Description of WALANT technique in open bone and ligament wrist surgery

The gold-standard for bone, ligament and joint surgery in the wrist is locoregional anesthesia in most countries. Wide-Awake Local Anesthesia No Tourniquet (WALANT) is commonly used for simple soft-tissue hand surgery procedures such as carpal tunnel or trigger finger release, and can now also be safely used in procedures such as proximal row carpectomy, scapholunate ligament repair or partial wrist fusion, to name but a few. This article describes the use of WALANT for complex surgery in the wrist. WALANT surgery offers many known benefits, such as enhanced patient safety and comfort, simplified perioperative process and avoidance of anesthesia-related risks, and also allows the surgeon to perform intraoperative testing of the repaired structures. Thus, the surgeon can tailor the rehabilitation program and shorten recovery time. We describe detailed guidelines for performing WALANT procedures safely and effectively, making it a favorable option for complex surgeries in the wrist.

Osteoid osteoma of the wrist: Recent advances

Osteoid osteoma is a benign bone tumor usually arising in the diaphysis and metaphysis of the long bones, with male predominance (sex ratio, 2:1). Despite being the most common bone tumor in the wrist, it is still an atypical location for this lesion. The usual presentation is pain that is exacerbated at night and relieved by aspirin or non-steroidal anti-inflammatory drugs. This presentation is not always the case in the wrist, which leads to numerous differential diagnoses and often a delay in definitive diagnosis and treatment. Various imaging modalities can confirm the presence of the tumor and guide the surgical approach. Resection is the gold-standard, with radiofrequency gaining popularity in recent years.

Radiolunate arthrodesis and scaphoidectomy combined to Sauvé-Kapandji procedure as treatment of wrist osteoarthritis: Clinical and radiological results

OBJECTIVE

The aim of this study was to analyze clinical and radiological results for 1-stage radiolunate arthrodesis and scaphoidectomy associated to the Sauvé-Kapandji procedure, to alleviate pain and conserve wrist motion.

METHODS

Seven patients (8 wrists) with symptomatic osteoarthritis of the radiolunate and distal radioulnar joints were treated from 1999 to 2016. Mean age at surgery was 49 years and M/F sex ratio was 6/1. Etiologies were distal radial intra-articular malunion for 6 patients and bilateral gouty arthritis for 1. The procedure was performed by a dorsal approach in a single step. Pain was assessed on visual analogue scale (VAS). Pre- and post-operative active flexion-extension and pronation-supination were compared. The secondary endpoint was onset of postoperative complications.

RESULTS

At a mean 71 months' follow-up (range, 30-168 months), there was significant reduction in pain (VAS, 0.5/10; p < 0.0001). Motion results were satisfactory, with 32° flexion, 39° extension, for a non-significant decrease of 11° and 5° respectively; pronation and supination were significantly increased, by a mean 23° and 30° respectively. Three wrists (37.5%) required a second surgery. There were no cases of surgical site infection or non-union.

CONCLUSION

Radiolunate arthrodesis and scaphoidectomy combined to Sauvé-Kapandji procedure was an effective solution for the treatment of symptomatic radiolunate and distal radioulnar osteoarthritis.

LEVEL OF EVIDENCE

IV.

Tenosynovial chondromatosis of the wrist: A case report

We report the case of an 80-year-old woman who presented with an asymptomatic slowly growing mass in the dorsal aspect of her right wrist. Radiographs revealed a snail-shaped radiopaque structure. Surgical exploration and excision revealed a calcified lesion over the extensor digitorum communis. Histopathological analysis confirmed the diagnosis of tenosynovial chondromatosis. At the last follow-up, four years after surgery, the patient was asymptomatic and free of recurrence. Practitioners and hand surgeons should be aware of the dorsal involvement and evocative radiological calcifications of tenosynovial chondromatosis, which is a rare benign soft tissue neoplasm that affects all tendon sheaths of the hand.

Denervation of the thumb carpometacarpal joint for symptomatic osteoarthritis in 46 patients

We investigated the effect of an extended denervation procedure in the thumb carpometacarpal (CMC) joint in patients suffering from CMC osteoarthritis. Between 2006 and 2018, 46 patients underwent the procedure in our clinic and were included in this retrospective study. Pain, strength, range of motion, DASH score, complications and overall satisfaction were determined. Assessment showed a significant decrease in pain and excellent physical function at a median 5 years' follow-up. Twelve patients needed secondary surgery due to persistent pain. Overall, 28 of the 46 patients were satisfied with the results of the denervation. Even though the results of CMC denervation are poorer than with simple trapeziectomy, considerable pain relief can be achieved in selected young, physically active patients by exclusively soft-tissue surgery, conserving the biomechanical properties of the joint. In case of failure of the procedure, all other options remain available.

Intercarpal arthrodesis: A systematic review

Intercarpal arthrodesis is a well-established option to treat various disorders of the carpus, such as localized osteoarthritis, carpal instability, and Kienböck's disease. This is a non-conservative procedure aimed at obtaining a stable and congruent interface between the radius and the proximal carpal row, which restores wrist function by minimizing pain and restoring grip strength. These procedures generally yield good predictable results that are maintained over time. However, all intracarpal arthrodesis procedures cause a loss of wrist range of motion. To optimize outcomes and minimize complications, especially nonunion, this surgery may require a learning curve. A precise surgical technique for preparing the bone surfaces, bringing enough bone graft, and using reliable fixation is essential. Since the late 1960s, several intracarpal arthrodesis procedures have been described. Commonly used fusions target the scaphotrapeziotrapezoid, scaphocapitate, four corners, capitolunate or capitohamatolunate regions. Lesser used fusions focus on specific lesions such as the scapholunate, scapholunocapitate, lunotriquetral and triquetrohamate. Here, we propose a systematic review of the various types of intercarpal arthrodesis procedures described in the literature. After having described each arthrodesis, we specify their indications, the variations of the surgical techniques, and then present an overview of the results and complications. Finally, we discuss how these surgeries affect wrist biomechanics. LEVEL OF EVIDENCE: III.

Factors affecting contralateral wrist surgery after one carpal tunnel release in bilateral carpal tunnel syndrome

Carpal tunnel syndrome (CTS) can be bilateral, with varying incidence. Carpal tunnel release (CTR) in one wrist may relieve the symptoms of the contralateral wrist, avoiding the need for second surgery; conversely, the symptoms may persist or worsen, requiring contralateral surgery in some cases. The present study investigated whether surgical treatment was finally required for the non-operated CTS wrist, and in what cases non-operative treatment was possible. We compared baseline characteristics, risk factors and electrodiagnostic data between CTS patients who underwent only unilateral CTR and those who subsequently underwent bilateral surgery at various time intervals. This single-center retrospective study included 188 patients with bilateral CTS managed between 2010 and 2020; 137 patients (group 1, 73%) underwent only unilateral CTR, and 51 (group 2, 27%) subsequently underwent contralateral CTR. In group 1, contralateral CTS symptoms were assessed in 4 categories and compared to the presenting symptoms in the index wrist. There were no significant differences in age, gender, preoperative symptom duration, body status, addictive behavior, electrodiagnostic study or comorbidities, other than a higher rate of dialysis in group 2. The contralateral wrist showed partial or complete symptom relief in 57% of patients undergoing unilateral CTR. High BMI and history of diabetes were risk factors for persistent severe CTS or subsequent contralateral CTR.

Hamatolunate impingement syndrome in golfers: results of arthroscopic burring of the apex of the hamate

Hamatolunate impingement syndrome is an uncommon cause of ulnar-sided wrist pain in the general population. Often misdiagnosed and untreated by non-specialized physicians, it is an important source of chronic ulnar wrist pain in golfers. The purpose of this retrospective study was to report results of arthroscopic burring of the apex of the hamate for hamatolunate impingement, whether isolated or not, in golf players, with a minimum of six months follow-up. Fifteen golf players (10 amateur, 2 semi-professional and 3 professional players), aged 40-61 years, with ulnar carpal pain implicating hamatolunate impingement with Viegas type-II carpal configuration, were included. Treatment consisted in arthroscopic burring of the apex of the hamate. At an average follow-up of 11 months (range, 6-24 months), all patients were satisfied with functional results, except 1 with persistent pain and stiffness; 93% returned to sport to their prior level. Mean range of motion was improved by 17 ° for wrist flexion (range, 15 ° to 30 °) and 15 ° for wrist extension (range, 10 ° to 25 °). All patients except 1 recovered grip strength, improving from 27 kg (range, 12-53) preoperatively to 35 kg (range, 17-61) at last-follow-up, and ulnar-sided pain was alleviated during golf practice. Return to prior sport level was possible by 5.5 months for professional players and by 9 months for amateurs. Arthroscopic burring of the apex of the hamate provided good clinical results for function and pain, with fairly rapid return to sport. Hamatolunate chondritis does not always mean pathology but represents the natural progression of Viegas type II wrists.

Complications of Scheker semiconstrained distal radioulnar joint arthroplasty in a low-volume unit

Semiconstrained arthroplasty of the distal radioulnar joint (DRUJ) (Scheker prosthesis, Aptis Medical, Glenview, KY, USA) is a treatment option in case of irreparable destruction of the DRUJ. In our unit, a Scheker endoprosthesis was implanted in 5 wrists in 4 patients. 3/5 wrists (60%) in 3/4 patients (75%) underwent revision surgery. Reasons for revision surgery were implant loosening, periprosthetic fracture of the radius and suspicion of periprosthetic infection. Asymptomatic loosening of the screw of the radial head cover was detected in one wrist. Scheker arthroplasty is technically demanding. The prosthesis is prone to failure over the long term. Before implantation, all patients should be informed of the high risk of revision surgery.

Evaluation of the validity and reliability of the KFORCE Sens® electrogoniometer in evaluation of wrist proprioception

The aim of this study was to determine the validity and reliability of the KFORCE Sens® electrogoniometer in the evaluation of wrist proprioception. Wrist position sense was assessed on a Baseline® 360° universal goniometer and a KFORCE Sens® device. The validity and reliability of the KFORCE Sens® device for wrist position sense evaluation were investigated by comparing the two data sets. Fifty-three healthy volunteers (39 female, 14 male) with a mean age of 22.83 ± 1.28 years (range, 21-27 years) were included. Joint position sense test-retest reliability (intra-class correlation coefficient) on KFORCE Sens® was "very good" for all wrist movements. There was a very strong correlation between flexion-extension movements on the dominant side (r = 0.955), and a strong correlation between ulnar-radial deviation movements (r = 0.745). There was also a very strong (r = 0.863) correlation between flexion-extension movements on the non-dominant side and a strong correlation (r = 0.690) between ulnar-radial deviation movements (p < 0.05). Our results showed that the KFORCE Sens® device was a valid and reliable evaluation means of assessing wrist position sense.

Shortening wrist arthrodesis using a Rush pin in adult spastic wrist: A series of 15 cases

In spastic patients, shortening wrist arthrodesis (SWA) is indicated in cases of severe fixed flexion contracture. At present, the most commonly used technique is dorsal plate osteosynthesis. Ideally, fixation with smaller hardware volume farther from the tendons would limit postoperative tendon irritation and reoperation rates for hardware removal. The objective of our study was to evaluate the efficacy of Rush pin SWA in adults. A retrospective study included all patients with a central neurological impairment, undergoing SWA using a Rush pin inserted through the head of the third metacarpal, and with at least 6 months' follow-up. Attainment of preoperative objectives was evaluated by Global Assessment of Response to Treatment (GART, ranging from -4 to +4) and, for functional objectives, the House score and the Frenchay Arm Test. Consolidation and any degenerative changes in the third metacarpophalangeal joint were assessed on X-ray. Fifteen patients were included, with a mean follow-up of 13 months (range, 6-29). In general, the preoperative objectives were attained: mean GART score was 2.7 (range, 1-4). Functional objectives were attained in 3 of the 11 patients followed up (27%). In all cases, the arthrodesis had healed at a mean 74 days (range, 39-102). Three had hardware removed after consolidation; 1 experienced discomfort at the head of the third metacarpal. Rush pin arthrodesis is an interesting alternative to plate arthrodesis in the management of severe wrist flexion contracture in spastic patients. It gives satisfactory results with regard to preoperative objectives and is not associated with complications. LEVEL OF EVIDENCE: IV, retrospective study without control group.

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.

Scaphotrapeziotrapezoid arthrodesis for isolated osteoarthritis: results at a mean 8 years' follow-up

The aim of this retrospective study was to report medium- to long-term outcome of scaphotrapeziotrapezoid (STT) arthrodesis with staple fixation to treat painful isolated osteoarthritis (OA). Twenty-one consecutive patients (22 wrists) who had undergone STT arthrodesis were retrospectively reviewed by an independent examiner. Clinical and radiological evaluation was performed. At a mean follow-up of 8 years (range 2-20 years), pain levels were significantly decreased, and functional scores were significantly improved. Grip and pinch strength were 86% and 82% of those of the contralateral side. Wrist range of motion in flexion-extension and radial-ulnar deviation was significantly less than on the contralateral side at last follow-up (104° vs. 131° and 38° vs. 55°, respectively). Non-union was found on X-ray in 4 wrists (18%), but in 2 cases showed as partial non-union on CT, with complete scaphotrapezial consolidation; 1 of the 4 wrists required surgical revision. Another patient was re-operated on for symptomatic external staple displacement without non-union. There were 8 cases (36%) of radiographic narrowing of the styloscaphoid joint space; contact between the staple and styloid was found in all 8 cases. Four patients (18%) had narrowing of the scaphocapital joint space; protrusion of the proximal part of the staple into the joint space was noted in all 4 wrists. No differences were found for the radioscaphoid, capitolunate and scapholunate angles before and after surgery. STT arthrodesis with staple fixation to treat isolated STT OA led to a significant reduction in pain, with improved strength and functional scores. To avoid styloid impingement, we recommend systematic styloidectomy. Complete non-union seems to be overestimated on radiographs. Partial non-union with scaphotrapezial union should not be considered as a complication. LEVEL OF EVIDENCE: IV.

Universal 2™ total wrist arthroplasty: A single-surgeon 6.5-year follow-up study of 22 prostheses

Total wrist arthroplasty remains controversial, with the few studies undertaken being heterogeneous and having low patient numbers. This prospective study involved 22 Universal 2™ total wrist prostheses implanted by the same surgeon between 2003 and 2017. There were 13 women and nine men with an average age of 56 (42-69.5) years. Indications for total wrist arthroplasty were post-traumatic arthritis, rheumatoid arthritis and Kienböck's disease. The mean follow-up was 6.5 (3-17) years. Two failed implants required total wrist fusion. Postoperative pain, grip strength, QuickDASH, patient-rated wrist evaluation, and Mayo wrist scores improved significantly compared with preoperative scores. The prosthesis preserved equal or slightly greater range of motion than the preoperative range of motion, sufficient to undertake activities of daily living and improve quality of life. Postoperative radiographs 1 month after the surgery and then annually showed signs of bone deterioration in 64% of implants, most osteolysis without loosening, compatible with asymptomatic function. Although a high number of radiographic signs of implant changes were apparent in the midterm, 91% of prostheses are still in place. The long-term survival of this implant is uncertain. LEVEL OF EVIDENCE: Therapeutic IV.

Preiser's disease or avascular osteonecrosis of the scaphoid: An updated literature review

Avascular necrosis of the scaphoid, often referred to as Preiser's disease, is little known despite the scaphoid being the second most frequently involved location in avascular pathology of the carpal bones after the lunate (Kienböck's disease). Nonetheless, very few cases have been reported in the medical literature over the last century. Its pathophysiology is not completely elucidated although the unique vascularization of the scaphoid and several risk factors seem to be recurrently incriminated. Two new classifications based on modern imaging have appeared in the last decade and are now considered essential supplements to Herbert and Lanzetta's original radiographic classification. Because of the lack of formal treatment guidelines, a wide range of different treatments have been explored over time, contributing to the confusion around this pathology. Adding to this confusion, are the numerous terms used to designate the condition and lack of knowledge concerning its pathophysiology, risk factors, clinical and radiographic presentation. The aim of this review is therefore to explore and clarify Preiser's disease in terms of history, terminology, pathophysiology, clinical considerations and imaging and to propose a simple updated treatment algorithm based on the results provided by a thorough review of literature (53 publications, 170 patients) since Georg Preiser's original and controversial description in 1910.

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.

Surgical treatment of distal radius giant cell tumors

We aimed to evaluate the effectiveness of surgical methods commonly used for the clinical treatment of giant cell tumors (GCT) of the distal radius. From 2010 to 2018, 32 patients with GCT of the distal radius who underwent surgical treatment were eligible for the study. Among them, 21 patients with available pathological results, complete imaging data and at least 18 months of follow-up were enrolled in the study. Eleven of the patients underwent en bloc resection and non-vascularized autologous fibula reconstruction (Group A), while 10 patients underwent microwave ablation, lesion curettage, and internal fixation with bone cement (Group B). Imaging was carried out to understand the effect of the surgical treatment and postoperative complications. Variables of interested included operation time and blood loss, preoperative and postoperative wrist joint mobility, and postoperative complications during follow-up. The operation time and intraoperative blood loss in group A were higher than in group B, and the difference between groups was statistically significant. The wrist range of motion before and after surgery was statistically significant both in Group A and Group B (p < 0.05). The scale deviation and MSTS scores of group A were better than group B (p > 0.05), flexion, extension, radial deviation index in group B was better than group A (p < 0.05). By evaluating the postoperative functional outcomes of the operated wrist in the two groups, we found that both surgical methods are reliable for treating GCT of the distal radius, with satisfactory postoperative functional recovery and a low incidence of postoperative recurrence (only 1 of 10 patients in group B). The two surgical methods have their own advantages and disadvantages and provide surgeons with one more choice in the clinical context.

Mid-term follow-up of surgically treated and healed scaphoid fractures

The aim of this study was to evaluate the mid-term results of surgically treated scaphoid fractures since we were concerned that good results might deteriorate over time due to osteoarthritis or functional impairment. Thirty-three out of 121 surgically treated patients (isolated scaphoid fractures n = 23; scaphoid fractures with concomitant injuries n = 10) were evaluated retrospectively (47-138 months). Five patients (4%) had a non-union after internal fixation and were excluded because of additional treatment. The remaining 83 patients were not available for a follow-up examination. Patients with an isolated scaphoid fracture had a mean extension-flexion of 68°-0°-64°, a radial-ulnar deviation of 27°-0°-41° and a grip strength of 39 kg (corresponding to 87-98% of the uninjured contralateral wrist), while patients with concomitant injuries had a mean extension-flexion of 60°-0°-44°, radial-ulnar deviation of 22°-0°-38° and a grip strength of 42 kg (corresponding to 73-98% of the uninjured contralateral wrist). The Michigan Hand Questionnaire score was 85 and 75 and the Patient-Rated Wrist Evaluation score was 8 and 21, respectively. Fifteen patients had radiological signs of radiocarpal osteoarthritis with a significantly higher occurrence in those who had concomitant injuries compared to those with isolated scaphoid fractures (p < 0.01). There was no significant group difference in scaphotrapeziotrapezoid (STT) osteoarthritis (p = 0.968). One STT osteoarthritis case occurred after plate fixation, one after antegrade screw fixation and 10 after retrograde screw fixation. Surgical treatment of an acute isolated scaphoid fracture has excellent clinical, functional, and radiologic mid-term results, while scaphoid fractures with concomitant wrist injuries have slightly inferior results.

A new capsulotomy-based dorsal approach to the wrist: A cadaver study

Using a cadaver study, we described a new dorsal approach to the wrist joint using a "U-shaped with proximal base" capsulotomy. Six fresh adult cadaveric wrists were dissected after intra-arterial silicone injection. We did a dorsal approach to expose the dorsal joint capsule. It was then possible to identify the dorsal radiocarpal and intercarpal ligaments, the dorsal radiocarpal and intercarpal arterial arches, the dorsal branch of the anterior interosseous artery and the terminal branch of the posterior interosseous nerve. Wrist arthrotomy was done using our capsulotomy. In each dissected capsular flap, we always found the individual ligament, vascular, and nerve structures, implying they were intact over their trajectories. The mean surface area of the articular exposure was 945 mm² (range 725-1102 mm²) allowing easy access to the carpal bones and the radiocarpal and midcarpal joint spaces. This surgical approach to the wrist is technically feasible and avoids damaging the dorsal extrinsic ligaments fibers. Keeping the vascularization intact could improve capsular healing, while preserving innervation could maintain wrist proprioception.

Similar effects of two different external supports on wrist joint position sense in healthy subjects: A randomized clinical trial

The hand is one of the most injured organs. Proprioceptive rehabilitation decreases the incidence of injury while using external supports can increase proprioception. The aim of this study was to investigate the effects of taping and elastic bandaging on wrist joint position sense (proprioception) in healthy individuals. Sixty-eight healthy students were included in our study and randomized into two groups. External supports were to apply to the dominant hand for 24hours in both groups. Joint position sense was evaluated with an angle reproduction test before applying the external support and 20 minutes after and then 24hours later with the external support and after removing it. There were significant improvements in joint position sense 20 minutes after applying the external support and 24hours later (P<0.05). Although a significant decrease in joint position sense was observed after removing the external support compared to while wearing it (P<0.05), there was a significant improvement in the joint position sense relative to the pre-study assessment (P<0.05). In between group comparisons, the only significant difference was observed 20 minutes after the external support was applied: the taping group had better results in joint flexion position sense than the bandaging group (P<0.05), but in the other assessments there were no significant differences between two groups (P>0.05). It was found that two different types of external support can improve the wrist joint's position sense in healthy subjects. These procedures can be used as a supplemental treatment in wrist rehabilitation.

Wrist opener splint: An effective way to treat chronic wrist flexion contracture

In Senegal, patients are seen an average of 16 months after their injury in a specialized hand and upper limb surgery department. Because of this lengthy delay, these patients have severe functional sequelae, such as wrist flexion contracture, averaging 45 degrees in our case series (range, 35 to 90 degrees). After reviewing the literature, we did not find any splint that was well suited to these patients. Inspired by the general splinting rules set out by Schultz, MacConaill and Brand, we constructed a volar/dorsal splint to reduce these contractures. We have been using this serial static splint for 2 years. We performed a prospective study of 17 wrists to evaluate its therapeutic benefit, describe its use and outline its optimal application.

Clinical and radiological outcomes of 40 cases of SLAC and SNAC wrist treated by four-corner arthrodesis with locking plate

The treatment of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist varies. No clear consensus exists on surgical indications. Scaphoid excision and four-corner arthrodesis with locking plate is one of preferred treatments for these lesions. The purpose of this study was to assess the clinical and radiological outcomes of locking plates for treating SNAC and SLAC wrist after a mean follow-up of 5 years and to compare these outcomes with the results reported in the literature. A retrospective study was conducted in two hospitals, involving 40 patients who underwent scaphoid excision and four-corner arthrodesis with locking plate between January 2006 and September 2016. All patients were reviewed as outpatients with clinical and radiographic measurements. At the last follow-up, the mean pain level on visual analog scale (VAS) was 2.5/10 [0-7] (SD: 1.7). Patients had a mean flexion of 46% and a mean extension of 46% compared to the contralateral side. An 18% gain was observed in grip strength. The mean postoperative QuickDASH score was 30 [0-57] (SD: 15.3). Seventy percent of patients were satisfied with the operation. Complete (all four joint interfaces) joint space fusion was achieved in 55% of patients. Only one patient (2.5%) had no joint fusion. The joint between the lunate and the capitate was fused in 38 patients (95%). Nine patients suffered complications; eight of them required surgical revision (20%). Four-corner arthrodesis with locking plate is a valuable surgical technique for treating SLAC and SNAC wrist because it preserve satisfactory range of motion and grip strength (64% compared to the non-operated side), maintains the height of the carpus and prevents the premature appearance of radiocarpal osteoarthritis, as long as the technical challenges of this procedure are mastered.

Outcomes of ulnar shortening osteotomy using a new compression plate

Ulnar impaction syndrome (UIS) is a frequent cause of ulnar-sided wrist pain. Several open and arthroscopic surgery techniques have been described. Ulnar shortening osteotomy (USO) is often the method of choice. It has the advantage of leveling the distal radioulnar joint extra-articularly while maintaining the integrity of the soft tissues that stabilize the joint. This retrospective study reports the short-term outcomes of 20 patients who underwent surgery between 2013 and 2015. USO was performed with a locked plate and a new compression device (Alians®, Newclip™, Haute Goulaine, France). Preoperative and postoperative ulnar variance were measured on wrist X-rays in neutral pronation-supination. Functional outcomes were evaluated with the QuickDASH score and the pain on VAS (visual analog scale). Postoperative range of motion and grip strength were compared to those of the contralateral wrist. The average follow-up was 16 months (4 to 28 months). Preoperative ulnar variance was positive with an average of 4mm (1-11mm). The average length of the final ulna shortening was 3.5mm (1.5-6mm); the mean time to union was 4 months (3-12 months). The average QuickDASH was 12 and pain had decreased 2.4mm on the VAS. The results achieved with this new compression plate designed specifically for USO are similar to those described in the literature. This kind of device has an easily reproducible technique and can reduce the operative time. LEVEL OF EVIDENCE: IV.

Arthroscopic treatment of scaphoid nonunion with humpback deformity and DISI with corticocancellous bone grafting: Technical note

For two decades, scaphoid nonunion has been treated arthroscopically. However, compressed cancellous bone graft does not have the same mechanical properties as corticocancellous bone graft for reducing the scaphoid humpback deformity and DISI tilt. Here, we describe an arthroscopic technique to treat Alnot stage IIB scaphoid nonunion. We treated a 27-year-old male patient for scaphoid waist nonunion with humpback deformity and DISI. A 8×8×10 mm cylindrical corticocancellous bone graft was harvested from the dorsal aspect of the radius using a single-use osteochondral autograft transfer system (OATS®, Arthrex Inc., Naples, USA). It was inserted in the nonunion site through an arthroscopic volar approach. Bone union was obtained at 3 months with lasting correction of the scaphoid humpback deformity and DISI. The functional result at 6 months was excellent. There were no complications. Scaphoid nonunion with humpback deformity and DISI may be treated arthroscopically with a corticocancellous bone graft.

Adaptive Proximal Scaphoid Implant (APSI): 10-year outcomes in patients with SNAC wrists

Radioscaphoid arthroplasty with the Adaptive Proximal Scaphoid Implant (APSI^®) is an attractive treatment alternative in the short and medium term for patients with early scaphoid non-union advanced collapse (SNAC) wrist. The purpose of our study was to determine the long-term outcomes of this implant in SNAC wrists. All patients who received the implant from October 2002 to October 2010 were included. A clinical and radiographic study was performed. Our case series included 39 patients, of which 33 were contacted, with a mean follow-up of 10 years (5.8-13.4). Most of the patients had stage-1 SNAC wrist (95%). There were nine complications (27%), seven of which required reoperation: implant dislocation (44%) or progression of the carpal degeneration (33%). Ninety-six percent of patients contacted were satisfied or very satisfied with their surgery (although 21% needed a second surgery) with a Mayo Wrist Score of 80/100 and a Patient-Rated Wrist Evaluation of 17.5/100. Wrist strength was 86% of the contralateral side. Flexion-extension range was 101° and pain assessed using a visual analog scale was at 1.2 (0-6). We report satisfactory and lasting results with the APSI^®, similar to those of scaphoid excision with four-corner fusion and proximal row carpectomy. Hence, the APSI^® is a reliable alternative for treating osteoarthritis in SNAC wrists.

What happens to the posterior comminution in extra-articular fractures of the distal radius treated with volar locking plates?

Extra-articular fractures of the distal radius with posterior displacement are typically treated with volar locking plates. However, this fixation method does not address the posterior comminution, which seems to have no impact on the final result. The purpose of this study was to determine the fate of the posterior comminution. This was a retrospective study of 22 patients over 50 years old with a distal radius fracture. A preoperative computed tomography (CT) scan was performed to evaluate the comminution. All fractures were fixed with a volar locking plate. All patients underwent a bone density scan. Patients were reviewed at 6 months post-operative to determine their clinical, radiological and functional outcomes. The CT scan was performed again to determine the fate of the comminution. At 6 months post-operative, 82% of patients had an oval metaphyseal defect. The mean volume of this defect was 1.86 mL. The contents of this defect most closely resembled fat. There was no statistical link between the defect's volume and the various parameters studied. On the other hand, the defect's density was positively related to the functional outcome and negatively related to the patients' body mass index. Because of the compression experienced by the cancellous bone, a distal metaphyseal defect often persists after consolidation in dorsally displaced distal radius fractures. The posterior comminution is ultimately of little consequence.

Vein conduit with microsurgical suture repair of superficial branch of the radial nerve injuries at the wrist

The superficial branch of the radial nerve (SBRN) at the wrist is susceptible to trauma and lacerations. These lesions can develop into painful neuromas with debilitating consequences. The aim of our study was to demonstrate the effectiveness of systematic use of vein conduits associated with microsurgical suture repair in SBRN injuries to prevent the occurrence of these neuromas. Our study was retrospective and performed at a single site. An independent examiner performed the clinical assessment. The study included 33 patients and the mean follow-up was 63 months. We looked for a so-called "trigger point". None of the patients developed a painful neuroma or experienced any pain. All the patients were either satisfied or very satisfied with their treatment. Systematic use of vein conduit in SBRN injuries at the wrist helps prevent the occurrence of painful neuroma and the disorder's inherent consequences, which can be severe not only clinically, but also socially and professionally.

Long-term outcomes of proximal row carpectomy: A series of 62 cases

The aim of this study was to determine and analyze the functional and radiographic outcomes after proximal row carpectomy (PRC). We hypothesized that this surgery could restore wrist mobility and function in case of radiocarpal osteoarthritis or severe carpal trauma. Sixty-two patients who had undergone PRC were included in this study: 44 patients with wrist osteoarthritis (11 SNAC, 24 SLAC, 3 Kienböck's disease, 6 other) and 18 patients with severe carpal trauma. Each patient underwent clinical (pain, range of motion, grip strength, functional scores) and radiographic evaluations. At the latest evaluation after a mean of 11.8 years, 15 patients (24.2%) required revision total wrist arthrodesis surgery in a median of 22 months (range, 6-179) because of disabling pain and lack of strength. The failure was statistically correlated with being young and a manual laborer. The range of motion and strength of the operated wrist were 61.5% and 70%, respectively, compared to the contralateral side. PRC remains a reliable procedure for treating wrist arthritis and severe carpal trauma. However, manual activity and being under 50years of age can lead to an early salvage procedure such as total arthrodesis of the wrist. In this subset of the population, another alternative must be considered.

Trans-metacarpophalangeal traction to avoid finger-related complications during wrist arthroscopy: Feasibility study with 20 cadaver wrists

Some of the iatrogenic complications of wrist arthroscopy are related to the traction applied to the fingers. The aim of this work was to test whether trans-metacarpophalangeal (trans-MCP) traction would provide sufficient distraction of the radiocarpal and midcarpal joint spaces to perform wrist arthroscopy without exerting any mechanical stress on the fingers, from the metacarpophalangeal (MCP) joints to the distal phalanges. Our study included 20 cadaveric wrists mounted on an arthroscopic traction tower maintained by finger traps placed on the 2nd and 4th fingers. For each wrist, three fluoroscopic views were taken: without traction, with finger traction (78.45N), with trans-MCP traction (78.45N). The average height of the midcarpal joint space was 0.8305cm without traction, 1.037cm with finger traction, and 1.1cm with trans-MCP traction. The height of the radiocarpal joint space averaged 0.853cm without traction, 1.167cm with finger traction, and 1.187cm with trans-MCP traction. There were no differences between the heights of joint spaces between digital and trans-MCP traction. Our results show that trans-MCP traction provides distraction of the wrist joint spaces equivalent to that obtained with finger traction. However, we still need to develop a trans-MCP traction device usable in clinical practice.

Physical therapy under hypnosis for the treatment of patients with type 1 complex regional pain syndrome of the hand and wrist: Retrospective study of 20 cases

Type 1 complex regional painful syndrome (CRPS-1) has a complex physiopathology. The aim of this study was to evaluate the effectiveness of physical therapy under hypnotherapy to treat this condition. Twenty patients with CRPS-1 at the wrist and hand were evaluated retrospectively: 13 women and 7 men with an average age of 56 years (34-75). Thirteen patients were in the inflammatory phase and 7 in the dystrophic phase. The main endpoints were pain (VAS, analgesic use), stiffness (wrist and finger range of motion), and strength (pinch and grasp). Secondary endpoints were functional scores (QuickDASH, PWRE), patient satisfaction, return to work, and side effects. Results were satisfactory in all cases after 5.4 sessions on average. VAS decreased by 4 points, PWRE-pain by 4.1 points, and analgesic use was limited to paracetamol upon request. Finger and wrist range of motion increased and the QuickDASH decreased by 34 points, PRWE-function by 3.8 points, pinch strength increased 4 points, and grasp strength by 10 points. Return to work was possible in 80% of the cases. All patients were satisfied or very satisfied with the treatment. Physical therapy under hypnosis appears to be an effective treatment for CRPS-1 at the wrist and hand no matter the etiology.

[Descriptive, radiographic, topographic and functional anatomy applied to distal radius fractures]

Extensive anatomical knowledge is needed in order to correctly treat distal radius fractures: normal and pathological osteology of the distal radius, distal radio-ulnar joint and radiocarpal joint-both on the descriptive and functional level-the neurovascular and muscular environments of the distal radius-which are essential to the surgical approaches-and the angles that need to be restored during the reduction. All of these concepts are broached in this article.

Inside-out method to develop volar arthroscopic portals of the wrist in cadaver specimens

Three direct volar portals for wrist arthroscopy have been described previously: two radiocarpal and one midcarpal. The aim of this study was to systematically describe four volar arthroscopic portals through minimally invasive incisions using an inside-out approach from known dorsal portals. Four volar arthroscopic wrist portals were studied on six hand specimens using an inside-out technique: a radial radiocarpal approach (RRCA), an ulnar radiocarpal approach (URCA), a radial midcarpal approach (RMCA) and an ulnar midcarpal approach (UMCA). Each volar approach corresponded to a dorsal approach: the 3/4 portal for RRCA, 4/5 portal for URCA, dorsal radial midcarpal approach for RMCA, and dorsal ulnar midcarpal approach for UMCA. The average range of motion of the scope through the RRCA was 65° in radial deviation and 72° in ulnar deviation; through the URCA it was 62° in radial deviation and 64° in ulnar deviation; through the RMCA it was 62° in radial deviation and 60° in ulnar deviation, and through the UMCA it was 59° in radial deviation and 68° in radial deviation. No iatrogenic injuries to important anatomical structures were noted. Based on these results, it is possible to perform these four volar portals through an inside-out technique with incisions mirroring the dorsal portals. They were easy to perform, safe and should be useful in ligament or bony intracarpal repair indications.

Subcutaneous rupture of the superficial branch of the radial nerve at the wrist. A case report and review of literature

Isolated neuropathy of the superficial branch of the radial nerve (SBRN) is a rarely recognized pathology. It was initially described by Wartenberg in 1932. Various causes have been published. We report a case of an unusual injury of the SBRN at the wrist, never been previously reported in the literature. A 40-year-old woman presented with pain and paresthesia over the area of the lateral aspect of the wrist, thumb and first web two months after a blunt trauma of the left forearm. After failure of conservative treatment, surgical exploration found a neuroma of one branch of the SBRN. No distal nerve stump was found. Neuroma resection was performed and the nerve was transposed and embedded into the flexor pollicis longus muscle. With a six months follow-up, the result was satisfactory.

[Evaluation of a technical modification to Mannerfelt's total wrist fusion technique in a series of 19 rheumatoid wrists]

We studied a technical modification of Mannerfelt's total wrist fusion technique in a series of 19 wrists. A fully intramedullary technique without dorsal carpal fixation was used to protect the extensor tendons. Two intramedullary Rush pins without dorsal staples were used during the arthrodesis procedure. Nineteen rheumatoid arthritis wrists (2 bilateral cases) were reviewed with a mean follow-up of 4.9 years (range 2-10 years). Clinical outcomes were assessed using the VAS pain scale, DASH-score and wrist strength measurements. Wrist fusion was assessed on AP and lateral X-rays of the wrist. The position of the carpal Rush pin entry points and distal hook orientation were also assessed. Pain was 8.9 preoperatively and 1.1 at the last follow-up with 95% patients satisfied. Mean DASH-score was 46.9 points. The pinch strength was 79% and the grip strength was 68% of the contralateral wrist. Carpal height, carpal anterior subluxation and ulnar deviation were stable at the last follow-up. All of the wrists were in straight position and no extensor tendon ruptures were noted. Fusion was complete in all cases within 6 to 12 weeks, except in one case. The technical modification proposed in the current study -intraosseous fixation only- appears to be a good alternative to Mannerfelt's original technique. Every case treated with this modified technique had good functional results and none required pin removal.

Radial artery pseudoaneurysm: a rare complication after arthroscopic treatment of a volar wrist ganglion in a hemophilia patient

Vascular complications of wrist arthroscopy are rare. We report the case of a 42-year-old male patient with a history of hemophilia who had a ganglion located where the radial pulse is taken that had been causing him pain for five months. After infusion of Exacyl (antifibrinolytic agent), the ganglion was drained arthroscopically. Fifteen days later, the patient presented with a pseudoaneurysm of the radial artery requiring urgent reoperation.

Outcome measurements in hand and upper limb surgery

Of marginal importance only 20 years ago, outcome measurement has become one of the most widely published topics in medical literature. The concept of global health is described by the International Classification of Function, Disability and Health. Today, the surgeon's perspective is no longer sufficient to evaluate global health condition of a patient. The patient cannot be reduced to an organ. Outcome measurement must take into consideration body structures and function (symptoms, organ function) as reviewed by a professional, the individual's functional health status in terms of activity and evaluated by the patient himself, and his participation in his social environment. These principles are now being applied to our specialty and it is essential to know them to be able to collect, analyze and publish valid results. This review article defines the rules for using clinical outcome tools, provides the most widely used clinical and self-evaluation forms for our specialty as well as instructions for their use. Global outcome is usually obtained by arithmetic addition of scores; which is a simple but questionable method. The sieving and radar charts can be used for a more comprehensible representation showing areas of relative strength and relative weakness on a graph, as well as depicting general overall performance. The reliability of data is also affected by declaration of conflicts of interest, negligence or fraud. The level of evidence is questionable as long as a data verification system is not implemented.

[Étienne Destot (1864-1918): the first radioanatomist in Lyon, France]

Destot was born in Dijon, France, in 1864. He began his education in Burgundy, then he started his preclinical curriculum in Lyon, France, from 1884. He had to leave Lyon, and spent some times in Algeria to treat a tuberculosis. He came back in Lyon as a resident in 1886. Destot worked as an assistant in the laboratory of anatomy of Leo Testut in 1880. His thesis, in 1892, analyzed mortality in the departments of surgery of the Lyon hospitals. The polemical results he presented compromised his surgical career. He went on as prosector by Leo Testut, and then became electrician-physician in 1895 (electrotherapy and galvanotherapy). Étienne Destot of Lyon, France, developed in 1895 the first radiography room ever at the Hôtel-Dieu of Lyon, France. Wilhelm Röntgen discovered the X-rays in the same year, and Destot felt his discovery could revolutionize the approach of anatomy and traumatology. He studied wrist, ankle and calcaneus fractures, and described a new anatomy: "traumatic anatomy". For example, he focused on the posterior talar surface hollow in posterior tarsus fractures. He proposed the term of "thalamus" for this articular surface; this term is nowadays widely used by the clinicians. He introduced the term of "third malleolus" to describe the posterior part of the distal extremity of the tibia. He was the first author to analyze the normal and pathological movements of the scaphoid bone and the lunatum in wrist extension.

[Is there any correlation between the strength of pronation and supination of the dominant hand and that of the non-dominant one in right-handed healthy adults: preliminary results]

We searched the existence of a link between the strength of pronation and supination of the dominant forearm and those of the non-dominant one. Ninety-seven volunteers were tested in pronation and supination with an analog dynamometer. Gender, age, dominance, height and weight were recorded. The measurement position was: 90° of elbow flexion, 0° of shoulder abduction, wrist slightly extended and neutral pronation-supination. We took four measurements per patient: strength in pronation and supination, in both the dominant and non-dominant sides. Fifteen subjects were evaluated twice. The left-handed (4) were removed from the statistical analysis. There were 38 men (37 years, 18-66) and 55 women (45 years, 21-71). Torques were higher (P<0.05) in men than in women, higher in supination than in pronation and in the dominant side compared to the non-dominant one (average ratio "non-dominant/dominant": 0.85; σ=0.16). There was a strong correlation between non-dominant hand strength and dominant hand strength (Pearson>0.6). Relating to the 15 subjects evaluated twice, the value of the forces varied during the day, but the ratio "non-dominant/dominant" was constant. The left-handed people were excluded, their values may be different from those of right-handers, as has been shown for grip strength. There was a strength variation during the day, but the ratio "non-dominant/dominant" was constant, making it more relevant intra-individual comparison (non-dominant side versus dominant side) rather inter-individual (based on charts of gender, age, weight and height). In the right-handed, the ratio "strength non-dominant side/dominant" is constant, defining easily in consultation the expected value of recovery of an injured forearm.

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.