Arthoscopic diagnosis of partial scapholunate ligament tears as a cause of radial sided wrist pain in patients with inconclusive x-ray and MRI findings

To clarify the pathology of radial-sided wrist pain with inconclusive X-ray and MRI findings, we performed arthroscopic examinations of 11 wrists in 10 patients. Physical examination and various image investigations could not identify the cause of the pain. Arthroscopy revealed partial to complete tears of the scapho-lunate interosseous ligament and synovitis and/or chondral bone defects at the scaphotrapezio-trapezoidal joint in all 11 wrists. Surgical procedures consisted of eight simple synovectomies, two ligament reconstructions and one percutaneous pinning. Pain relief was achieved in 10 wrists. One wrist which had a simple synovectomy did not recover, so underwent secondary scaphotrapezio-trapezoidal fusion. In conclusion, we found that various degrees of scapholunate interosseous ligament tear and scaphotrapezio-trapezoidal joint osteoarthritis were the main causes of radial-sided wrist pain with inconclusive X-ray and simple MRI findings.     

Ulnar variance in Kienb?ck's disease

Forty four patients with forty seven wrists suffering from Kienb?ck's disease were re-examined. The mean observation time was 20.5 years. In all forty seven wrists the treatment had been immobilization. Using a standard X-ray projection, and a reliable method of ulnar variance measuring, the ulnar variance was determined by three observers independently. Comparing the result with the ulnar variance in normal wrists we found the so-called "ulnar minus variant" overrepresented in patients with Kienb?ck's disease. However, comparing X-rays taken at the time of diagnosis with X-rays at re-examination, we found in eight out of forty seven wrists that a subchondral bone formation in the distal radium opposite the lunate bone had taken place. This bone formation will tend to enhance the negative value of ulnar variance measurements, and suggests an explanation of the overrepresentation of "ulnar minus variants" in Kienb?ck's disease. Excluding these eight wrists from the material and comparing the mean ulnar variance value in the remaining thirty nine wrists with the mean value in normal wrists no statistical difference was shown. Based on these observations it seems unlikely that the "ulnar minus variant" has any bearing on the cause of Kienb?ck's disease.     

Use of sonography in carpal tunnel syndrome surgery. A prospective study

The diagnosis of carpal tunnel syndrome (CTS) is mainly based on the characteristic symptoms and confirmed with nerve conduction studies. Sonography can provide measurements of the increased cross-sectional area of median nerve. The use of sonography was evaluated for the diagnosis and postoperative follow up of 48 wrists in 26 consecutive patients with CTS. Clinical evaluation and sonography were effective for the diagnosis in 40 wrists. Nerve conduction studies were needed in eight wrists, because of the decrease in cross-sectional area of the nerve as a result of degenerative changes. After 3 months, sonography detected statistically significant decreases in the cross-sectional areas of the median nerves. The sonographic studies were well tolerated by all patients. Sonography was both time-saving and cost-effective.     

Trispherical total wrist arthroplasty in rheumatoid arthritis

Thirty-four patients, with 35 trispherical total wrist arthroplasties for treatment of rheumatoid arthritis, were evaluated at an average follow-up of 9 years (range, 5 to 11 years). The average preoperative score was 25 points inasmuch as all patients had severe pain and loss of function. The average postoperative score improved to 87 points since 30 wrists were free of pain. Twenty-eight wrists rated as a good-to-excellent result. The average arc of flexion and extension improved from 35 to 50 degrees. There were no deep infections or dislocations. Two wrists required revision, one for loosening and one for persistent pain, both requiring removal of the implant and arthrodesis. Postoperative tendon attrition occurred in six wrists, all of which had preoperative tendon ruptures necessitating tendon transfer. Radiographs showed radiolucencies in seven wrists, including seven around the metacarpal stem and one around the radial stem. The optimum results were achieved in those patients with intact extensor tendons before operation.     

Resection of the distal scaphoid for scaphotrapeziotrapezoid osteoarthritis.

Twenty-one patients with symptomatic scaphotrapeziotrapezoid osteoarthritis were treated with partial distal scaphoid excision. In 12 wrists the joint defect was filled with either capsular or tendinous tissue, while in nine no fibrous interposition was done. At an average follow-up time of 29 (range, 12-61) months, 13 wrists were painfree, while eight had occasional mild discomfort. Mean wrist flexion-extension was 119 degrees. Grip and pinch strength improved by an average of 26% and 40% respectively compared with their preoperative status. Fifteen patients returned to their original jobs, while six, who were unemployed, felt unrestricted for activities of daily living. Although patient satisfaction was comparable for both types of treatment, the wrists without fibrous interposition showed significantly greater wrist flexion-extension than patients with soft-tissue interposition. Removal of the distal scaphoid resulted in a DISI pattern of carpal malalignment in 12 wrists. At follow-up, none of these wrists showed further joint deterioration due to residual malalignment.     

Long-term results of dorsal stabilization in the rheumatoid wrist

Dorsal stabilization was performed on 85 rheumatoid wrist in 62 patients for an average follow-up of 6.8 years. Of these, 37 wrists were followed an average of 10 years. The chief component was pain in 79 of the wrists. Pain, on a scale of 0 to 100, showed a preoperative score of 32 and postoperative ratings of 89 for the total group and 96 for the long-term group. Range of motion decreased in virtually all patients. Spontaneous ankylosis occurred in eight wrists. Because of the presence of associated deformities, usually subluxated metacarpophalangeal joints, evaluation of functional improvement of the wrist was difficult. Those hands in which metacarpophalangeal subluxations were corrected or prevented showed maximum functional improvements. The procedure is beneficial for long-term relief of pain and maintenance of a range of motion which arthrodesis would eliminate.     

Wrist arthrodesis: modified Gill's technique

Twenty-five wrist arthrodesis procedures were performed on 24 patients, applying a modification of Gill's technique, which used a corticocancellous strut graft from the distal radius. Patients were followed up until solid bony fusion was established. Union was achieved in 21 of 25 wrists and was subsequently achieved with a further procedure in the remaining four wrists. We have found that the modified Gill's technique is a reliable, simple procedure with a low complication rate which does not require the harvest of a distant bone graft.     

Magnetic resonance imaging of the carpal tunnel

Eleven wrists in eight patients with carpal tunnel syndrome were investigated by electrophysiological studies and magnetic resonance imaging (M.R.I.). The operative findings in ten wrists correlated with the M.R.I. evidence of synovial disease, carpal tunnel stenosis and median nerve compression.     

Total wrist replacement using the modified Volz prosthesis

Eighteen total wrist arthroplasties in sixteen patients were done using the modified Volz prosthesis. The length of follow-up ranged from twenty-four to sixty-six months, with a mean of forty months. A 100-point scoring system was used to evaluate the outcome. Muscle imbalance developed in five wrists, the carpal component became loose in three wrists, and two prostheses dislocated. In five patients six arthroplasties (33 per cent) were considered to have failed because one reoperation or more was required for loosening of the components in two wrists, dislocation in two wrists, and muscle imbalance in two wrists. Of the remaining twelve arthroplasties (eleven patients) eight (45 per cent) had an excellent result; two (11 per cent), a good; and two (11 per cent), a poor result. The over-all rate of complications was 44 per cent. Patients who had significant preoperative deformity did poorly postoperatively. The surgeon should be prepared to perform other types of arthroplasty or an arthrodesis if the extensor tendons are structurally inadequate, as this may lead to progressive flexion deformity postoperatively.     

Proximal row carpectomy: review of rheumatoid and nonrheumatoid wrists

Proximal row carpectomy was first done in 1939 and was indicated for treatment of posttraumatic problems or Kienb?ck's disease. Use of this procedure in patients with rheumatoid arthritis has not been reported. Our series consists of eighteen wrists, nine with rheumatoid arthritis, and nine with other various nonrheumatoid conditions. Follow-up ranged from 12 to 120 months and included x-ray films and assessment of pain, range of motion, balance, grip strength, and patient satisfaction. Our results showed only two of the eight rheumatoid wrists to be satisfactory; failure was caused by pain and imbalance. Of the nonrheumatoid wrists, six of the eight were satisfactory, although in one of the six sclerosis is developing between the capitate and radius. Proximal row carpectomy is not recommended for the rheumatoid wrist but may be useful where other pathologic conditions are involved if the remaining articular surfaces are uninvolved.     

Proximal row carpectomy in perilunate dislocations and lunatomalacia

Proximal row carpectomy was performed in 13 wrists with old unreduced perilunate dislocations and in 4 wrists with Kienb?ck's disease. One failure was converted to wrist arthrodesis, and 2 patients were lost to follow-up. The remaining 14 patients were reexamined after 11 (3-19) years. Average ranges of wrist motion were 37 degrees of dorsiflexion, 30 degrees of palmar flexion, 5 degrees of radial deviation, and 24 degrees of ulnar deviation. Grip strength averaged two thirds of the uninvolved hand. Pain relief was achieved in 12 patients, who all returned to their previous occupations. The results according to Cooney's criteria were 1 good, 8 fair, and 5 poor.     

Total wrist arthroplasty. Experience with Swanson flexible silicone implants, 1982-1988.

In a study of the results of silicone rubber arthroplasty of the wrist 18 patients (19 operated wrists) were re-examined after a mean follow up of five years. Experience with the ulnar head implant was discouraging, and it was not used in the last eight wrists. This did not affect the outcome, patients having good supination and pronation without pain. The range of motion with the radiocarpal prostheses was 0-70 degrees, mean 39 degrees. Radiological results showed severe subsidence in all patients followed up for more than two years, and prosthetic fracture in five (26%), which was disappointing. Nevertheless the patients had a useful range of motion and all but two were relieved of pain. By the patients' own assessments 16 wrists were considered good, one fair, and two poor. Predictors of failure (prosthetic fracture) were poor alignment before operation, postoperative range of motion of more than 50 degrees, and rupture of the carpal extensor tendon. With these reservations we recommend the silicone spacer as the best solution for most patients with severe problems of the wrist as a result of rheumatoid arthritis.     

A comparison of plate and pin fixation for arthrodesis of the rheumatoid wrist

This retrospective study compared plate fixation versus pin fixation in 57 patients with rheumatoid arthritis who underwent wrist arthrodesis. Fixation was achieved by using plates in 32 patients and longitudinal pins in 25 patients. Clinical follow-up averaged 29 months (range: 12-57 months) and radiographic follow-up averaged 16 months (range 12-39 months). Union occurred in 97% of the wrists fixed with plates and in 96% of the wrists fixed with pins. There were 6 (19%) complications in the plate group and 7 (28%) complications in the pin group. Three (12%) wrists fixed with pins moved from the immediate postoperative position to a position of relative volar flexion, while radiographs showed no changes in wrist position in the plate group. With both methods, successful arthrodesis stabilized the wrist in a high percentage of patients. Plate fixation offers an excellent alternative method for arthrodesis of the rheumatoid wrist.     

Arthrodesis of the wrist by internal fixation in rheumatoid arthritis: a follow-up study of forty-five consecutive cases

Between 1972 and 1981, 59 wrists of 44 patients destroyed by rheumatoid arthritis were arthrodesed by internal fixation with a Rush pin. This study comprises 45 wrists of 38 surviving patients--nine men and 29 women, aged 20 to 72 years. The follow-up time ranged from 1 to 11 years with a mean of 3.9 years. The surgical technique used in this study is simple and safe, and a good position of the wrist in both frontal and lateral projections can easily be achieved. The Rush pin is passed down the third metacarpal and into the radius. It stabilizes the wrist adequately. All the wrists operated on obtained a strong bony fusion of the radiocarpal joint. The complication rate was low. Five of 45 Rush pins were removed because the subcutaneously located distal tip between the metacarpals irritated tendons and skin. In one male patient a thin Rush pin broke and a pseudoarthrosis of the intercarpal joints developed; there was, however, no need to remove the pin.     

Radiographic studies of the wrist and elbow in cerebral palsy

We retrospectively studied and evaluated radiographs of the bilateral wrists and elbows in 96 patients with cerebral palsy. There were 55 patients (57.3%) with athetospastic quadriplegia, 30 (31.3%) with spastic diplegia, and 11 (11.4%) with spastic hemiplegia. Plain antero-posterior and lateral roentgenograms were taken of both wrists and both elbows. Overall negative ulnar variance was seen in 18.2% of wrists, and, the variance was highest in athetospastic quadriplegia. We could not find any case of Kienb?ck's disease. The radiolunate angle was negative in the wrists of those with athetospastic quadriplegia. Scapholunate dissociation was found in 2 wrists (1%). Four dislocations of the radial head were found in 2 patients (2%). The humero-radial distance and humero-ulnar distance were both narrowed. The formation of osteophytes was mainly found in the humero-ulnar joint, especially in those with athetospastic quadriplegia. Received for publication on April 16, 1999; accepted on Nov. 2, 1999     

Radiolunate arthrodesis in the rheumatoid wrist: a retrospective clinical and radiological longterm follow-up

A retrospective study was performed to investigate the clinical and radiological results of radiolunate arthrodesis in the rheumatoid wrist. Ninety-one wrists in 78 patients were assessed at a mean follow-up of 60 months. Most patients were pain-free and content with the overall result. In 68 wrists the carpus had been repositioned or maintained in neutral or slightly ulnar alignment and no further translation occurred. Midcarpal dislocation occured in ten and midcarpal rotation in 13 wrists. The midcarpal joint underwent further arthritic destruction in 34 wrists and secondary arthrosis in 32 wrists. In 25 wrists the midcarpal joint space remained unchanged. Radiolunate arthrodesis can successfully be performed in wrists even with advanced destruction. In cases with fixed carpal collapse, anatomical repositioning of the lunate and restoration of carpal height should not be attempted as this causes midcarpal dislocation or rotation or precipitates secondary arthrosis.     

Triquetral-lunate arthritis secondary to synostosis

Until recently the problem of painful, symptomatic arthritis of the wrist secondary to congenitally incomplete separation of carpal bones has been infrequently recognized. Five patients with either excessive stress loading or trauma had eight symptomatic wrists with congenitally incomplete separation of the triquetral-lunate joint. Three of these patients had bilateral symptoms. Six of the wrists had been treated by a limited wrist arthrodesis of the triquetral-lunate joint resulting in asymptomatic wrists and improved range of motion. It appears that patients with this congenital condition poorly tolerate stress loading or trauma secondary to deficient intra-articular cartilage formation resulting in a clinical and anatomic state similar to degenerative arthritis. We suggest a limited wrist arthrodesis as definitive treatment for symptomatic congenitally incomplete separation of the triquetral-lunate joint, with possible application in incomplete separation of the other intercarpal joints.     

Comparative results of resection of the distal ulna in rheumatoid arthritis and post-traumatic conditions

The purpose of this study was to determine whether the results of resection of the distal ulna differed depending upon the underlying aetiology of the condition. Patients with rheumatoid arthritis were compared with patients with post-traumatic wrist complaints. Fifty resections in 40 patients (eight male, 32 female) were assessed with respect to pain, range of motion, and grip strength. Of the 23 rheumatoid wrists, 86% were pain-free following surgery; however, only 36% of the patients in the trauma group reported pain relief postoperatively. Pain relief in post-traumatic patients was more predictable when distal radioulnar joint arthrosis was identified as the sole cause of wrist pain.     

A new plate for partial wrist fusions: results in midcarpal arthrodesis

Partial wrist fusions are commonly performed for various degenerative conditions. In this series 30 wrists had a scaphoidectomy and midcarpal arthrodesis performed with a new plate. The most common indications were SLAC and SNAC wrists. In 24 cases a four-corner arthrodesis was done and in the other six the triquetrum was not included. Mean follow-up was 3 years. Mean flexion was 31° and extension 35°. Union was achieved in all wrists despite movement being commenced early. The plates proved straightforward to use, allowing some latitude in placement. This series confirms that scaphoidectomy and midcarpal arthrodesis is a useful salvage procedure and that these plates are suitable for that purpose.     

Palmar shelf arthroplasty in the rheumatoid wrist. Results of long-term follow-up

Sixty-three palmar-shelf arthroplasties (so-called pseudofusions of the wrist) that had been performed between 1970 and 1978 in forty-nine patients were evaluated. The length of follow-up averaged eighty-three months (minimum, twelve months for the wrists that fused and twenty-four months for those that did not). Preoperatively, all wrists were painful, with 96 per cent being moderately or severely so. Carpal subluxation was present in 79 per cent of the wrists. Postoperatively, pain recurred in 84 per cent of the wrists, but it was less severe (mild in 48 per cent, moderate in 35 per cent, and severe in 2 per cent). Sixty-eight per cent of the wrists fused spontaneously and were no longer painful. Of the twenty wrists (32 per cent) that did not fuse, 70 per cent were mildly or moderately painful. In patients who have rheumatoid arthritis, we found that palmar shelf arthroplasty was followed by a high rate of delayed spontaneous fusion and an unacceptably high rate of recurrent pain, although the pain was less severe.