Long-term assessment of proximal row carpectomy for chronic perilunate dislocations

Twelve patients with chronic stage III or stage IV perilunate dislocations were managed over the past 7 years by proximal row carpectomy. All dislocations were untreated or incompletely reduced for a minimum of 8 weeks after injury. The mean time from injury to definitive treatment was 15 weeks (range, 8 weeks to 6 months). Surgical management was inclusive of a dual dorsal and volar approach. Median nerve decompression, lunate excision, and capsuloligament repair was performed volarly and scaphoid and triquetrum carpectomy was accomplished dorsally. Temporary radio capitate K-wire fixation during early soft tissue healing was uniformly performed. All patients were evaluated at an average postoperative duration of 40 months (range, 28 months to 7 years). Marked relief of wrist pain and median nerve dysesthesias was routinely achieved. Effective wrist range of motion and grip strength were restored. Untreated stage III and IV chronic perilunate dislocation treated by proximal row carpectomy eliminates pain and restores function to a severely injured wrist.     

Treatment of chronic perilunate dislocations

Fifteen patients with 16 perilunate dislocations that had been untreated for a minimum of 6 weeks after the injury were evaluated after subsequent treatment at a mean of 6.4 years. The median time from injury to definitive treatment was 17 weeks. Ten wrists had completely ligamentous injuries and six had fracture-dislocations. Treatment consisted of open reduction and internal fixation in six patients, isolated carpal bone excision in four, wrist arthrodesis in two, proximal row carpectomy in two, and bilateral carpal tunnel release in one. In this series the results of excision of the lunate or scaphoid alone were uniformly poor. One of the two patients who had a proximal row carpectomy required secondary radial styloidectomy, and a pseudarthrosis developed in one of the two patients who had a wrist arthrodesis. All six patients treated by open reduction and internal fixation had satisfactory outcomes and none required additional surgery.     

Functional outcome of neglected perilunate dislocations treated with open reduction and internal fixation

Introduction:

Management of neglected perilunate dislocations is controversial. The various procedures such as open reduction and internal fixation (ORIF), proximal row carpectomy, lunate excision, and wrist arthrodesis have been advocated. The aim of our study was to evaluate the functional outcome of neglected perilunate dislocations managed by ORIF.

Materials and Methods:

Over a period of 10 years (1996 to 2006), 14 patients with neglected perilunate dislocations (undiagnosed or untreated for 6 weeks or more) were managed by ORIF. Six patients had dorsal trans-scaphoid perilunate dislocation, 6 patients had volar lunate dislocation while the remaining two had a dorsal perilunate dislocation The results were evaluated by clinical scoring system of Cooney et al.

Results:

The average followup was 4.1 years (range 2-12 years). All except one of the patients operated earlier than 5 months had good results. Of the four patients operated after 5 months, two had a fair result while two had a poor outcome. Chondral damage to the capitate was noted intraoperatively in both the cases with poor outcomes. The two patients were found to have avascular necrosis (AVN) of the lunate; however, functional outcome was fair in both, and both were able to return to their profession.

Conclusion:

We observed favorable functional results of ORIF in neglected perilunate dislocations up to 5 months after injury. The development of AVN or midcarpal arthritis was not a major disabling factor as long as stability of wrist has been restored. Beyond 5 months, an alternative surgical procedure such as proximal row carpectomy should be contemplated as results of ORIF have not been good uniformly.     

Acute Proximal Row Carpectomy after Complex Carpal Fracture Dislocation

Acute proximal row carpectomy is an uncommon definitive treatment for perilunate fracture dislocations. In this report, we present five patients who had acute proximal row carpectomy (PRC) to treat perilunate fracture-dislocations. All patients were men between ages 31 and 87. The indication for PRC was lunate fracture in two patients, concomitant displaced scaphoid fracture and scapholunate ligament injury in two patients, and perilunate fracture-dislocation with preexisting articular damage from long-standing gout in one patient. At the final follow-up ranged from 4.5 month to 7.5 years, four patients had no pain and one patient was lost to follow-up. One patient had a concomitant PRC and a bridging plate that was never removed. The remaining three patients gained satisfactory range of motion. Our observation reveals that acute proximal row carpectomy is an option for some patients with complex carpal fracture dislocations, particularly those with fracture of the lunate, concomitant scaphoid fracture and scapholunate ligament injury, or preexisting wrist arthritis.     

Correlation between clinical results and carpal instabilities in patients after reduction of lunate and perilunar dislocations

Thirteen patients with lunate and perilunar dislocations were treated in our department in the last five years. Ten out of the thirteen patients were followed more than eight months with an average of two years and two months. Two out of the ten patients followed failed to obtain normal anatomical carpal architecture. These two patients were treated by arthrodesis of the wrist and proximal row carpectomy, respectively. The remaining eight patients, that obtained reduction, were classified into three groups according to existence of gap between the scaphoid and lunate, and incongruity between the lunate and triquetrum. Patients with a gap between the scaphoid and lunate of more than 3 millimetres after reduction of their dislocations had poor clinical results. This suggests significant correlation between clinical results and carpal instabilities.     

The unreduced carpal dislocation. A method of treatment

Unreduced lunate, perilunate, and transscaphoid perilunate dislocations present a difficult and challenging surgical problem. The authors feel that all efforts should be made to obtain a reduction of the old dislocation. They support a combined dorsal and palmar approach, open reduction, and internal fixation of scaphoid with a Herbert screw to obtain midcarpal stability. A carpal tunnel decompression should be performed if symptoms suggest median nerve entrapment. When the dislocation is unable to be reduced, the authors favor limited wrist arthrodesis or a proximal row carpectomy in the absence of significant arthritis.     

Staged reduction of neglected transscaphoid perilunate fracture dislocation: A report of 16 cases

ABSTRACT: BACKGROUND: Transscaphoid perilunate fracture dislocation is a rare injury and can be easily missed at the initial treatment. Once ignored, late reduction is not possible and needs extensive dissection. An alternative treatment such as proximal row carpectomy may be required for neglected injuries, but surgical outcome is not as good as that of an early reduction. We aim to present an alternative technique of staged reduction and fixation in patients of neglected transscaphoid perilunate dislocations and study its outcome. Material & Methods 16 cases (14 males & 2 females) with neglected transscaphoid perilunate fracture dislocation (> 3 month old) were treated with staged reduction. Mean duration between injury and surgery was 4.5 months. In first stage an external fixator was applied across the wrist and distraction was done at 1mm/day. Second surgery was done through dorsal approach and we were able to reduce all the fractures & dislocations. Herbert screws and K wires were used for fixation. RESULTS: The mean duration between two surgeries was 2.4 weeks (range 2- 4 weeks). 9 cases had excellent results, 5 had good result. Two patients developed reflex sympathetic dystrophy and had fair results. CONCLUSION: Staged reduction should be considered for neglected transscaphoid perilunate dislocations. If properly executed, a good functional pain free range of motion is the usual outcome.     

Proximal row carpectomy

Proximal row carpectomy is extremely useful as a wrist reconstructive technique for cases of degenerative joint arthritis of the radiocarpal joint cause by scapholunate advanced collapse, scapholunate advanced collapse, schaphoid nonunion advanced collapse, trans-scaphoid perilunate fracture dislocations, lunate dislocations, and Kienb?ck disease. It should be selected with caution for patients younger than 35 years old. The procedure can be performed with or without temporary internal fixation with with Kirschner wires, and adjunctive techniques of dorsal capsule interposition, proximal capitate excision, and radial styloidectomy can be used. The longevity of the operation is good, but the patient should be informed preoperatively that secondary procedures may be required. Based on historical series, these procedures have included addition have included of radial styloidectomy when this has not been performed at the index procedure, revision of the surgery with capitate debridement or conversion to total wrist arthodesis. Conversion of proximal row carpectomy to total wrist arthoplasty with implants can be contemplated in selected patient particularly as newer implants are designed. The technique the senior author has used on occasion has been to perform revision surgery on those patients who have chronic pain who might need further debridement of the radius in the radial styloid, the proximal capitate, or evaluation of the integrity of the interposition.     

Chronic trans-scaphoid perilunate dislocation: Current management protocol

Trans-scaphoid perilunate dislocations are complex injuries; usually occur as a result of high-energy trauma and are frequently missed. Chronic trans-scaphoid perilunate dislocation is often difficult to manage and delayed presentation leads to poor functional outcomes. Various treatment modalities have been described which range from open reduction and internal fixation, staged reduction, proximal row carpectomy and wrist arthrodesis.     

Open reduction of chronic lunate and perilunate dislocations

Four patients with chronic lunate and perilunate dislocations were treated by open reduction and internal fixation. The interval between injury and operation was 7, 8, 14 and 18 weeks, respectively. Both palmar and dorsal surgical approaches were needed to reduce the old dislocation in all cases. A case of dorsal trans-scaphoid perilunate dislocation showed concurrent partial disruption of the scapholunate ligament. Transient vascular compromise of either the lunate or the proximal scaphoid fragment was noted in three patients. Despite the delay in treatment, all patients had satisfactory outcomes.     

Complete palmer lunate enucleation -- is proximal row carpectomy or wrist arthrodesis the only choice？

Perilunate dislocations are rare injuries of the wrist and complete dislocation of the lunate is also rare. There is controversy in literature regarding the optimal management of such injuries. Complete lunate enucleation is associated with high rate of osteonecrosis of lunate thus wrist arthrodesis or proximal row carpectomy has been ad- vocated as primary treatment for such injuries. We report a case of transradial styloid complete palmar lunate enucle- ation in a 25-year-old male patient who sustained injury to the left wrist due to fall on outstretched hand. Carpal row salvage surgery initially by closed reduction and wrist distractor application followed by open reduction and in- ternal fixation with K-wires along with ligamentous repair resulted in restoration of normal wrist anatomy and good functional outcome. As many of these injuries are missed on initial presentation and outcome is poor for missed injuries, prompt diagnosis and early surgical management to restore vascularity of lunate is recommended.     

近排腕骨切除术治疗陈旧性经舟骨月骨周围骨折-脱位

目的报道近排腕骨切除术治疗陈旧性经舟骨、月骨周围脱位的临床效果。方法对 34例应用此手术的患者进行功能评价,平均随访5年3个月。结果29例腕部疼痛症状消失,5例仍有轻微腕部疼痛不适;腕关节屈伸活动度较术前增加了30°～50°;尺、桡偏活动较差,范围20°～30°;握力较健侧稍减弱;29例恢复了原来的工作,5例改为轻工作。结论近排腕骨切除术是治疗陈旧性经舟骨、月骨周围脱位的一种可靠有效的方法。     

Luxation ouverte transscaphorétrolunaire du carpe avec avulsion antébrachiale du semi-lunaire et du fragment scaphoïdien

The authors report a case of dorsal transscaphoid perilunate dislocation which is noteworthy because there was significant anterior displacement of the lunate together with the proximal part of the scaphoid. The lunate was propelled in front of the radial epiphysis and the proximal part of the scaphoid ended up in front of the metaphyseal part of the radius. An emergency partial proximal row carpectomy was performed, preserving the distal part of the scaphoid. Good anatomic and functional result was observed at 6 years follow-up.     

Functional results after proximal row carpectomy to salvage a wrist

Proximal row carpectomy is a movement-preserving procedure in the treatment of arthrosis of the wrist. We have retrospectively assessed the objective and subjective functional results after proximal row carpectomy. Assessment of outcome included measurement of range of movement (ROM), grip strength and self-assessment of pain relief with a visual analogue scale (VAS) and the Disabilities of arm, shoulder, and hand (DASH) questionnaire. Results were graded using the Mayo and Krimmer wrist scores. Fourty-five patients (mean age 48 (30–67) years) were evaluated with a follow-up of 32 (8–115) months. Underlying conditions included: degenerative arthritis secondary to scapholunate advanced collapse deformity, or chronic scaphoid non-union (n=35), Kienböck disease stage III (n=4), chronic perilunate dislocation and fracture-dislocation (n=4), avascular necrosis of the scaphoid (n=1), and severe radiocarpal arthrosis secondary to distal radial fracture (n=1). Active ROM for wrist extension and flexion was 70° and mean radial and ulnar deviation 30.8°. Grip strength was 51% of the unaffected side. The average DASH score was 26. The intensity of the pain, measured by VAS, was reduced by 44% after strenuous activities and by 71% at rest. The Mayo and Krimmer wrist scores were 55 and 62 points indicating good results; 32 patients returned to work and 25 patients to their former occupation. Our results show that proximal row carpectomy is a technically easy operation that preserves a satisfying ROM and pain relief, and is recommended when the head of the capitate and the lunate fossa are not affected by arthrosis.     

Dorsal perilunate dislocations and fracture-dislocations: questionnaire, clinical, and radiographic evaluation

Twenty-two consecutive patients (23 wrists) underwent open reduction internal fixation of dorsal perilunate dislocations and fracture-dislocations through combined dorsal and volar approaches. One of 5 experienced wrist surgeons performed these procedures within an average of 3 days of injury (range, 0-26 days) and intercarpal fixation was kept within the proximal carpal row. Motion was instituted an average of 10 weeks (range, 5-16 weeks) after injury. All patients were males. The average age at the time of injury was 32 years (range, 16-60 years). The average follow-up period was 37 months (range, 13-65 months). Average flexion-extension motion arc and grip strength in the injured wrist were 57% and 73%, respectively, compared with the contralateral wrist. The scapholunate angle increased and the revised carpal height ratio decreased over time, which was statistically significant for both measurements. Three patients (3 wrists) required wrist arthrodesis and a fourth patient had an immediate scaphoid excision and 4-corner arthrodesis secondary to an irreparable scaphoid fracture. One patient required a proximal row carpectomy to treat septic arthritis. Nine of the remaining 18 wrists had radiographic evidence of arthritis, most often at the capitolunate or scaphocapitate articulations. Short form-36 mental summary scores were significantly greater than age- and gender-matched US population values; physical summary scores were significantly less. The disabilities of arm, shoulder, and hand evaluation, Mayo wrist score, and patient-rated wrist evaluation all reflected loss of function. Seventy-three percent of all patients had returned to full duties in their usual occupations and a total of 82% were employed.     

Concurrent scaphoid fracture with scapholunate ligament rupture

Various patterns of traumatic carpal injury have been described in the literature. Although the combination of scaphoid fracture and scapholunate ligament rupture in the same injury has been reported and these lesions can no longer be considered mutually exclusive, little information is available on management methods and the long-term results of such seemingly paradoxical complex injuries. This study reviews 11 previously described cases and reports an additional two cases of concurrent scaphoid fracture with scapholunate ligament rupture. This concurrent injury has two presentations; namely perilunate fracture-dislocation, which is the most common presentation, and complex scaphoid fracture. No single mechanism of injury exists that accounts for these complex injuries. High-energy trauma was the only characteristic common to all these cases. Most cases had unsatisfactory radiographic results including scaphoid nonunion, avascular necrosis of the lunate or the proximal pole of the scaphoid and arthrotic wrist changes at an average follow-up of 11 months. Managing these difficult problems needs critical recognition and repair of both bony and ligamentous damage. Early proximal row carpectomy or four-corner midcarpal fusion is another option when these injuries preclude stable reduction and fixation.     

Changes in radiocarpal loading characteristics after proximal row carpectomy

PURPOSE: To document the changes in wrist loading that occur after proximal row carpectomy in a cadaver model. METHODS: The normal radioulnar carpal pressure distributions of 7 cadaver wrists were measured using super-low-pressure-sensitive film. Proximal row carpectomies were performed and the loading characteristics re-evaluated. RESULTS: In the lunate fossa the contact area increased 37%, the average contact pressure increased 57%, and the location of the contact moved radially 5.5 mm. With wrist motion between 40 degrees of extension and 20 degrees of flexion the volar/dorsal excursion of the lunate fossa contact point increased by 108%. CONCLUSIONS: Significant changes in radiocarpal loading occur after proximal row carpectomy. The increased radiocarpal excursion with wrist motion may explain the low incidence of radiocapitate arthritis in patients who have had proximal row carpectomy.     

Acute dorsal trans-scaphoid perilunate fracture-dislocations: medium-term results

The purpose of this study was to investigate the medium-term results (mean follow-up, 8 years) of a series of 14 trans-scaphoid dorsal perilunate fracture-dislocations treated operatively at an average of 6 days following injury. Eleven underwent open reduction and internal fixation through a dorsal approach. Combined palmar and dorsal approaches were used in only three cases, for open reduction and internal fixation in two and proximal row carpectomy in one. The Mayo wrist score revealed five excellent, three good, five fair and one poor result. The average score was 79% (range 55-95%). All internally fixed scaphoids healed and no lunate or scaphoid fragment avascular necrosis with collapse was observed. Carpal alignment was satisfactory in most cases. Post-traumatic radiological midcarpal and/or radiocarpal arthritis were almost always observed at follow-up, but this did not correlate with the Mayo wrist score.     

Greater Arch Injuries

Dislocations and fracture dislocations of carpal bones are uncommon injuries which invariably poses challenges in the management. Perilunate fracture dislocations are the combination of ligamentous and osseous injury that involve the “greater arc” of the perilunate associated instability. Despite their severity, these injuries often go unrecognized in the emergency department leading to delayed diagnosis and treatment. A Prospective study was done from June 2008 to December 2013 in 15 cases of complex wrist injuries which included of greater arch injuries, perilunate fracture dislocation and one dorsal dislocation of Scaphoid. 10 cases of perilunate fracture dislocation underwent open reduction and internal fixation with Herbert screw and k-wire, 4 cases of greater arch injury underwent closed reduction and kwire fixation and one case of neglected dorsal dislocation underwent proximal row carpectomy. One patient had Sudecks osteodystrophy 1 had Scaphoid nonunion and 6 had median nerve compression. Overall outcome according to Mayo wrist score was 53 % excellent, 33 % good and 14 % fair. Greater arch injuries are difficult to treat because injuries to many ligaments are involved and failure to recognize early leads to persistent pain, disability and early onset of arthritis. Prompt recognition requires CT scan and MRI. Management requires reduction and multiple K-Wiring according to merits of the case.     

On resection of the proximal carpal row

Thirty-one patients (30 men and one woman) ranging from 19 to 64 years of age underwent proximal row carpectomy for posttraumatic arthrosis of the carpus. The injuries included transscaphoid perilunate dislocations with late subluxation and arthritis, ununited scaphoid fractures with arthritis, scapholunate dissociations with arthritis, and acute carpal injuries, including dislocations and comminuted fractures. The follow-up period ranged from two to 12 years. Wrist motion and grip strength were satisfactory. There were two failures, both of which converted to wrist arthrodesis.