Early results of reconstruction of the dorsal scapholunate ligament

We present the clinical results of a study of chronic dynamic scapholunate (SL) dissociation treated by reconstruction of the dorsal SL ligament. A total of 35 patients who presented with chronic dynamic SL instability had the scapholunate ligament reconstructed with a tendon graft. Twenty-nine patients were available for follow-up evaluation after a minimal interval of 17 months (range 17-72). Patients' satisfaction was good in 26/29 patients. Postoperative range of movement was reduced in extension and improved for flexion and ulnar deviation. Mean wrist movements were 75% of those on the opposite side. Most patients had good pain relief and recovered their grip strength, and returned to their regular employment. Follow-up stress radiographs showed a reduction in the SL angle and gap. Reconstruction of the dorsal SL ligament provides sufficient restoration of stability, pain relief, and functional improvement of the wrist for patients with dynamic SL instability. Although the short-term results are encouraging, we think that this method should be verified by longer follow-up.     

Results of tri-ligament tenodesis: a modified Brunelli procedure in the management of scapholunate instability

One hundred and sixty-two patients with a diagnosis of scapholunate instability underwent a modified Brunelli procedure over a 7-year period. One hundred and seventeen were assessed with the help of a questionnaire and, of these, 55 patients attended for clinical evaluation. The mean follow-up was 4 (1-8) years. There were 72 patients with dynamic scapholunate instability and 45 patients with static instability. The average age was 38 years. There were 50 males and 67 females. A total of 77 (62%) patients had no to mild pain with a mean visual analogue score of 3.67 (SD=2.5). The loss in the arc of flexion-extension was due to a reduced range of flexion (mean loss 31%), while 80% of extension was maintained, compared with the contralateral side. The grip strength on the operated side was reduced by 20% of the non-operated side. There was no statistically significant difference (P>0.05) in the range of movement or the grip strength between the static and dynamic group and patients with or without legal claims. Ninety (79%) patients were satisfied with the result of the surgery (good to excellent) and 88% of the patients felt that they would have the same surgery again. We feel that these results compare favourably with the early results published from this unit and recommend this procedure for dynamic and static scapholunate instability.     

Early results of reconstruction of the dorsal scapholunate ligament

Abstract

We present the clinical results of a study of chronic dynamic scapholunate (SL) dissociation treated by reconstruction of the dorsal SL ligament. A total of 35 patients who presented with chronic dynamic SL instability had the scapholunate ligament reconstructed with a tendon graft. Twenty-nine patients were available for follow-up evaluation after a minimal interval of 17 months (range 17–72). Patients' satisfaction was good in 26/29 patients. Postoperative range of movement was reduced in extension and improved for flexion and ulnar deviation. Mean wrist movements were 75% of those on the opposite side. Most patients had good pain relief and recovered their grip strength, and returned to their regular employment. Follow-up stress radiographs showed a reduction in the SL angle and gap. Reconstruction of the dorsal SL ligament provides sufficient restoration of stability, pain relief, and functional improvement of the wrist for patients with dynamic SL instability. Although the short-term results are encouraging, we think that this method should be verified by longer follow-up.     

Long-term results after repair and augmentation ligamentoplasty of rotatory subluxation of the scaphoid

Twenty-two patients had scapholunate ligament repairs combined with a new augmentation ligamentoplasty for chronic scapholunate dissociation. All were evaluated by physical and radiologic examination after a mean postoperative follow-up period of 63 months (range, 12-134 mo). According to Green and O'Brien and Johnson and Carrera scores 5/8 had excellent, 13/12 good, and 4/2 fair results. Thirteen were free of pain; 6 had mild pain and 3 had moderate pain. Nineteen returned to their original occupation. There was an average loss of 10 degrees of flexion, 9 degrees of extension, and 11% of grip force compared with the opposite wrist. Radiologic examination showed an average decrease of 12 degrees of the scapholunate and 10 degrees of the radiolunate angles compared with the levels before surgery. No signs of degenerative osteoarthritis were found in 16 (73%) cases. Five wrists showed a distinct pattern of midcarpal degeneration correlating with notable dorsal intercalated segment instability after surgery, and 2 cases had signs of radioscaphoid degeneration.     

Scaphoid-trapezium-trapezoid fusion in the treatment of chronic scapholunate instability

Limited intercarpal arthrodesis for chronic scapholunate instability has been the subject of several recent publications. We have followed nine patients, who had scapho-trapezio-trapezoidal (S-T-T) fusion for scapholunate instability. All nine patients were re-examined recently after an average follow-up period of 19 months (range, 12 to 25 months). Six of the nine patients believed that their symptoms were significantly improved. The postoperative range of wrist motion (ROM) was decreased in all directions of motion. The pinch strength averaged 86% on the treated side and the grip strength averaged 74% of the unoperated side. Review of follow-up x-ray films showed radiographic evidence of union in eight of nine patients. We conclude that, with careful patient selection and close attention to operative detail, S-T-T fusion can be an effective treatment for scapholunate instability. However, the results are not uniformly predictable, and neither range of motion nor strength is normal after the procedure.     

Long-term Outcomes of Arthroscopic Debridement and Thermal Shrinkage for Isolated Partial Intercarpal Ligament Tears

A retrospective analysis was performed based on the medical records and imaging studies of 16 wrists (14 patients) with isolated partial intercarpal ligament tears (scapholunate ligament: 6 wrists, lunotriquetral ligament, 10 wrists) treated with arthroscopic debridement and thermal shrinkage. Three wrists had Geissler grade 1 tears and 13 wrists had grade 2 tears. Mean follow-up was 52.8 months. Overall pain visual analog scale scores improved significantly (P<.05) at rest and during activities of daily living and heavy manual work. Mean flexion-extension arc was 136.5°. Mean postoperative grip strength was 106 lb, which was significantly better than preoperative grip strength. Mean modified Mayo wrist score was 70 preoperatively and 94.7 postoperatively, a significant improvement. Overall functional outcomes according to the modified Mayo wrist score were rated as excellent in 13 wrists and good in 3. No patient had radiographic evidence of instability or arthritic changes. The scapholunate and lunotriquetral intervals in all patients were less than 3 mm on neutral and pronation grip radiographs. On lateral radiographs, no signs of intercalated segmental instability were seen, with a mean scapholunate angle of 55.3°.The results of this study suggest that arthroscopic debridement and thermal shrinkage provide symptomatic pain relief and prevention of intercarpal instability for a significant period of time in patients with partial intercarpal ligament tear.     

The Floating Lunate: Arthroscopic Treatment of Simultaneous Complete Tears of the Scapholunate and Lunotriquetral Ligaments

Carpal instabilities continue to be a controversial topic in hand surgery. Accurate diagnosis of the ligament injuries is usually difficult without an arthroscopic evaluation. Few studies have focused on the diagnosis and proper management of simultaneous scapholunate (SL) and lunotriquetral (LT) ligament tears. This is an uncommon injury that leads to marked disability and chronic wrist pain. This is essentially a “floating lunate” and indicates a severe ligamentous lesion. Thirteen patients (six female and seven male) with complete SL and LT tears and with gross arthroscopic dynamic carpal instability were included in the present study. None of the patients showed radiographic evidence of lunate dislocation. One patient presented acutely and was operated on 3 days after the injury. The average time from the initial injury to the arthroscopy for the other 12 patients was 13.5 months (range 1.5–84 months). All patients underwent arthroscopic debridement of the SL and LT ligaments coupled with percutaneous pinning (two 0.045-in. Kirschner wires) in both joints. At the final follow-up, the average range of motion was 50° of flexion, 54° of extension, 77° of pronation, 80° of supination, 25° of ulnar deviation, and 15° of radial deviation. The average final grip strength was 67% from the non-affected side. All patients had negative shifting tests at final follow-up. Furthermore, there was no evidence of any static or dynamic instability in all the patients except for one patient who developed a volar intercalated segment instability 8 months after the surgery. At the final follow-up, ten patients had no pain, one had mild pain, and two experienced moderate pain.     

Scaphotriquetral capsulodesis for scapholunate instability

Objectives

Scapholunate ligament injuries may lead to scapholunate instability and wrist osteoarthritis. Many surgical techniques have been described to repair these injuries. The goal of our study is to assess the clinical results after capsulodesis with the scaphotriquetral ligament for scapholunate instabilities.

Methods

Twenty-eight patients, 22 men and six women, were operated for scapholunate instability between January 2006 and December 2008. The average age was 37, 8 years, and the average time between trauma and surgery was 9,9 months. The scaphoid shift test was present in 26 patients. All patients underwent static and dynamic X-rays of the wrist and scan. A capsulodesis with scaphotriquetral ligament was performed in all patients.

Results

At 24 months follow-up, a 13° significant decreased of wrist range-of-motion was noted. The strength was significantly improved after surgery. The wrist stability was improved in 26 patients. Concerning pain, a significant reduction was noted with Analogical Visual Scale after surgery (p < 0.005). Twenty-one patients returned to their previous work. Complications were reflex dystrophy in one patient and wrist infection in one patient.

Conclusion

Many techniques were described for treatment of scapholunate injuries, from the simple scapholunate ligament suture to partial wrist arthrodesis. Capsulodesis with scaphotriquetral ligament improves grip strength, decreases wrist instability and pain with a slight lost of range-of-motion.     

Outcome of proximal row carpectomy.

Fifty-one patients who had had proximal row carpectomy between 1992 and 2002 with a minimum follow-up of one year were followed up clinically and radiologically retrospectively. Their diagnoses included Kienb?ck disease (n=21), avascular necrosis of the scaphoid (n=4), nonunion of the scaphoid with osteoarthritis (n=9), and scapholunate advanced collapse (n=17). The mean follow-up was 5 years, 8 months. The mean "disabilities of the arm, shoulder and hand" (DASH) score was 18. The mean patient-rated wrist evaluation (PRWE) score list was 25% of maximum disability for the function and pain score. Thirty-four patients (87%) were able to return to work a mean of six months after operation (range 3 weeks - 35 months). Nine patients (11%) required arthrodesis of the wrist and are considered as failures. Mean flexion of the wrist was 66%, extension 73%, radial deviation 74%, ulnar deviation 76%, and grip force 70% of the opposite side. Excision of the proximal row provided predictable and durable pain relief, restored functional movement and grip strength, and allowed returned to gainful employment in most of the patients.     

Management of complex elbow instability

Scapholunate instability is the most common form of carpal instability. Repair or reconstruction of the scapholunate interosseus ligament is advocated to reduce symptoms, stabilize the scapholunate joint and avoid the progression of carpal degeneration. Aim of this study is to evaluate the results (clinical and radiographic) obtained in 18 patients treated in our department for acute lesions SLIL from 2003 to 2008. Patients were 16 males and 2 females with an average age at the time of the trauma of 33.8 years old (min 17 and max 68 years). The diagnosis of scapholunate dissociation relies on a through history and physical examination and imaging studies. Early surgical repair of the torn schapolunate ligament was performed in all the patients. The method used for the treatment of these lesions was open reduction and direct ligament reinsertion through a minianchor MITEK^®. In our surgical experience in 3 cases we have found a combination between an isolated scaphoid fractures and a scapholunate ligament rupture without carpal dislocation. We reviewed all patients treated with an average follow-up of 32 months (range 9–68 months). The review was carried out both clinically and radiographically (static and dynamic). We achieved 13 excellent results (Mayo score average 94,77), 3 good results (Mayo score average 84), 1 sufficient results (Wrist score 72) and 1 bad result (Wrist score 35). From the radiographic evaluation we found a loss of reduction in the two cases identified clinically as sufficient and bad. One patient after an optimal ligament healing, underwent to a recurrence of the lesion SLIL 2 years from surgery. Open reduction and direct bony fixation of the torn scapholunate ligament using a suture anchor is generally successfull in restoring scapholunate stability and has produced good functional mid-term results. At an average follow up of 32 months excellent or good functional outcomes were reported in 88% of the patients despite a large number of cases with a high energy trauma and other associated injury. The association between an isolated scaphoid fracture and a SLIL lesion is rare but not impossible in presence of a scapholunate instability we recommend the immediate reconstruction of the torn ligament.     

Soft tissue stabilization in the management of chronic scapholunate instability without osteoarthritis. A 15-year series

Management of chronic scapholunate instability without osteoarthritis remains controversial. Some surgeons favor partial wrist arthrodesis; others, soft tissue stabilization. Many techniques for soft tissue repair have been described but with few or unpredictable results. We reviewed all our cases of scapholunate instability without osteoarthritis treated by soft tissue stabilization. Since 1979, 37 soft tissue stabilization procedures have been performed to correct dynamic (25) or static (12) scapholunate instability without osteoarthritis. The average time from injury to surgical treatment was 7.2 mos. (range 0.25 to 36 mos.). Three cases were treated within the first month of injury. The choice of repair was determined intraoperatively. The scaphoid shift must be easily reducible to make the case eligible for soft tissue repair. The scapholunate ligament was usually disrupted from palmar to dorsal, and the average amount of disruption was 74%. When scapholunate ligament remnants were of sufficient quality, secondary repair was performed; but if not, ligament reconstruction using tendon grafts or capsulodesis was performed. The procedures used were secondary ligamentous repair in 16 (by direct suture, reinsertion using anchor and/or transosseous reattachment), ligament reconstruction using tendon grafts in 6, capsulodesis in 7 and a combination of these procedures in 8. The mean follow-up was 27 mos. (range 2 to 62 mos.). Postoperatively, there was an 83% decrease in pain. The average wrist motion was 60 degrees extension, 47 degrees flexion, 18 degrees radial deviation and 28 degrees ulnar deviation (92%, 84%, 106% and 88% of preoperative values and 88%, 75%, 78% and 76% of the uninvolved wrists, respectively), and the grip strength was 28 kg (117% of preoperative value and 78% of the uninvolved wrists). On roentgenograms, the mean static scapholunate distance was 4.2 mm (a 26% loss of reduction compared to the early postoperative gap), but scapholunate and radiolunate angles were within normal values (58 degrees and 9 degrees, respectively). At follow-up, one patient presenting a small zone of chondromalacia on the scaphoid at the time of secondary ligamentous repair developed severe radioscaphoid arthritis 15 months postoperatively. The results were further assessed according to the form of instability, delay before surgery, severity of disruption and type of repair. Patients with static instability showed worse clinical and radiological findings than those with dynamic instability. Surgical delay did not influence the outcome. The more severe the ligament disruption was, the poorer were the results. All types of repair had a comparable outcome except those treated by ligament reconstruction using tendon grafts. The results in the latter group were unsatisfactory in terms of motion, grip strength and radiological findings. This technique has been abandoned by the group. In conclusion, soft tissue stabilization is part of the armamentarium in the management of reducible chronic scapholunate instability without osteoarthritis. Ligament reconstruction using tendon grafts gave, in our hands, unsatisfactory results. Otherwise, all types of repair achieved a relatively pain-free wrist, with acceptable motion, grip strength, scapholunate and radiolunate angles but with a wider than normal static scapholunate distance. A longer follow-up is needed to assess the effect of this abnormal gap. Factors that favorably affected the outcome were: dynamic type of instability and partial disruption of the ligament.     

Dorsal capsulodesis for scapholunate instability--effect on patient disability and wrist pain

Twenty cases of scapho-lunate instability have been reviewed, to determine the effect of dorsal capsulodesis on disability and wrist pain. The average follow-up was 41 (range 13-63) months. There was a significant improvement in the pre-operative Patient Rated Wrist Evaluation score from 108 (range 18-150) to a postoperative score of 60 (range 0-132). All wrist movements and grip strength were reduced postoperatively but only the reductions in flexion and radial deviation were statistically significant. Seventeen (85%) patients were satisfied with the operation. One patient remained unemployed after surgery. Five patients returned to their normal jobs. This study shows that dorsal capsulodesis should remain an important option in the treatment of scapholunate instability.     

The efficacy of ultrasound in the evaluation of dynamic scapholunate ligamentous instability

BACKGROUND: The accuracy of diagnostic imaging modalities that are currently used to evaluate dynamic scapholunate ligamentous instability is equivocal. Ultrasound is commonly used for a wide variety of diagnostic purposes in orthopaedics. The purpose of the present study was to determine the efficacy of ultrasound in the diagnosis of dynamic scapholunate ligamentous instability. METHODS: Two groups of individuals were prospectively studied. Group A included patients with a clinical diagnosis of unilateral dynamic scapholunate ligamentous instability, and Group B included asymptomatic volunteer control subjects. Dynamic ultrasound examinations of the dorsal portion of the scapholunate ligament in both wrists of all individuals were performed by radiologists. The radiologists were blinded with regard to the group to which each person belonged as well as with regard to the affected wrist in the patients in Group A. Arthroscopic examinations of the affected wrist in all of the patients in Group A were then performed by surgeons who were blinded with regard to the results of the ultrasound examination, and the results of the arthroscopic and ultrasound examinations were compared. The ability of ultrasound to discern asymptomatic from symptomatic individuals was also determined. RESULTS: Over a period of 1.5 years, a total of sixty-four wrists were evaluated in fourteen patients (Group A) and eighteen normal subjects (Group B). All fourteen nonaffected wrists in Group A and all thirty-six wrists in Group B were correctly identified as normal with use of ultrasound. Of the fourteen affected wrists in Group A, thirteen were found to have scapholunate ligament laxity on the basis of arthroscopy (twelve wrists) or arthrotomy (one wrist); six of these thirteen wrists had been correctly identified as abnormal with use of ultrasound (a true-positive result), and seven had false-negative results. There was one true-negative result. The ability of ultrasound to differentiate between normal and abnormal wrists was significant (p < 0.001). For the sixty-four wrists, statistical analysis revealed that ultrasound had a sensitivity of 46.2%, a specificity of 100%, and an accuracy of 89.1%. CONCLUSIONS: We conclude that ultrasound has a high specificity and accuracy but a low sensitivity for the evaluation of dynamic scapholunate ligamentous instability, and we recommend its use as an adjunct to other diagnostic modalities for this purpose.     

Surgical technique for the treatment of radial wrist pain.

Chronic radial wrist pain with no radiographic evidence of scapholunate instability or other wrist disease can be difficult to diagnose and treat. Our purpose was to evaluate the results of an operation to treat chronic radial or periscaphoid wrist pain that has failed to respond to conservative treatment. We examined the scapholunate ligament and performed a dorsal capsulodesis. One hundred-and-two patients were reviewed retrospectively. Casenotes were available for 88 patients. Function, pain, range of movement (ROM), and grip and pinch strengths were evaluated. Twenty (23%) of the patients were found to have a scapholunate ligament tear of 0-30%, 55 (61%) had a tear of 30%-60%, and 14 (16%) had a tear of 60%-100%. Mean postoperative grip strength was 29.5 kg (80% of the normal side). Postoperative range of movement was significantly limited in flexion compared with the normal side. All patients returned to their previous employment. Seventy (80%) of the patients described improvement in pain and function. Twenty-two (25%) required further operation on the same wrist. This procedure may be indicated in patients with chronic radial wrist pain and no overt instability that is resistant to conservative treatment. It has minimal morbidity and gives good results.     

Tenodesis of the extensor carpi ulnaris for chronic, post-traumatic lunotriquetral instability

We describe a technique of soft-tissue reconstruction which is effective for the treatment of chronic lunotriquetral instability. Part of extensor carpi ulnaris is harvested with its distal attachment preserved. It is passed through two drill holes in the triquetrum and sutured to itself. This stabilises the ulnar side of the wrist. We have reviewed 46 patients who underwent this procedure for post-traumatic lunotriquetral instability with clinical signs suggestive of ulnar-sided carpal instability. Standard radiographs were normal. All patients had pre-operative arthroscopy of the wrist at which dynamic lunotriquetral instability was demonstrated. A clinical rating system for the wrist by the Mayo clinic was used to measure the outcome. In 19 patients the result was excellent, in ten good, in 11 satisfactory and in six poor. On questioning, 40 (87%) patients said that surgery had substantially improved the condition and that they would recommend the operation. However, six (13%) were unhappy with the outcome and would not undergo the procedure again for a similar problem. There were six complications, five of which related to pisotriquetral problems. The mean follow-up was 39.1 months (6 to 100). We believe that tenodesis of extensor carpi ulnaris is a very satisfactory procedure for isolated, chronic post-traumatic lunotriquetral instability in selected patients. In those with associated pathology, the symptoms were improved, but the results were less predictable.     

软组织重建舟月骨间韧带治疗慢性舟月分离的影像学改变

目的 观察背侧腕骨间韧带关节囊固定术和3-韧带肌腱固定术治疗慢性舟月分离术后腕关节的影像学改变,明确术后舟月分离复发的比例及时间.方法 自2008年1月至2011年1月,共治疗慢性舟月分离患者23例,19例行背侧腕骨间韧带关节囊固定术,4例行3-韧带肌腱固定术.平均随访10.1个月.分别记录术前、拔针后1个月和末次随访时的影像学和临床结果.在手术前后采用疼痛视觉模拟评分(visual analog scale,VAS)和DASH表格问卷评估主观的疼痛程度、功能改善和患者满意度.结果 影像学结果显示,所有患者腕骨的排列异常在手术中均获得完全纠正.拔针后1个月,舟月间隙平均为4 mm、舟月角平均为75°,舟月间隙和舟月角较术前改善,但61％患者的舟月间隙、52％患者的舟月角恢复至术前水平.末次随访时,舟月间隙平均为4,3 mm、舟月角平均为78°,舟月间隙和舟月角较拔针后1个月时畸形加重,但与术前比较差异无统计学意义.临床结果显示,腕关节屈曲和背伸分别从术前为健侧的66％和69％降至术后的52％和50％.握力从健侧的71％降至66％.结论 背侧腕骨间韧带关节囊固定术和3-韧带肌腱固定术后慢性舟月分离多在短期内复发,拔针后1个月时超过半数病例的舟月分离恢复至术前水平,治疗慢性舟月分离的理想手术方式仍不得而知.     

Anatomical reduction of intra-articular fractures of the distal radius. An arthroscopically-assisted approach

We treated 31 intra-articular fractures of the distal radius by arthroscopically-assisted reduction and percutaneous fixation with Kirschner (K-) wires. Tears of the triangular fibrocartilage (58 %), scapholunate (85 %) and lunotriquetral (61%) instability and osteochondral lesions (19%) were also treated. A total of 26 patients was independently reviewed at an average of 19 months. The mean pain score was 1.3/10, the range of movement 79% and the grip strength 90% of the contralateral wrist. Using the New York Orthopaedic Hospital score, 88% were graded excellent to good. On follow-up radiographs, 65% had no step and 31% had a step of < or =1 mm. Pain was significantly related to the size of the step. There was a significant difference in the incidence of persistent scapholunate diastasis and the Leibovic and Geissler grade (p < 0.01): I (0%), II (0%), III (42%) and IV (100%). We recommend anatomical reduction and acceptance of a step of <1 mm since the size of the step is related to the incidence of pain.     

Arthroscopic dorsal capsuloplasty in chronic scapholunate ligament tears: a new procedure; preliminary report

We report our preliminary results of arthroscopic dorsal capsuloplasty for chronic scapholunate lesions to obviate the need for an open exposure of the wrist capsule. Twenty-two consecutive patients with scapholunate ligament tears underwent an arthroscopically-assisted dorsal capsuloplasty with or without percutaneous pinning. The mean age of subjects was 36 years (range, 27 to 55 years). The mean preoperative delay was 9 months (range 3 to 24 months). Criteria for surgery were persistent pain over the dorsal radial wrist in the scapholunate region and a positive finding on performing Watson's test. All patients were reviewed at a mean follow-up of 13 months (range, 7 to 19 months). The range of motion was recovered with a slight limitation in flexion in only four cases. The average grip strength attained was 96% of the contralateral side. The results in terms of pain were excellent. The seven high level athletes resumed practice at the same level as prior to the injury. A longer follow-up is necessary to confirm these encouraging preliminary results.     

Degenerative arthritis of the wrist: proximal row carpectomy versus scaphoid excision and four-corner arthrodesis

Two cohort populations of 19 patients from separate institutions performing exclusively either a scaphoid excision and 4-corner arthrodesis (lunate, capitate, hamate, and triquetrum) or proximal row carpectomy (PRC) for scapholunate advanced collapse arthritis were compared. There were no preoperative differences with respect to age, gender, dominance, stage of arthritis, or preoperative measures of pain and function. The length of the follow-up period averaged 28 months for the 4-corner arthrodesis group compared with 19 months for the PRC patients. At the follow-up examination wrist motion revealed no significant differences in the flexion-extension arc, averaging 81 degrees in the PRC patients and 80 degrees following 4-corner arthrodesis, which was 62% and 58%, respectively, of the opposite wrist. The 4-corner arthrodesis patients maintained greater radial deviation and total percent radial-ulnar deviation of the wrist. Grip strength averaged 71% for the PRC group compared with 79% for the 4-corner arthrodesis patients. Pain relief was similar using a variety of measures and patient satisfaction was equivalent. Function was similar except that the 4-corner arthrodesis patients scored significantly higher on the mental health component of the short form-36 health status survey. No differences were seen on the physical health component or an outcome scale specifically designed for the wrist. Both PRC and scaphoid excision and 4-corner arthrodesis are motion-preserving options for the treatment of scapholunate advanced collapse arthritis with minimal subjective or objective differences in short-term follow-up evaluations.     

Atlantoaxial stabilization: clinical comparison of posterior cervical wiring technique with transarticular screw fixation

Symptomatic atlantoaxial instability requires atlantoaxial stabilization. In this study the authors compared clinical, radiographic, and cervical outcome questionnaire results in 67 such patients who underwent 71 separate procedures. Thirty-eight patients had traditional posterior C1-C2 cervical wiring and halo-vest immobilization (group 1), whereas 33 were alternatively managed with transarticular screw fixation without rigid external immobilization (group 2). Mean follow-up in group 1 was 53.2 months and mean follow-up in group 2 was 41.0 months. Radiographic evaluation demonstrated seven pseudoarthroses and four fibrous unions in group 1, with six patients subsequently undergoing reoperation. There were no pseudoarthroses and two fibrous unions in the transarticular screw group (p = 0.015). In those that fused, >2-mm displacement occurred in six of the group 1 patients (p = 0.027). There was a trend toward fewer complications in group 2 patients (p = 0.085) with four complications, as compared with 12 complications in group 1, including a 21% incidence of halo-vest-related complications. These results demonstrate the significant benefits of transarticular screw fixation over posterior cervical wiring techniques in the management of atlantoaxial instability.