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.     

Treatment of radiocarpal degenerative osteoarthritis by radioscapholunate arthrodesis: long-term follow-up

Radioscapholunate arthrodesis is the treatment of choice for symptomatic, degenerative radioscapholunate osteoarthritis. We report on three patients after radioscapholunate arthrodesis with a follow-up of 22-28 years. There were no short-term postoperative complications; range of motion and strength were stable. All three patients showed radiological evidence of progressive, but clinically asymptomatic midcarpal osteoarthritis. The conversion rate for radioscapholunate to panarthrodesis of the wrist is reported at 31% with follow-ups of more than five years, invariably due to either non-union, or progressive, symptomatic midcarpal osteoarthritis. Primary excision of the distal pole of the scaphoid during radioscapholunate arthrodesis probably plays an important role in avoiding these conditions in the long-term. This measure allows a residual range of motion more than previously believed; considering that the dart thrower's motion is the physiological axis of wrist motion.     

Distal scaphoid resection arthroplasty for the treatment of degenerative arthritis secondary to scaphoid nonunion

Nineteen patients with chronic scaphoid nonunion and associated degenerative arthritis between the distal fragment and the radial styloid were treated by resection of the distal fragment. All patients had a dorsal intercalated segment instability wrist collapse pattern with an average radiolunate angle of -32 degrees and a 10% reduction in the carpal height, both of which changed minimally during the follow-up period. The duration of the nonunion averaged 12 years and the follow-up period averaged 49 months. Range of motion improved 85% and grip improved 134%. Thirteen of the patients experienced complete pain relief. One patient required additional surgery and elected wrist arthrodesis. Resection of the distal fragment is not recommended for patients with capitolunate arthritis. Two of the 4 patients with capitolunate arthritis had persistent symptoms; 3 had progressive degenerative changes.     

Combined fractures of the scaphoid and distal radius: a revised treatment rationale using percutaneous and arthroscopic techniques

Revision of the treatment rationale for combined fractures of the scaphoid and distal radius is based on evolution of treatment goals. The trend toward early recovery of hand function requires rigid fixation of both fractures before the start ofa hand therapy program. It is clear that prolonged immobilization of the scaphoid fracture jeopardizes early motion protocols for the distal radius.The fixation of unstable distal radius fractures with volar locking plates appears to offer the most stable construct to permit early motion. Evaluation, reduction, and fixation should be accomplished without disruption of the uninjured ligaments required for stable motion or the soft tissue envelope required for healing. Minimally invasive or percutaneous techniques are the meth-ods required. The tools needed are a clear understanding of anatomy, minifluoroscopic imaging units, and small-joint arthroscopy instruments. Many investigators advocate these techniques for scaphoid and distal radius fractures. It is only natural that these techniques should be used for these combined injuries.The key to success is a three-step process: (1)percutaneous reduction of the scaphoid fracture and provisional stabilization with a guide wire placed along its central axis, (2) percutaneous/arthroscopic reduction and rigid fixation of the distal radius fracture to permit early motion, and(3) fixation of the scaphoid fracture. This final step is accomplished by dorsal percutaneous implantation of a cannulated headless compression screw along the central scaphoid axis. Dorsal percutaneous fixation of scaphoid fractures with headless compression screws and rigid fixation of unstable distal radius fractures with a volar lock-ing plate system offer the most secure fixation.This small series suggests that the goals of early recovery of hand function can be accomplished using percutaneous/miniopen techniques for fracture reduction with rigid fixation and minimal risks.     

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.     

部分腕骨融合术或切除术对腕关节运动影响的实验研究

目的 研究临床常用的部分腕骨融合术或切除术对腕关节运动的影响程度。方法 将１２侧新鲜上肢处理后,固定于特制的测试架上,在腕背部打入２根或多根克氏针,作舟头骨、舟大小多角骨、舟月骨、月三解骨、桡月骨、ｆｏｕｒ ｃｏｒｎｅｒ、头月骨融合术、舟骨切除＋ｆｏｕｒ ｃｏｒｎｅｒ、舟骨切除＋头月融合术。观测腕关节正常运动活动范围,及作上述不同部分腕骨融合术后腕关节屈曲、伸腕、尺偏、桡偏度数。结果 桡舟月骨融合     

Scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis--update on evaluation and treatment

Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse are common patterns of wrist arthritis. Scaphoid nonunion advanced collapse is caused by trauma, whereas SLAC wrist may also result from chronic pseudogout and can appear bilaterally without a clear history of injury. Surgical treatment for SLAC wrist includes 4-corner arthrodesis, capitolunate arthrodesis, complete wrist arthrodesis, proximal row carpectomy (PRC), denervation, and radial styloidectomy. Scaphoid nonunion advanced collapse wrist has the additional surgical option of excision of the distal ununited scaphoid fragment. Controversy persists over the relative merits of PRC versus 4-corner arthrodesis and whether PRC may be performed in the setting of capitate arthritis.     

Management of the scaphoid during four-corner fusion-a cadaveric study

PURPOSE: To examine the effects of scaphoid retention, inclusion, and excision on wrist motion and radiolunate contact characteristics in a cadaveric model after simulated 4-corner fusion with rigid internal fixation. METHODS: Seven fresh-frozen cadaveric upper extremities were examined. For all surgical manipulations the motion was measured and contact characteristics were assessed using ultra-low prescale pressure-sensitive film. RESULTS: Compared with the intact specimen, simple 4-corner fusion with scaphoid retention led to a significant decrease in extension, radial deviation, and ulnar deviation, but no change in radiolunate contact characteristics. After 4-corner fusion there was no significant difference in motion or radiolunate contact characteristics between scaphoid retention and scaphoid inclusion. After 4-corner fusion scaphoid excision allowed significantly greater radial deviation compared with scaphoid retention and scaphoid inclusion. Compared with the intact specimen 4-corner fusion with scaphoid excision also led to a significant increase in radiolunate contact area and mean contact pressure. CONCLUSIONS: When performing 4-corner arthrodesis in the absence of radioscaphoid arthritis, scaphoid excision may improve motion at the cost of increased mean radiolunate contact pressure.     

Radioscapholunate arthrodesis

Although RSL fusion is a viable option for isolated radiocarpal arthritis, the enthusiasm for this procedure should be tempered with the reality that kinematics of the wrist is not entirely suited for independent midcarpal flexion and extension [10]. Limited wrist flexion and extension is expected following a successful RSL arthrodesis. The effects of imposed abnormal kinematics are further shown by the high incidence of RSL nonunions, occurrence of scaphoid fractures, and postoperative deterioration of the midcarpal joint [15,22]. In a young patient with posttraumatic arthritis or rheumatoid arthritis limited to the radiocarpal joint, however, RSL arthrodesis remains a viable alternative to complete wrist arthrodesis if the midcarpal joint is normal. Internal fixation with plates and screws and distal scaphoid excision are technical alternatives to consider when an RSL arthrodesis is performed.     

Sigmoid notch reconstruction using osteoarticular graft in a severely comminuted distal radius fracture: a case report

A case of a young patient with a severely comminuted intra-articular distal radius fracture dislocation and severe injury of the distal radioulnar joint is presented. Early reconstruction of the sigmoid notch and radioulnar ligaments was performed using the remaining scaphoid facet of the distal radius articular surface, an autogenous tendon graft for ligament reconstruction, and radioscapholunate arthrodesis. The patient was able to return to his manual work without limitations. We present additional information on the comparative anatomy of the sigmoid notch and scaphoid facet that may guide surgeons in treating this severe injury.     

Intercarpal fusion for the treatment of scaphoid nonunion.

Salvage of the ununited scaphoid may not always be feasible or advisable, hence the availability of a number of alternative techniques which prioritize restoration of pain relief and range of motion. The role of intercarpal fusion reflects the importance of midcarpal stabilization when the scaphoid is resected. While scaphocapitate and scaphocapitolunate fusions have been described, these techniques provide less pain relief than midcarpal fusion with scaphoid excision, and are associated with an increased risk of radioscaphoid arthritis. In this article, the author will address the rationale for, technique of, and outcome after midcarpal arthrodesis and scaphoid excision.     

Results of four-corner arthrodesis using dorsal circular plate fixation

PURPOSE: Four-corner arthrodesis with scaphoid excision has been used to reduce pain and preserve functional range of motion for patients with radioscaphoid arthritis. Early results of 4-corner arthrodesis with scaphoid excision using dorsal circular plate fixation are compared with reported results in the literature. METHODS: We reviewed retrospectively the first 18 four-corner arthrodeses performed with this system by 4 hand surgeons. Two patients had revision surgery for nonunions before the study that were considered failures. Eight patients returned for final radiographs, objective examination, and functional questionnaire. The average follow-up period was 20 months (range, 13-33 mo). These results were compared with reported results in the literature using alternate fixation methods. RESULTS: Radiographic union was achieved in only 3 wrists. Range of motion was 46% that of the opposite normal wrist and grip strength compared with the opposite wrist was 56%. Five patients would have the procedure again and 6 of 8 have returned to their original employment. CONCLUSIONS: Four-corner arthrodesis with scaphoid excision using a circular internal fixation plate produced a high number of nonunions. Grip strength and range of motion results also were inferior to those reported in the literature.     

Giant cell tumor of the capitate

A case of giant cell tumor of the capitate is presented. Its recurrence and the problem of reconstruction after resection are discussed. Recommended treatment of this tumor if it occurs within the carpals is resection of the carpus with intercarpal arthrodesis if the distal row is involved or proximal row carpectomy if the scaphoid or lunate is involved.     

Evolution of arthritis of the wrist

Degenerative arthritis of the wrist follows very specific patterns from onset to terminal severe bone and joint destruction. About 95% of them occur as periscaphoid area problems: SLAC (scapholunate advanced collapse pattern) wrist (55%), triscaphe arthritis (26%), and a combination of the two (14%). In SLAC wrist, the repeating sequence of degenerative change is based on and caused by articular alignment problems between the scaphoid and the radius. Changes then progress between the capitate and the lunate that are secondary to carpal collapse. In triscaphe arthritis, the degenerative change is limited to between the trapezium, trapezoid, and distal scaphoid. SLAC procedure (fusion of the capitate, lunate, hamate, and triquetrum along with silastic scaphoid implant) for SLAC wrists and triscaphe arthrodesis (fusion of the scaphoid, trapezium, and trapezoid) for triscaphe arthritis, are designed to make maximum use of undamaged structures and to maintain full-power, painless, mobile human wrists.     

Proximal row carpectomy and intercarpal arthrodesis for the management of wrist arthritis

For advanced noninflammatory wrist arthritis, the most common surgical treatments to preserve motion are proximal row carpectomy and scaphoid excision with capitohamate-lunotriquetral arthrodesis. Both procedures have documented successful outcomes. Proximal row carpectomy is simpler but typically is contraindicated when degeneration of the capitate head cartilage exists. Scaphoid excision with capitohamate-lunotriquetral arthrodesis is more complex but may provide greater grip strength and can be successful in the presence of capitate degeneration. Treatment selection should be based on surgeon preference and experience as well as on the patient's understanding of the possible complications and benefits of each procedure.     

腕舟骨周围韧带解剖学研究

目的观察和研究分布在腕舟骨周围的腕外源性或内源性韧带的结构及特点。方法采用１４侧成人尸体上肢，分离和解剖出舟骨周围的韧带，观察并记录其起止点、行程、长宽度及解剖结构特征。结果在舟骨周围观察到８根韧带，为桡舟头韧带（ＲＳＣ）、桡舟月韧带（ＲＳＬ）、桡月韧带（ＲＬ）、背侧腕间韧带（ＤＩＣ）、桡三角骨韧带（ＲＴ）、和舟月骨间韧带（ＳＬＩＬ）、舟骨大多角和舟骨小多角骨间韧带。ＲＳＣ、ＤＩＣ和ＳＬＩＬ对舟骨的位置、稳定性和运动尤为重要。结论腕舟骨周围存在复杂的韧带结构，其中ＲＳＣ、ＤＩＣ和ＳＬＩＬ对舟骨的稳定，舟骨骨折后畸形的形成、舟骨不稳定的形成起着重要作用。这些韧带的结构或功能在治疗腕不稳定中应予以恢复     

Ipsilateral fractures of the distal radius and scaphoid treated by Herbert screw and external skeletal fixation. A report of two cases.

Two patients with comminuted, displaced fractures of the distal radius associated with ipsilateral, undisplaced scaphoid fractures were treated by internal fixation of the scaphoid fracture with a Herbert screw in association with external fixation of the distal radial fracture. One of the patients had a limited open reduction of the distal radius combined with bone grafting. Both patients had satisfactory results. Internal fixation of the scaphoid is indicated if distraction is applied to the carpus to treat an associated fracture of the distal radius, even if the scaphoid fracture is undisplaced.     

Functional outcome of four-corner arthrodesis for treatment of grade IV scaphoid non-union

Functional limitations and pain are end results of scaphoid nonunion with progressive carpal collapse and radiocarpal arthritis. The aim of this study was to assess the functional outcome of four-corner arthrodesis with scaphoidectomy for the treatment of grade IV scaphoid nonunion with Scaphoid Nonunion Advanced Collapse (SNAC) stages II and III. Ten patients with symptomatic grade IV non union of the scaphoid and a mean duration of non unions of 12.1 +/- 2.81 months were treated using the four-corner arthrodesis technique. A dorsal midline longitudinal approach centered over the third metacarpal-capitate-lunate-radius axis, excision of the scaphoid, neutral alignment of the remaining carpal bones, and arthrodesis of the capitate, hamate, lunate, and triquetrum, were performed. Kirschner wires were used to secure the arthrodesis in all cases. A below-elbow thumb spica cast was applied for 3 months. Follow up period ranged from 8 to 24 months, with a mean of 16 +/- 4.7 months. All patients were assessed both functionally for pain, range of motion and grip strength, and radiographically for evidence of fusion and carpal alignment. Good results were achieved in 7 patients (70%) according to the modified Mayo Wrist Scoring Chart. There were no intraoperative complications. Postoperatively, one patient suffered superficial wound infection One patient showed dorsal impingement of the capitate and radius. Also, two patients suffered reflex sympathetic dystrophy. No patients showed deep infection or nonunion. The Four-corner Arthrodesis technique is a motion-sparing, limited arthrodesis that reliably results in pain relief, improved grip strength, and overall patient satisfaction with low associated non union and complication rates.     

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.     

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.