarter of cases, TFCC foveal tears are associated with lesions of the ulnotriquetral ligament. There is no long-term degeneration of the DRU joint.

Evaluation of Kienböck's Disease Treated by Camembert Osteotomy at Seven Years

In Kienböck's disease, radius shortening osteotomy is the most common treatment. The Camembert procedure is a wedge osteotomy that shortens only the radius facing the lunate. Its aim is to offload the lunate by redirecting the compression stress of the grip forces toward the scaphoid. The purpose of this study was to determine if the Camembert osteotomy is effective in improving clinical symptoms and limits lunate collapse. The series include 10 patients who underwent a Camembert osteotomy for Kienböck's disease between 2002 and 2012 (one bilaterally). They are six men and four women, aged 40.6 years. Five patients had an additional ulnar shortening osteotomy if ulnar variance was neutral or positive. The mean follow-up is 7 years. Preoperatively, range of motion, grip strength, pain, and functional scores were poor. All osteotomies healed within 3 months. Extension, ulnar deviation, grip, functional scores improved significantly. In 10 cases, there were improvement in the T1 and T2 signals on the magnetic resonance imaging (MRI). There was no lunate collapse. This series shows good results with no worsening of the lunate shape. There was no ulnocarpal impingement. The Camembert osteotomy proposes to offload the lunate and redirect strains toward the scaphoid. The supposed interest is to protect the lunate from collapse. In this small series, the Camembert osteotomy improved function in patients with early stage Kienböck's disease. MRI aspects improve in most cases and no patients collapsed. Camembert can be used in combination with a Sennwald's ulnar shortening when ulnar variance is neutral or positive. Authors propose this procedure for Lichtman's stages 1-2-3A if there are no cartilage or ligament lesions. This is a Level IV, case series study.

Treatment of the distal radius fractures with percutaneous pinning: evolution to the HK2 system

Displaced fractures of the distal radius often require reduction and fixation to improve outcome in active patients. The volar locking plate gained ground over pinning, which was the first surgical solution described. But pinning methods have since evolved with fewer complications. The authors present a clinical study of distal radius fracture fixation using the HK2 technique, where subchondral pins are connected to intra-focal pins. The results are satisfactory with a lower complication rate compared to other pinning methods. This technical improvement relaunches the pinning technique, with its two advantages, being faster and significantly cheaper than locking plates, with similar long-term functional results.

Arthroscopic Classification of the Lesions of the Dorsal Capsulo-Scapholunate Septum (DCSS) of the Wrist

The dorsal capsulo-scapholunate septum (DCSS) is an anatomic structure linking the scapholunate ligament and the dorsal capsule of the wrist. It should be a predynamic scapholunate stabilizer. The authors, using their experience for the extrinsic ligaments testing, suggest an arthroscopic testing of the DCSS. The status could be graded in 4 stages according to the trampoline aspect and to the fiber attachment. They report a preliminary study on a series of 53 arthroscopies made between January 2014 and December 2015 with evaluation of scapholunate ligament instability and DCSS laxity. There is a significant correlation between the lesional stage of the DCSS and the arthroscopic predynamic scapholunate instability stage (P<0.01).

A systematic method of arthroscopic testing of extrinsic carpal ligaments: implication in carpal stability

Several biomechanical studies have shown that the scapholunate and lunotriquetral ligaments are not the only stabilizers of the proximal carpal row. However, no study has yet analyzed the spectrum of ligamentous lesions in vivo, leading to instability. We describe an arthroscopic technique for evaluating the extrinsic carpal ligaments. The testing relies on visualization and palpation of different ligaments. Their integrity is assessed with a 4-stage scale. Radiocarpal arthroscopy enables assessment of the following ligaments: the radiocarpal part of the radio-scapho-capitate, the long radiolunate, the short radiolunate, the ulnolunate, the ulnotriquetral, and the dorsal radiocarpal. Midcarpal arthroscopy enables assessment of the mid part of the radio-scapho-capitate, the triquetrocapitate, the scaphotrapezial, and the dorsal intercarpal. Above assessment is proposed in addition to assessing the articular cartilage, scapholunate, and lunotriquetral ligaments. This method allows a precise arthroscopic assessment of the extrinsic ligaments of the wrist. It could give an important help in the understanding of carpal instability.

Dorsal scapholunate stabilization using Viegas' capsulodesis: 25 cases with 26 months-follow-up

Intercarpal instability is often secondary to a scapholunate interosseous (SLIO) ligament lesion. Its reconstruction is thus essential. Classical capsulodesis techniques fix the scaphoid in extension and do not reproduce the physiologic ligamentous isometry of the wrist. The authors use the technique of Viegas, which seems to respect this isometry: the dorsal intercarpal ligament is re-inserted dorsally to reattach the capsule on the dorsal SLIO and to reinforce it. Between 2006 and 2010, 25 wrists were operated on in 12 men and 12 women of mean age 38 years. All patients presented with pain often associated with loss of power, decreased mobility or a debilitating click. The mean follow-up was 26 months. Postoperative and preoperative data were compared. Flexion/extension range increased by 2.6°, radioulnar deviation increased by 21.1°. Grip strength increased by 8.7 kgf. Pain decreased by 3 points on the VAS and the PRWE improved by 59 points. We observed four CRPS, one EPL lesion and one case of superficial track pin infection. We got eleven excellent results, nine good, two moderate and three bad, two of which were re-operated. Viegas' capsulodesis does not present major technical difficulty. The results show no stiffness in flexion/extension. There was evident improvement in radioulnar deviation, grip strength, pain and PRWE scores. This technique provides effective treatment for a difficult or irreparable lesion of the SLIO ligament, without fixed carpal instability corresponding to Geissler arthroscopic stages 2 to 4 and Garcia-Elias stages 3 and 4. The capsulodesis produces an effective stabilization without stiffness. Precautions should be undertaken to avoid CRPS and pin complications.

Anatomical Description of the Dorsal Capsulo-Scapholunate Septum (DCSS)-Arthroscopic Staging of Scapholunate Instability after DCSS Sectioning

Background The dorsal capsuloligamentous scapholunate septum (DCSS) is a confluence of the dorsal capsule, the dorsal intercarpal ligament (DIC), and the scapholunate interosseous ligament (SLIOL). It appears to play a role in the stability of the scapholunate articulation. The purpose of this study was to describe the anatomical basis for this structure and to investigate its role in scapholunate instability through sectioning of this structure followed by an arthroscopic and fluoroscopic analysis. Material and Methods In the anatomical part of the study we dissected 3 fresh cadaver wrists to examine the anatomy of the DCSS. In the arthroscopic part of the study we assessed the EWAS grade of SL instability before and after sectioning the DCSS and measured the scapholunate and radiolunate angles fluoroscopically. Results Sectioning the DCSS increased the EWAS grade of SL instability but did not affect the scapholunate gap, the scapholunate angle or radiolunate angle. Conclusion We have demonstrated that there is a distinct structure that is separate from the dorsal capsule, which we have labeled the Dorsal Capsuloligamentous Scapholunate Septum. We believe that the DCSS is a previously unreported secondary stabilizer of the SL joint which may have therapeutic and prognostic implications.

Surgical technique of a radial wedge "camembert" osteotomy in Kienböck disease

The main accepted principle to treat Kienböck disease is to decompress the lunate. Radius shortening is the most used technique. Three transverse osteotomies of the radius are described: neutral shortening osteotomy, lateral closing wedge osteotomy, and medial closing wedge osteotomy. Shortening the radius decompress the lunate and more or less the scaphoid. This deviates axial constraints toward ulna and triangular fibrocartilage complex. But the ulnar wrist is not able to support important axial constraints. The authors propose a solution to decompress only the lunate and not the scaphoid. This solution deviates axial constraints toward the scaphoid, which is naturally the most capable bone to support it. The authors describe a new radial nontransverse decompression wedge osteotomy. It allows to shorten the radius in front of the lunate. The fixation is done with a dorsal staple. To complete lunate decompression, authors propose to associate a metaphysal ulnar oblique shortening, essentially if ulnar variance is neutral or positive. The preliminar results on 10 cases are presented.

Kinematics of the wrist using 2D and 3D analysis: biomechanical and clinical deductions

Surgery of the wrist relies on the known notions of biomechanics of the wrist. But these notions are incomplete. For a better understanding of the movements of the wrist, we studied five wrists of healthy volunteers with CT scanning. Each wrist was studied in neutral position, and in the four extreme positions: flexion, extension, radial and ulnar deviations. Using oblique reformatted CT sections, we measured the angular displacements in frontal and sagittal views of every carpal bone in the different positions of the wrist. This allowed us to construct a table of intracarpal mobility. By comparing the angle values and the three-dimensional pictures of these wrists, we illustrate some fundamental points regarding intracarpal movement. The dynamics of the wrist are like those of two super-imposed mobile cups with different movements. The proximal row is malleable with flattening and torsion according to the transverse axis and its behavior is like that of an articular meniscus. The distal row, more rigid but deformable, behaves like a T-handle giving attachment to the hand and articulating under the proximal row around the head of the capitate and the proximal pole of the hamate. During radial and ulnar deviations of the wrist, the movement between the two rows is like an inverse pronation-supination shearing. During flexion-extension, the distortion of the two rows allows maximal congruence to be maintained between the different carpal bones.