Treatment of radiocarpal degenerative osteoarthritis by radioscapholunate arthrodesis and distal scaphoidectomy

PURPOSE: The purpose of this study was to assess wrist pain, range of motion, and the presence of radiographic midcarpal degenerative joint disease (DJD) in patients who had a distal scaphoidectomy in association to a radioscapholunate (RSL) arthrodesis and to compare these findings with prior studies of patients with only an RSL fusion. METHODS: Sixteen patients with radiocarpal DJD treated by RSL arthrodesis and distal scaphoidectomy were evaluated retrospectively for pain relief and range of motion at an average follow-up period of 37 months (range, 12-84 mo). Radiographs were assessed for the presence of secondary radiographic midcarpal DJD. RESULTS: Complete pain relief was obtained in 10 patients, 3 patients complained of slight pain during strenuous loading, and 3 patients had occasional pain with regular activities. The average postoperative ranges of motion were 32 degrees of flexion, 35 degrees of extension, 14 degrees of radial deviation, and 19 degrees of ulnar deviation. Two patients exhibited secondary midcarpal DJD. These results are significantly better compared with those previously published about RSL arthrodesis alone in terms of residual pain and decrease of wrist radial deviation and flexion. CONCLUSIONS: Patients who require an RSL arthrodesis for the treatment of severe localized radiocarpal DJD appear to have less pain and to retain more flexion and radial deviation if the distal scaphoid is excised concomitantly. This associated procedure also may help prevent secondary midcarpal DJD.     

Radiocarpal arthrodesis in the treatment of the rheumatoid wrist. A prospective midterm follow-up

This prospective study was performed to evaluate the clinical and radiological results of radiocarpal joint arthrodesis in the treatment of unstable Simmen group III and Larsen grade II or III rheumatoid wrists. Radiolunate arthrodesis was performed in 16 wrists and radioscapholunate arthrodesis in 7 wrists in 20 patients. When they were evaluated at a mean of 5.8 (range 3.5-9.8) years later, flexion was 29 degrees and extension 34 degrees , representing 67% and 92% of the preoperative values, respectively. Patient satisfaction was excellent, or good, for 20 wrists and satisfactory for 1 wrist. In two patients with poor satisfaction, arthritis progressed to the midcarpal joint and necessitated total arthrodesis of the wrist. Radiolunate joint arthrodesis, with inclusion of the scaphoid in the fusion if necessary, is a useful operation in the treatment of this degree of wrist disease as it produces a functional and pain-free wrist at the same time as preserving much of the mobility and bone stock.     

Kinematics of the midcarpal and radiocarpal joint in flexion and extension: an in vitro study

PURPOSE: To apply carpal kinematic analysis using noninvasive medical imaging to investigate the midcarpal and radiocarpal contributions to wrist flexion and extension in a quasidynamic in vitro model. METHODS: Eight fresh-frozen cadaver wrists were scanned with computed tomography in neutral, full flexion, and full extension. Body-mass-based local coordinate systems were used to track motion of the capitate, lunate, and scaphoid with the radius as a fixed reference. Helical axis motion parameters and Euler angles were calculated for flexion and extension. RESULTS: Minimal out-of-plane carpal motion was noted with the exception of small amounts of ulnar deviation and supination in flexion. Overall wrist flexion was 68 degrees +/- 12 degrees and extension was 50 degrees +/- 12 degrees. In flexion, 75% of wrist motion occurred at the radioscaphoid joint, and 50% occurred at the radiolunate joint. In extension, 92% of wrist motion occurred at the radioscaphoid joint, and 52% occurred at the radiolunate joint. Midcarpal flexion/extension between the capitate and scaphoid was 0 degrees +/- 5 degrees in extension and 10 degrees +/- 13 degrees in flexion. Midcarpal flexion/extension between the capitate and lunate was larger, with 15 degrees +/- 11 degrees in extension and 22 degrees +/- 19 degrees in flexion. CONCLUSIONS: The capitate and scaphoid tend to move together. This results in greater flexion/extension for the scaphoid than the lunate at the radiocarpal joint. The lunate has greater midcarpal motion between it and the capitate than the scaphoid does with the capitate. The engagement between the scaphoid and capitate is particularly evident during wrist extension. Out-of-plane motion was primarily ulnar deviation at the radiocarpal joint during flexion. These results are clinically useful in understanding the consequences of isolated fusions in the treatment of wrist instability.     

Distal scaphoid excision after radioscaphoid arthrodesis

Radioscaphoid and radioscapholunate arthrodeses are effective surgical procedures for the treatment of nonsalvageable and isolated radiocarpal arthritis. These procedures, however, limit wrist motion significantly as the immobile scaphoid bridges the remaining midcarpal joint. A cadaver study of radioscaphoid arthrodesis followed by distal scaphoid excision was undertaken. Range of motion after radioscaphoid K-wire fixation alone demonstrated a 58% decrease in the preoperative flexion-extension arc to 60 degrees. After distal scaphoid excision (with the radioscaphoid pins still in place) the flexion-extension arc increased to 122 degrees or 86% of the preoperative range of motion; most of the increase in motion occurred at the midcarpal joint. Distal scaphoid excision releases the midcarpal joint following radioscaphoid fixation and results in a significantly greater wrist motion. If the results of this cadaver study are extrapolated to clinical practice the addition of this step to the previously described procedures of radioscaphoid or radioscapholunate arthrodesis addresses their major limitation, restricted motion.     

Radioscapholunate Fusion Following Comminuted Fractures of the Distal Radius

Radioscapholunate (RSL) arthrodesis must be considered an appropriate procedure in painful radiocarpal arthrosis following comminuted fractures of the distal radius. Despite total wrist fusion, it offers the possibility to exclusively eliminate the destroyed articulation preserving a certain degree of motion in the midcarpal joint. Accordingly, 22 patients with painful posttraumatic arthrosis of the radiocarpal joint underwent RSL fusion between 1992 and 1998. Average follow-up was 18.7 months. Postoperatively, total range of wrist motion decreased by an average of 21° E-F and 6° U-R deviation. Average grip strength of the affected wrist improved from 31.9 to 51.1 kPa. There was a considerable decrease of pain during activity and at rest. Using the DASH questionnaire, an average of 25.7 points was reached. Radiologic examination revealed no major signs of arthritis at the midcarpal joint. In one patient, nonunion as well as reactivation of deep infection secondary to an infection sustained during surgical stabilization of the initial radial fracture were recorded. In our opinion, however, RSL fusion represents a good alternative to total wrist fusion, since valuable wrist motion is preserved.     

The effects of wrist distraction on carpal kinematics

Changes in carpal kinematics under wrist distraction were studied in fresh cadaveric specimens. A magnetic tracking device measured kinematic motions of the scaphoid, lunate, and third metacarpal relative to the fixed radius in 3 planes of passive motion (coronal, sagittal, and "dart throwers") under progressive distraction loads. The change in percent contribution of the radiocarpal and midcarpal joints was calculated. Radiocarpal motion during extension was decreased as increasing traction was applied, but it increased with flexion. Motion of the scaphoid relative to the lunate was smaller in the oblique plane, resulting in less radiocarpal motion than in the sagittal plane. In the coronal plane, traction had little effect on radial deviation, but ulnar angulation of the scaphoid was greater with ulnar deviation of the wrist. These results suggest that different degrees of tension exist in the palmar and dorsal ligaments with the wrist under traction and during different planes of wrist motion. If wrist motion is desired during fixed traction, such as used clinically with external fixation, the dart-throwers motion (wrist extension with radial deviation and wrist flexion with ulnar deviation) appears to have the least impact on radiocarpal motion. If greater radiocarpal motion is desired, however, such as during postoperative mobilization, flexion-extension and radioulnar deviation will create more radiocarpal motion than the dart-thrower's motion.     

In vivo radiocarpal kinematics and the dart thrower's motion

BACKGROUND: Wrist motion is dependent on the complex articulations of the scaphoid and lunate at the radiocarpal joint. However, much of what is known about the radiocarpal joint is limited to the anatomically defined motions of flexion, extension, radial deviation, and ulnar deviation. The purpose of the present study was to determine the three-dimensional in vivo kinematics of the scaphoid and lunate throughout the entire range of wrist motion, with special focus on the dart thrower's wrist motion, from radial extension to ulnar flexion. METHODS: The three-dimensional kinematics of the capitate, scaphoid, and lunate were calculated from serial computed tomography scans of both wrists of fourteen healthy male subjects (average age, 25.6 years; range, twenty-two to thirty-four years) and fourteen healthy female subjects (average age, 23.6 years; range, twenty-one to twenty-eight years), which yielded data on a total of 504 distinct wrist positions. RESULTS: The scaphoid and lunate primarily flexed or extended in all directions of wrist motion, and their rotation varied linearly with the direction of wrist motion (R2= 0.90 and 0.82, respectively). Scaphoid and lunate motion was significantly less along the path of the dart thrower's motion than in any other direction of wrist motion (p < 0.01 for both carpal bones). The scaphoid and lunate translated radially (2 to 4 mm) when extended, but they did not translate appreciably when flexed. CONCLUSIONS: The dart thrower's path defined the transition between flexion and extension rotation of the scaphoid and lunate, and it identified wrist positions at which scaphoid and lunate motion approached zero. These findings indicate that this path of wrist motion confers a unique degree of radiocarpal stability and suggests that this direction, rather than the anatomical directions of wrist flexion-extension and radioulnar deviation, is the primary functional direction of the radiocarpal joint.     

2007 IFSSH committee report of wrist biomechanics committee: biomechanics of the so-called dart-throwing motion of the wrist

The dart-throwing motion (DTM) plane can be defined as a plane in which wrist functional oblique motion occurs, specifically from radial extension to ulnar flexion. Most activities of daily living are performed using a DTM. The DTM utilizes the midcarpal joint to a great extent. Scaphotrapezio-trapezoidal anatomy and kinematics may be important factors that cause a DTM to be a more stable and controlled motion. During a DTM, there is less scaphoid and lunate motion than during pure flexion-extension or radioulnar deviation. Clinically, a DTM at the plane approximately 30 degrees to 45 degrees from the sagittal plane allows continued functional wrist motion while minimizing radiocarpal motion when needed for rehabilitation.     

Proximal row fusion as a solution for radiocarpal arthritis

A retrospective study evaluated the function of thirty-six patients treated by radius-scaphoid-lunate arthrodesis for painful posttraumatic radiocarpal arthritis from 1982 through 1987, and determined whether the procedure created arthritis or other functional problems in the remaining joints. Thirty-one men and five women with a mean age of 41 years were studied. The standard surgical technique employed iliac crest bone graft and internal fixation. Seven patients required revision of the proximal fusion to complete wrist fusion because of pain; arthritic changes in the midcarpal joint had been noted in these patients at the time of the limited fusion. The remaining twenty-nine patients required no further surgical treatment. Grip strength averaged 70% of the uninvolved side. The average arc of wrist flexion and extension was forty-eight degrees. Eighteen patients returned to their original employment, in many cases to heavy labor. Five did not return to work because of wrist problems. We conclude that the probability of a good functional result is high for this procedure if there is no midcarpal arthritis.     

The effect of sectioning the dorsal radiocarpal ligament and insertion of a pressure sensor into the radiocarpal joint on scaphoid and lunate kinematics.

The role of the dorsal radiocarpal wrist ligament has been the subject of several investigations. Several biomechanical studies have used sensors inserted dorsally into the wrist joint to evaluate its pressure distribution. The purpose of this study was to evaluate whether a dorsal capsulotomy that sections the dorsal radiocarpal ligament or insertion of a flexible pressure sensor alters scaphoid or lunate kinematics. Eight cadaver upper extremities were instrumented with motion sensors and placed in a wrist joint simulator. Each arm was moved through continual cycles of wrist flexion/extension and radial/ulnar deviation. Motion data were obtained in the intact state, after a capsulotomy, and after insertion of the sensor. We found that either a dorsal capsulotomy sectioning the dorsal radiocarpal ligament or insertion of the pressure sensor alters scaphoid and lunate kinematics during dynamic wrist motion. This study supports the clinical belief that this dorsal wrist ligament should be spared during surgical approaches to the carpus.     

Capitate-based kinematics of the midcarpal joint during wrist radioulnar deviation: an in vivo three-dimensional motion analysis

PURPOSE: The purpose of this study was to obtain qualitative and quantitative information regarding in vivo 3-dimensional (3D) kinematics of the midcarpal joint during wrist radioulnar deviation (RUD). METHODS: We studied the in vivo kinematics of the midcarpal joint during wrist RUD in the right wrists of 10 volunteers by using a technology without radioactive exposure. The magnetic resonance images were acquired during RUD. The capitate was registered with the scaphoid, the lunate, and the triquetrum by using a volume registration technique. Animations of the relative motions of the midcarpal joint were created and accurate estimates of the relative orientations of the bones and axes of rotation (AORs) of each motion were obtained. RESULTS: The scaphoid, lunate, and triquetrum motions relative to the capitate during RUD were found to be similar, describing a rotational motion around the axis obliquely penetrating the head of the capitate in almost a radial extension/ulnoflexion plane of motion of the wrist. The AORs of the scaphoid, the lunate, and the triquetrum were located closely in space. In the axial plane the AORs of the scaphoid, lunate, and triquetrum formed a radially and palmarly opening angle of 43 degrees +/- 7 degrees, 41 degrees +/- 11 degrees, and 42 degrees +/- 14 degrees with the wrist flexion/extension axis, respectively. CONCLUSIONS: This study reports the in vivo 3D measurements of midcarpal motion relative to the capitate. Isolated midcarpal motion during RUD could be approximated to be a rotation in a plane of a radiodorsal/ulnopalmar rotation of the wrist, which may coincide with a motion plane of one of the most essential human wrist motions, known as the dart-throwing motion.     

Kinematics of the midcarpal and radiocarpal joints in radioulnar deviation: an in vitro study

PURPOSE: Carpal kinematics have been studied widely yet remain difficult to understand fully. The noninvasive measurement of carpal kinematics through medical imaging has become popular. Studies have shown that with radial deviation the scaphoid and lunate flex whereas the capitate moves radiodorsally relative to the lunate. This study investigated the midcarpal and radiocarpal contributions to radial and ulnar deviation of the wrist. This was accomplished through noninvasive characterization of the scaphoid, lunate, and capitate using 3-dimensional medical imaging of the wrist in radial and ulnar deviation. METHODS: Eight fresh-frozen and thawed cadaveric wrists were used in an experimental set-up that positioned the wrist through spring-scale actuation of the 4 wrist flexor and extensor tendon groups. The wrists were scanned by computed tomography in neutral and full radial and ulnar deviation. Body mass-based local coordinate systems were used to track the motion of the capitate, lunate, and scaphoid with the radius as a fixed reference. Helical axis motion and Euler angles were calculated from neutral to radial and ulnar deviation for the capitate relative to the radius, lunate, and scaphoid and for the lunate and scaphoid relative to the radius. RESULTS: The capitate, scaphoid, and lunate moved in a characteristic manner relative to the radius and to one another. Radial and ulnar deviation occurred primarily in the midcarpal joint. Midcarpal motion accounted for 60% of radial deviation and 86% of ulnar deviation. In radial deviation the proximal row flexed and the capitate extended; the converse was true in ulnar deviation. CONCLUSIONS: Radioulnar deviation (in-plane motion) occurred mostly through the midcarpal joint, with a lesser contribution from the radiocarpal joint. The results of our study agree with previous investigations that found the scaphoid and lunate flex in radial deviation (out-of-plane motion) relative to the radius whereas the capitate extends (out-of-plane motion) relative to the scaphoid/lunate (with the converse occurring in ulnar deviation). Our study shows how these out-of-plane motions combine to produce in-plane wrist radioulnar deviation. The use of 3-dimensional visualization greatly aids in the understanding of these motions. The results of our study may be useful clinically in understanding the consequences of isolated midcarpal fusions in the treatment of wrist instability.     

Radiocarpal arthrodesis for osteoarthritis following fractures of the distal radius.

To compare the radioscapholunate (RSL) arthrodesis and radiolunate (RL) arthrodesis as a treatment for radiocarpal osteoarthritis following fractures of the distal radius, nine patients, 23 to 70 years old (average 41) at the time of surgery, were assessed two to 33 years after surgery. The periods between injury and surgery ranged from four months to 30 years. RSL arthrodesis was performed in three cases and RL arthrodesis in six. Post-operative wrist pain disappeared in six and was decreased in the other three. In the RSL group, the total arc of wrist flexion and extension was reduced from 50 degrees pre-operatively to 35 degrees post-operatively. In the RL group, it was increased from 72 degrees to 76 degrees after surgery. Grip strength improved in most patients, from 7 to 18 kg in the RSL group, and from 16 to 27 kg in the RL group. On roentogenogram, three patients showed arthritic changes in the adjacent joints, but there were no symptoms in two of the three patients. We concluded that partial radiocarpal arthrodesis (preferably RL arthrodesis) is a reliable procedure for radiocarpal osteoarthritis following fractures of the distal radius.     

Effects of a scaphoid waist osteotomy on carpal kinematics

The effects of a scaphoid osteotomy on the kinematics of the carpal bones were determined in five cadaveric wrist specimens. Minute radiographic markers were inserted into the distal radius and selected carpal bones through limited arthrotomies between the intercarpal ligaments. Simultaneous biplanar radiographs were obtained in neutral and the extreme wrist positions of extension, flexion, radial deviation, and ulnar deviation, both before and after a scaphoid waist osteotomy. The positions of each of the carpal markers and their corresponding carpal bones were digitized for each wrist position , and a computer-assisted motion analysis was performed for each specimen before and after transverse scaphoid waist osteotomy. Following the osteotomy, there was a tendency for the scaphoid osteotomy to collapse into a dorsally angulated or "humpback collapse" deformity during each extreme wrist position. There was also multiplanar osteotomy site motion as well as complex collapse deformities of the midcarpal joint associated with loss of the mechanical tie-rod function of the scaphoid. These findings reveal the importance of the scaphoid in maintaining normal kinematics and the inherent instability of these fractures with loss of scaphoid integrity.     

Combined radiocarpal arthrodesis and midcarpal (lunocapitate) arthroplasty for treatment of rheumatoid arthritis of the wrist

Arthroplasties for the wrist with rheumatoid arthritis are usually revised for the articulation between radius and carpus. The midcarpal joint is disregarded although it remains structurally better preserved and is therefore better suited for the preservation of stable motion. When the midcarpal surfaces are satisfactory, a radio-scapho-lunate fusion, accompanied by a midcarpal synovectomy, is an excellent procedure. When the midcarpal surfaces, particularly the head of the capitate, are also destroyed, the tendency has been to either perform a pan-arthrodesis, or to insert a wrist endo-prosthesis. For these severely unstable and destroyed wrists, a stabilization of the radiocarpal joint by arthrodesis, combined with preservation of motion at the midcarpal level by resection of the damaged head of the capitate and its replacement with a small implant has been done. This procedure has allowed all patients to retain a functional range of motion and to experience satisfactory relief of pain.     

An in vitro analysis of wrist motion: the effect of limited intercarpal arthrodesis and the contributions of the radiocarpal and midcarpal joints

Radiocarpal and intercarpal arthrodeses were simulated in 12 fresh cadaver wrists by means of external fixation. Range-of-motion measurements were made before and after simulated arthrodesis and used to calculate the contribution of the midcarpal and radiocarpal joints to wrist motion, as well as the residual wrist motion after limited intercarpal arthrodeses. Relative contributions to wrist motion were as follows: wrist flexion: radiocarpal (RC) joint 63%, midcarpal (MC) joint 36%; wrist extension: RC joint 53%, MC joint 46%. The wrist motion remaining after simulated arthrodeses was as follows: capitate-hamate: flexion (Flx) 98%, extension (Ext) 92%, ulnar deviation (UD) 96%, radial deviation (RD) 90%; scaphoid-lunate: Flx 97%, Ext 91%, UD 90%, RD 91%; scaphoid-trapezium-trapezoid: Flx 86%, Ext 88%, UD 67%, RD 69%; scaphoid-lunate-triquetrum: Flx 91%, Ext 82%, UD 86%, RD 70%; capitate-lunate: Flx 70%, Ext 59%, UD 89%, RD 79%; capitate-hamate-triquetrum: Flx 88%, Ext 79%, UD 88%, RD 81%; hamate-triquetrum: Flx 90%, Ext 85%, UD 89%, RD 94%; scaphoid-trapezium-trapezoid-capitate: Flx 85%, Ext 77%, UD 64%, RD 57%.     

Radiolunate and radioscapholunate arthrodesis

Summary Eleven patients underwent radiocarpal arthrodesis for a wrist disease other than rheumatoid arthritis. Operations included seven radiolunate fusions and four radioscapholunate fusions. The indication for surgery was posttraumatic changes secondary to radius fracture (five), Kienböck's disease (three), localized arthritis secondary to sepsis (two) and acute comminuted fracture of the distal radius (one). All patients had arthritis or post-traumatic changes limited to the articulation between the radius and carpus. Follow-up ranged from 24 months to 7 years, with an average of 41 months. Postoperatively, average range of motion of the wrist was 30.9° of extension, 22.7° of flexion, 10° of radial deviation, and 19.3° of ulnar deviation, and grip strength averaged 81.8% of that for the uninvolved hand. Pain relief was achieved in all patients, and they were able to return to their previous occupation. Bony union was achieved in all cases. Degenerative changes in the midcarpal joint were not seen.     

Cineradiographic study of wrist motion

To make clear the kinematics of the wrist in flexion-extension and radial-ulnar deviation, a cineradiographic study was carried out on twenty normal hands. The intercarpal angles were measured on each picture of the cineradiogram. The relationship between the wrist angle and the intercarpal angles were calculated by a micro-computer giving a 5th degree regression curve. From the maximal dorsiflexion to the neutral position, the wrist moves in the radiocarpal joint more than in the midcarpal joint, while, from the neutral position to the maximal palmar flexion, the wrist moves more in the latter. From the neutral position to the maximal radial deviation, the wrist motion occurs in the midcarpal joint more than in the radiocarpal joint, while, from the neutral position to maximal ulnar deviation, the wrist motion occurs equally in the two joints. The movements of the carpal bones were regulated by the tension and the relaxation of the carpal ligaments.     

Contribution of arthroscopy in case of septic appearance arthritis of the wrist: A nine cases series

Septic arthritis of the wrist is a diagnostic and therapeutic emergency. Synovectomy and lavage by arthrotomy is often followed by stiffness. The purpose of this study was to evaluate the diagnostic and therapeutic contribution of emergency arthroscopic synovectomy with intraarticular lavage. Nine patients were operated on for wrist pathology with septic appearance. All had signs of local inflammation, three showed locoregional inflammation, three were febrile. In one patient several joints were involved. Seven patients presented with inflammatory or degenerative arthritis. All patients underwent emergency surgery using radiocarpal joint puncture, arthroscopic exploration, intraarticular lavage and synovectomy at both the radiocarpal and midcarpal joints. The results were evaluated by pain, Quick DASH, grip strength, and wrist range of motion. In three cases, joint fluid appeared clear, in three it was turbid, and in three purulent. Gram stain and culture revealed bacteria in four cases. Synovitis was radiocarpal four times, radiocarpal and midcarpal once. In one case, there was radiocarpal and midcarpal chondritis. Average pain was 5.3/10 preoperatively and 2/10 at the last clinical follow-up visit. Mean grip strength was 23.3 kg on the involved side vs. 33.5 kg on the opposite one. Mean flexion was 55° for the involved wrist vs. 68°; mean extension was 52° for the affected wrist vs. 59°. No patient was reoperated on. In all cases, there was no sign of local inflammation, regional lymphadenopathy or systemic infection at the last follow-up. One patient died of colon metastatic cancer. Another patient developed a severe Complex Regional Pain Syndrome type I (CRPS1). Our results suggest three principles of management of wrist arthritis with septic appearance: extended surgical indication, emergency operation and arthroscopic procedure.     

Scapho-capitate fracture syndrome. A case report

A rare injury of the wrist, scapho-capitate fracture syndrome, in a young patient is reported. Despite early recognition of the injury and surgical intervention, the scaphoid fracture did not unite and another attempt to achieve union with bone grafting and internal fixation also failed. The wrist continued to be painful and stiff. Radiographs of the wrist, 18 months after the injury, showed nonunion of the scaphoid, avascular necrosis of the scaphoid and the lunate and carpal collapse with midcarpal joint arthritis. Due to persistent and disabling symptoms arthrodesis of the wrist had to be carried out. Possible causes for the bad outcome after this injury are discussed. We recommend open reduction for the fracture of the capitate and open reduction and internal fixation with primary bone grafting for a displaced comminuted scaphoid fracture.