Capsulodesis for the treatment of chronic scapholunate instability

PURPOSE: Scapholunate (SL) instability is the most common form of carpal instability. The treatment of this disorder is challenging and varying treatment options have been described. The purpose of this study was to examine the intermediate-term results of dorsal capsulodesis for cases of chronic SL dissociation. METHODS: A retrospective analysis was conducted that examined all dorsal capsulodesis procedures performed for chronic SL dissociation between January of 1990 and February of 2000. Wrist pain had to be present for greater than 3 months. Patients had to have a minimum follow-up period of 2 years for inclusion in the study. Thirty-one patients were identified with isolated chronic SL dissociation. Of the 31 patients 18 had dynamic carpal instability and 13 had static carpal instability. The time from injury to surgery averaged 20 months. The follow-up period averaged 54 months (range, 24-96 mo). All patients had a dorsal capsulodesis procedure using either a Blatt or Mayo technique. Results were reviewed clinically and radiologically. Static and dynamic groups were compared with a Student t test. RESULTS: There was a 20% decrease in wrist motion after capsulodesis. There was no improvement in grip strength after surgery. Most patients had improvement in pain but only 2 patients were completely pain free. Radiographically the SL gap increased over time from 2.7 mm before surgery to 3.9 mm at the final follow-up evaluation. The SL angle also increased from 56 degrees before surgery to 62 degrees on final follow-up evaluation. There was no statistical difference in overall wrist motion, grip strength, or wrist score between the dynamic and static groups. The time to surgery and age had no significant effect on overall outcome. CONCLUSIONS: Dorsal capsulodesis provided pain relief for patients with both dynamic and static SL instability. Although pain was improved it was not completely resolved in the majority of cases. From a radiographic perspective dorsal capsulodesis did not provide maintenance of carpal alignment in cases of chronic SL dissociation.     

Arthroscopic debridement and closed pinning for chronic dynamic scapholunate instability

PURPOSE: For chronic dynamic scapholunate (SL) instability (>3 months after injury) open procedures (capsulodesis, limited intercarpal fusions, tenodesis, SL ligament reconstruction) have become popular in recent years but their long-term results have been suboptimal. We evaluated retrospectively the results of aggressive arthroscopic debridement of the SL ligament to bleeding bone in an effort to induce scar formation and closed pinning of the SL joint in patients unwilling to have an open procedure. METHODS: Eleven patients (mean age, 37 y) presenting with persistent posttraumatic pain and weakness to the wrist were diagnosed with dynamic SL instability (positive Watson scaphoid shift test result, SL gapping on grip-view radiographs, arthroscopic findings of a Geissler grade III or IV SL tear) and treated. Range of motion, grip strength, radiographic measurements, and the Mayo wrist score were used to evaluate the results. RESULTS: The mean follow-up period was 33 months (range, 12-76 mo). Three patients had subsequent surgery 9 to 11 months after the procedure. Subsequent surgeries included a dorsal capsulodesis, a four-corner fusion, and a wrist arthrodesis. Of the 8 remaining patients there were 2 excellent, 4 good, 1 fair, and 1 poor result based on the Mayo wrist score. In these patients the mean range of motion was 65 degrees of extension to 59 degrees of flexion and the mean grip strength was 82% of the uninjured contralateral extremity. Although persistent radiographic SL gapping in grip views was noted in all 8 patients none progressed to static instability or dorsal intercalated segment instability. CONCLUSIONS: The results of this technique are suboptimal; however, it may be an option for patients unwilling to have more than an arthroscopic procedure or those requiring maintenance of wrist motion, provided they understand the risks and benefits of this approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Chronic scapholunate dissociation: ligament reconstruction combining a new extensor carpi radialis longus tenodesis and a dorsal intercarpal ligament capsulodesis

Scapholunate dissociation (SLD) is the commonest cause of carpal instability and wrist osteoarthrosis. The value of early diagnosis and treatment of this injury is well established in the literature. When a partial or total rupture of the scapholunate ligament is treated with early anatomic reduction and repair, functional results may be good to excellent. However, if this ligament is not addressed acutely then an overall carpal malalignment may seem progressively as a result of failure of the secondary scaphoid stabilizers. Chronic SLD will lead to scapholunate advanced collapse and progressive painful arthritis of the wrist. Although most surgeons agree that operative intervention is indicated, no clear consensus exists on the best treatment for patients with chronic SLD. Several procedures have been described that include some sort of partial fusion, capsulodesis, tenodesis, or bone-ligament-bone graft. If there is no evidence for arthrosis, soft-tissue procedures using either capsulodesis or tenodesis may be carried out in an attempt to preserve radiocarpal and intercarpal motion whereas avoiding fusion. This article describes a scapholunate ligament reconstruction combining a new dorsal extensor carpi radialis longus tenodesis and a dorsal capsulodesis for the treatment of chronic SLD.     

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.     

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.     

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.     

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.     

Treatment of dynamic scaphoid instability

BACKGROUND: Chronic wrist pain attributable to scaphoid instability without fixed deformity (dynamic instability) presents a treatment dilemma. The diagnosis usually is delayed, missing the opportunity for direct repair. The intercarpal fusion, tenodesis, and capsulodesis procedures create a fixed deformity. This report presents an outcome study of a new treatment for dynamic scaphoid instability that spanned more than 5 years. METHODS: Arthroscopic evaluation was used to confirm the diagnosis for 105 wrists of 102 patients who had experienced wrist pain for an average of 24.4 months. The treatment for these patients involved transferring two thirds of the extensor carpi radialis longus through the distal pole of the reduced scaphoid volarly to the intact flexor carpi radialis. The postoperative follow-up period averaged 63 months. RESULTS: The average grip strength increased by 65%. The average active wrist extension-flexion increased by 9%, with an average radial deviation loss of 6 degrees. The overall results, as measured by the modified Green and O'Brien clinical wrist scale, were as follows: excellent (49%), good (24%), and fair (26%). Good to excellent results were reported by 85% of the patients. Pain relief was reported by 94% of the patients, and 93% of the patients would recommend the procedure to others. CONCLUSIONS: Scaphoid instability without fixed deformity is a complex problem. Conventional treatments have drawbacks. The new technique produced positive results that are quite promising for the management of dynamic scaphoid instability.     

Scapholunate stabilization with dynamic extensor carpi radialis longus tendon transfer

Dynamic extensor carpi radialis longus tendon transfer to the distal pole of the scaphoid acts synchronously and synergistically with wrist motion to restore the slider crank mechanism of the scaphoid after scapholunate interosseous ligament (SLIL) injury. The procedure is designed to simulate a hypothetical dorsal radioscaphoid ligament that more closely approximates the normal viscoelastic forces acting on the scaphoid throughout all phases of wrist motion than does the static checkrein effect and motion limitations of capsulodesis or tenodesis. Extensor carpi radialis longus transfer may be independently sufficient to support normal or near-normal scapholunate and midcarpal kinematics and prevent further injury propagation in patients with partial SLIL tears and dynamic scapholunate instability. Extensor carpi radialis longus transfer alone may improve carpal congruity in patients with static scapholunate instability, but SLIL and dorsal lunate ligament repair or reconstruction is essential for favorable durable outcomes. Extensor carpi radialis longus transfer offers a simple and reasonable alternative to capsulodesis or tenodesis to support these ligament repairs or reconstructions, does not require intercarpal fixation, and allows rehabilitation to proceed expeditiously at approximately 1 month after surgery.     

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.     

Extensor carpi radialis brevis ligamentoplasty and dorsal capsulodesis for the treatment of chronic post-traumatic scapholunate instability

ObjectivesTo present a novel surgical technique that includes both extensor carpi radialis brevis (ECRB) ligamentoplasty and dorsal capsulodesis for the treatment of chronic post-traumatic scapholunate instability.MethodsWe performed a retrospective review of 32 patients with chronic post-traumatic scapholunate instability (stage 4 or 5 according the Garcia-Elias’ classification) who were treated with this technique. Pre- or intraoperative arthroscopic evaluation was carried out in all cases.ResultsThe postoperative wrist range of motion was generally improved except for wrist flexion. In 20 patients out of 29, the DISI deformity was corrected. Grip strength and pain was also improved postoperatively. Based on the Mayo wrist scoring, 16 patients had excellent results, eight patients had good results, three patients had fair results, and five patients had poor results.ConclusionOur technique which combines ECRB ligamentoplasty with dorsal capsulodesis is a reliable option for the surgical treatment of chronic postchronic post-traumatic scapholunate instability.     

Scapholunate ligament injuries: a review of current concepts

Injuries to the scapholunate ligament are common, especially among young active individuals. Surgeons are faced with a difficult problem because of imperfect surgical outcomes and the high demands of this patient population. Here, we review the current concepts and newest literature on scapholunate ligament injuries as well as the classification and treatment options for each stage of scapholunate instability. Emphasis is on stages in which reconstructive rather than salvage procedures can be performed. The natural history is poorly understood; it is unknown which and how many scapholunate injuries lead to wrist arthritis (SLAC wrist). Partial injuries are rare and in small studies did well with arthroscopic treatment. Complete injuries are graded based on the acuity of the injury, the presence and reducibility of scapholunate malalignment, and, finally, cartilage status. In acute injuries, anatomic repair usually leads to satisfactory results, and many authors augment the repair with a capsulodesis technique. In chronic injuries, the presence of static malalignment usually leads to inferior outcomes. Various techniques have been devised and improved over the years. These techniques appear to provide a more anatomic reconstruction, with less loss of motion; motion is 60–80 % of the contralateral side and grip strength averages 65–90 %. Once there is cartilage loss, the surgeon only has salvage procedures to choose from, tailored to the degree of arthritis.     

Dorsal scapholunate stabilization using Viegas’ capsulodesis: 25 cases with 26 months-follow-up

Intercarpal instability is often secondary to a scapholunate interosseous (SLIO) ligament lesion. Its reconstruction is thus essential. Classical capsulodesis techniques fix the scaphoid in extension and do not reproduce the physiologic ligamentous isometry of the wrist. The authors use the technique of Viegas, which seems to respect this isometry: the dorsal intercarpal ligament is re-inserted dorsally to reattach the capsule on the dorsal SLIO and to reinforce it. Between 2006 and 2010, 25 wrists were operated on in 12 men and 12 women of mean age 38 years. All patients presented with pain often associated with loss of power, decreased mobility or a debilitating click. The mean follow-up was 26 months. Postoperative and preoperative data were compared. Flexion/extension range increased by 2.6°, radioulnar deviation increased by 21.1°. Grip strength increased by 8.7 kgf. Pain decreased by 3 points on the VAS and the PRWE improved by 59 points. We observed four CRPS, one EPL lesion and one case of superficial track pin infection. We got eleven excellent results, nine good, two moderate and three bad, two of which were re-operated. Viegas’ capsulodesis does not present major technical difficulty. The results show no stiffness in flexion/extension. There was evident improvement in radioulnar deviation, grip strength, pain and PRWE scores. This technique provides effective treatment for a difficult or irreparable lesion of the SLIO ligament, without fixed carpal instability corresponding to Geissler arthroscopic stages 2 to 4 and Garcia-Elias stages 3 and 4. The capsulodesis produces an effective stabilization without stiffness. Precautions should be undertaken to avoid CRPS and pin complications.     

Osteochondral resurfacing (OCRPRC) for capitate chondrosis in proximal row carpectomy

PURPOSE: Proximal row carpectomy (PRC) can be an effective treatment option for arthritis of the wrist, but the operation is contraindicated when there is substantial arthritis of the capitate head. We describe a new technique that involves resurfacing of the capitate when there is chondrosis by using osteochondral grafts harvested from the resected carpal bones. The purpose of this study was to assess the outcomes of patients who had osteochondral resurfacing in the setting of PRC (OCRPRC) for capitate chondrosis and to determine how they compare with published results of conventional PRC. METHODS: Patients having PRC who had grade II to IV (Modified Outerbridge Scale) capitate chondrosis underwent osteochondral resurfacing of the capitate. Preoperative and postoperative pain level, employment status, range of motion (ROM), grip strength, and Mayo wrist scores were assessed, and Student's t-test was used. Postoperative Disability of the Arm, Shoulder and Hand (DASH) scores were also calculated. RESULTS: Eight patients with an average age of 53 years were followed up for 18 months. Preoperatively, 7 patients described their pain as moderate to severe; postoperatively, 7 patients described their pain as mild to no pain. Preoperative arc of motion was 84 degrees (74% of the contralateral side); postoperative arc of motion was 75 degrees (66% of the contralateral side). Preoperative grip strength was 29 kg, or 62% of the contralateral side; postoperative grip strength was 34 kg, or 71% of the contralateral side. Preoperative Mayo wrist score was 51 ("poor"); postoperative Mayo wrist score was 68 ("fair"). Average postoperative DASH score was 19.5. Follow-up radiographs showed that 75% of patients had mild to no degeneration. Magnetic resonance imaging at 21 months postoperatively showed graft incorporation. No complications were encountered. CONCLUSIONS: Our results with osteochondral resurfacing compare favorably with the published results of conventional PRC in terms of pain relief, employment status, ROM, and grip strength.     

Rebalancing the tetraplegic wrist using extensor carpi ulnaris-tenodesis

Patients with cervical spinal cord injury and tetraplegia often present with a radial deviation deformity of the wrist owing to impaired active wrist flexion and extension. Tenodesis of the extensor carpi ulnaris can help optimize grip strength. The purpose of the study was to compare reconstruction of the grip with and without extensor carpi ulnaris-tenodesis, as well as evaluating the outcome of the procedure. The grip strength of the group with tenodesis of the extensor carpi ulnaris was twice as strong as of the group without the tenodesis and with similar wrist joint flexion-extension range of motion. Correction of the wrist deformity enables a more ergonomic use of the hand. This may also help prevent shoulder pain, which is common among patients with tetraplegia.     

The use of vascularized grafts from the distal radius for the treatment of Preiser's disease

PURPOSE: To examine the outcome of vascularized bone grafts (VBGs) used for the treatment of Preiser's disease. METHODS: Over a 10-year period (1993-2003) 8 pedicled VBGs were performed as the primary treatment for Preiser's disease. All patients had preoperative magnetic resonance imaging (MRI) scans that confirmed the diagnosis of avascular necrosis of the scaphoid. Bone revascularization was evaluated by examining preoperative and postoperative MRIs. All patients had a reverse-flow pedicled VBG from the distal radius. The average patient age was 40 years and the mean follow-up period was 36 months. Postoperative evaluation included range of motion, grip strength, pain evaluation, and Mayo wrist scores. RESULTS: All MRIs showed evidence of revascularization, with improvement in T2 and/or T1 signal; however, a consistent finding on MRI was incomplete revascularization of the entire proximal pole. Wrist motion averaged 55% of the unaffected side after surgery. Grip strength remained stable. Seven patients had long-term improvement in pain. The average Mayo wrist score was 68, with 1 patient rated as excellent, 1 as good, 5 as fair, and 1 as poor. There was 1 reconstructive failure that resulted in a proximal row carpectomy less than 1 year after the surgery. CONCLUSIONS: In this series VBGs led to reduced pain levels and preserved the radiocarpal wrist motion in most patients. Inability to revascularize the proximal pole of the scaphoid and ongoing wrist arthritis appear to persist despite revascularization attempts. VBGs for Preiser's disease should be limited to patients with early stage disease (Herbert stages I or II) without evidence of radiocarpal arthritis and no evidence of carpal instability. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Open Wedge Osteotomy for Malunited Extraarticular Distal Radius Fractures with Plate Osteosynthesis without Bone Grafting

Abstract Background: Malunion of distal radius fractures can cause pain, limited wrist motion, or loss of grip strength. The most important factors are incongruity in the distal radioulnar (DRU) joint and radial tilt which causes adaptive carpal instability. The purpose of open wedge corrective osteotomy is to restore congruency with minimal soft-tissue damage. Patients and Methods: Between 1993 and 2001, 47 patients with malunited extraarticular distal radius fractures who were treated by open wedge corrective osteotomy without bone grafting were included. The patients were divided into two groups, one group with dorsal tilt of the distal radius and one group with palmar tilt. Ulnar variance, radial inclination, and radial tilt were measured before and after operation. Also, the range of wrist motions was tested before and after correction, including grip strength. Fixation was performed with a dorsal or palmar plate, dependent on the side of radial tilt. Results: Improvement of especially radial tilt was seen in both groups. Also, an important increase in wrist motions was observed. Flexion of the wrist improved by 38.0° in the dorsal group and by 43.0° in the palmar group. With respect to rotation of the lower arm, supination improved most by 21.6° and 46.0° in the dorsal and palmar group, respectively. All osteotomies healed within 3 months without secondary displacement even after a short period of immobilization. Conclusion: Corrective osteotomy is a useful additional therapy in the treatment of malunited extraarticular fractures of the distal radius in which bone grafting is not necessary.     

Anterior and Posterior Interosseous Neurectomy for the Treatment of Chronic Dynamic Instability of the Wrist

The purpose of this study was to determine the results of combined anterior and posterior interosseous neurectomy (AIN/PIN) in patients with chronic wrist pain secondary to dynamic instability, and to determine the predictability of selective AIN/PIN blocks with respect to pain relief, grip strength, and outcome of the neurectomy. A prospectively accrued chronic wrist pain registry was undertaken. Inclusion criteria were patients with arthroscopically confirmed dynamic wrist instability who had undergone a diagnostic AIN/PIN injection, followed by a single dorsal incision neurectomy. All patients completed Disabilities of the Arm, Shoulder and Hand outcome questionnaires preoperatively and at intervals postoperatively. Pre- and postoperative range of motion, grip strength, and percentage pain relief were recorded. Over a 3-year period, 50 wrists (48 patients) were enrolled: average follow-up was 28 months (range: 24–42 months). The average improvement in grip strength after denervation was 16% (p = 0.076), the average improvement in subjective pain rating was 51% (p < 0.0001), and the average improvement in Disabilities of the Arm, Shoulder, and Hand scores was 15 points (p = 0.0039). Improvement of pain from diagnostic injections was not predictive of final improvement of pain; however, improvement in grip strength after diagnostic injections did correlate with improved grip strength after surgery. Lack of improvement in subjective pain rating or grip strength after diagnostic injection approached statistical significance. There was no decrease in range of motion postoperatively. Fourteen patients (16 wrists) failed as defined by need for subsequent surgery. The results of AIN/PIN neurectomy demonstrate that it may be an effective alternative to wrist salvage or reconstructive procedures within the first few years of follow-up.The Chief, Bureau of Medicine and Surgery, Navy Department, Washington, DC, Clinical Investigation Program, sponsored this report #S94-140 as required by NSHSBETHINST 6000.41B. The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.     

Partial scapholunate ligament injuries treated with arthroscopic debridement and thermal shrinkage

PURPOSE: To present the early results of arthroscopic debridement and thermal shrinkage using radiofrequency probes for partial (Geissler grades I and II) scapholunate (SL) interosseous ligament injuries of the wrist. METHODS: Sixteen patients with a mean age of 34 years (range, 18-54 y) presenting with chronic dorsoradial wrist pain unresponsive to initial conservative treatment for a mean period of 12 weeks were included in this study. No patient showed radiologic signs of static dissociation (SL interval, <3.5 mm; mean SL angle, 49 degrees ) before surgery. Diagnostic arthroscopy showed a partial SL tear in 14 patients and redundancy of the ligament in 2. Partial SL tears involved the membranous (proximal) and volar part of the ligament. All lesions were debrided and treated with thermal shrinkage using a bipolar radiofrequency probe. RESULTS: The mean follow-up period was 19 months (range, 9-34 mo). Fourteen patients experienced substantial pain relief whereas in 2 the pain remained unchanged. Eight patients were completely pain free. The mean flexion-extension arc was 142 degrees and the mean grip strength was 78% that of the unaffected side. No patient showed radiologic signs of arthritis or static or dynamic instability after surgery (SL interval remained <3.5 mm; mean SL angle, 53 degrees ). Based on the modified Mayo wrist score there were 8 excellent, 6 good, 1 fair, and 1 poor result. CONCLUSIONS: Partial SL ligament tears can be a source of radial-sided wrist pain. Scapholunate ligament debridement and thermal shrinkage effectively provided pain relief for most of the patients treated. Stability was maintained radiographically. No complications were noted from the use of radiofrequency probes. These reasonably favorable short-term results should be viewed cautiously. A longer follow-up study is necessary to determine the ultimate efficacy of this procedure.