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.     

Two cases of pisiform bone impingement syndrome after proximal row carpectomy

Proximal row carpectomy (PRC) is an established surgical procedure used to treat post-traumatic osteoarthritis of the wrist with sparing of the midcarpal joint and advanced aseptic necrosis such as lunatomalacia. Proximalization of the distal carpal row following PRC may lead to secondary problems such as radiocarpal impingement. At follow-up, two of our patients complained about ulnar-sided wrist pain after proximal row carpectomy. Computed tomography (CT) scans were taken for both patients with an additional magnetic resonance imaging scan for one patient. The CT scan revealed clear osteolysis consistent with a pisiform bone impingement on the ulnar styloid process in both the cases, and also on the hamate in one patient. An impingement syndrome of this nature has not previously been described and should be kept in mind when patients report ulnocarpal symptoms after PRC.     

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.     

Wrist arthrodesis with excision of the proximal carpal bones using the Ao/ASIF wrist fusion plate and local bone graft

We present our series of 17 patients who underwent wrist arthrodesis with excision of the proximal row carpal bones using the AO wrist fusion plate and local bone graft obtained from the excised proximal carpal row. All patients were evaluated using a questionnaire to assess pain, function, ability to perform an occupation and satisfaction with the procedure. The mean follow-up was 17 months, at which time all the fusions had united. Clinical outcome scores showed that 14 and 15 of the 17 patients achieved good or excellent results with regard to their current condition and clinical improvement, respectively. Four patients required secondary surgery, two for fractures and two for instability of the distal radio-ulnar joint unrelated to the wrist fusion.     

Distal ulna resection, extensor carpi ulnaris tenodesis, and dorsal synovectomy for the rheumatoid wrist

We conclude from this study that distal ulna resection coupled with stabilization by ECU tenodesis is a highly useful technique with a reproducibly successful outcome for DRUJ destruction resulting from rheumatoid arthritis. In this series, like those noted previously, alleviation of pain, preservation of wrist mobility, prevention of tendon rupture, and improved function have been consistently observed. Moreover, with adjunctive dorsal synovectomy this combined procedure has proved applicable to cases demonstrating not only mild but also moderate stages of radiocarpal disease, thereby avoiding the more extensive and less desirable surgical alternatives of complete wrist arthrodesis or total wrist arthroplasty. Recognizably, the long-term benefit of this surgery depends on maintaining stability of both the reconstructed radioulnar joint and the synovectomized radiocarpal joint. Although the data reported herein strongly support the efficacy of the tenodesis in preserving distal ulna stability and similarly indicate a favorable influence on maintenance of radiocarpal architecture, one must be cognizant that progressive radiocarpal deterioration is a characteristic, albeit somewhat unpredictable, manifestation of the chronic rheumatoid process, and is the principal factor apt to compromise an initially satisfactory result. In such cases demonstrating excessive carpal malalignment preoperatively and for those with an unremitting postoperative course of ulnar translocation or volar subluxation, additional radiocarpal stabilization, preferably by arthrodesis, is essential to salvage the benefits of distal ulna resection and ECU tenodesis.     

Intercarpal arthrodesis for static and dynamic volar intercalated segment instability

Since 1982 seven patients with volar intercalary segment instability (VISI) have been operated on at the Massachusetts General Hospital. All had preoperative wrist pain and described a painful "clunk" with ulnar deviation. In each case there was palpable evidence of instability when the wrist was deviated ulnarly that produced a "buckling" sensation as the distal and proximal rows rotated with ulnar deviation. Arthrograms in six patients and a cineradiography in one patient confirmed that this buckling correlated with volar rotation of the lunate and triquetrum and dorsal rotation of the capitate and hamate. All the patients had some type of intercarpal arthrodesis including four capitate-lunate-triquetrum hamate (CLTH), one lunate-triquetrum (LT), one lunate-triquetrum-hamate (LTH), and one triquetrum-hamate (TH). Surgical findings included the position of the lunate that had rotated on the capitate so that it was tilting volarly and the major ligament instability was between the proximal and distal rows although ligament tears were also present between lunate and triquetrum. Arthrodesis of the proximal and distal rows provided relief of wrist pain in five of six patients. The one patient with the arthrodesis limited to the proximal row had a poor result. Of the five successful cases, the postoperative range of wrist motion was 81 degrees of extension/flexion arc (63% of the normal contralateral) and 35 degrees of radial and ulnar deviation arc (57% of the normal contralateral wrist). The grip strength postoperatively averaged 58 pounds (74% of the normal contralateral side).     

Reconstruction radiocarpienne par transfert en îlot de l’articulation radio-ulnaire distale

IntroductionWe described the island transfer of the DRUJ to reconstruct the radiocarpal joint when the radiocarpal and the mediocarpal joints are destroyed. The objective is to avoid wrist arthrodesis or prosthesis.Patients and methodFrom 1993 to 1997, five patients were operated, five men, the average age was 55 years (36 to 67). The operated side was the dominant side one time. The joint destruction was secondary to: SLAC wrist (stage 3) in two cases, a failure of PRC in two cases and post-traumatic necrosis of the lunatum in one case.ResultsOne failure was resumed by total wrist arthrodesis at 1-year follow-up. Four patients were revised with 11 years follow-up (from nine to 13). Two patients presented a pain-free wrist, two patients complain of barometric pain or after heavy works. The average mobility was: extension 40°, flexion 25°, ulnar deviation 30°, radial deviation ?3°, complete pronosupination. The strength was 65% of the opposite side. X-rays showed an important radiocarpal reshaping and ulnar sliding of the carpus.DiscussionThe island transfer of the DRUJ was possible in every case. The discordance between clinical and radiological results can be explained by joint denervation. We stopped this procedure not to sacrifice any more the healthy DRUJ.ConclusionThe island transfer of the DRUJ to reconstruct the radiocarpal joint is a solution to avoid total wrist arthrodesis or prosthesis if we accept the DRUJ sacrifice.     

Management of post-traumatic instability of the wrist secondary to ligament rupture

A retrospective review of 55 patients with post-traumatic radioscapholunate ligament disruption suggests that rupture of this ligament can be treated successfully if certain guidelines are followed. If the rupture is seen within 4 weeks, an anatomic reduction maintained in plaster for 8 weeks leads to good results. Ligament ruptures that cannot be held in reduction or that are diagnosed after 4 weeks do poorly with immobilization only. Results after ligament reconstruction have ranged from good to fair but appear to have been sufficiently successful to warrant continued trial rather than resort to arthrodesis, proximal row carpectomy, or similar reconstructive procedures. Patients with degenerative joint disease associated with radioscapholunate rupture are not candidates for ligament reconstruction. Radial styloidectomy or some variety of wrist arthrodesis or wrist arthoplasty should be considered in these instances.     

Distraction resection arthroplasty of the wrist

Proximal row carpectomy should not be done if wrist degeneration includes cartilage destruction of the capitate or lunate fossa of the radius; yet total wrist arthroplasty has been disappointing for treatment of osteoarthritis. We have used a technique we call distraction resection wrist arthroplasty in such cases. We retrospectively reviewed distraction resection wrist arthroplasty in 14 wrists and compared them to nine patients who had PRC; average follow-up was 32 months. Three patients had spastic contractures and 20 had operation for painful osteoarthritis. Patient satisfaction was high but there were four failures requiring arthrodesis (1 PRC, 3 DRA). Average postoperative wrist motion was 41 degrees of extension, 38 degrees of flexion, 11 degrees of radial deviation, and 13 degrees of ulnar deviation. Static strength averaged almost two thirds of the uninvolved side and dynamic power more than half. Differences between the DRA and PRC patients were not statistically significant in single or aggregate analysis. We believe that distraction technique extends the indications for biologic arthroplasty to patients whose only prior option was wrist arthrodesis.     

Salvage procedures for degenerative osteoarthritis of the wrist due to advanced carpal collapse

Arthrodesis of the wrist has been considered as the gold standard for osteoarthritis of the wrist. In 1984 Watson and Ballet identified a specific pattern of carpal collapse (scapholunate advanced collapse = SLAC) with progressive osteoarthritis. In order to preserve some motion, other alternative procedures have been proposed: proximal row carpectomy (PRC) and scaphoidectomy combined with a four-corner arthrodesis (4CA). In this cohort of 63 patients, three types of surgical treatment were performed (arthrodesis in 19, PRC in 26 and scaphoidectomy with 4CA in 18). The DASH questionnaire was used to evaluate the residual disability. PRC had a significantly better outcome (DASH=16), while there were no significant differences between full arthrodesis (DASH=45) and four corner arthrodesis (DASH=39). In PRC and in four corner arthrodesis a functional range of motion could be preserved (resepectively 44 degrees and 52 degrees flexion/extension arc). Gripping force remained inferior to the non operated side. There was a significant increase in gripping force in the PRC group, but not in the others. The final gripping force was not significantly different in the three treatment regimes.     

Proximal row carpectomy in emergency

Proximal row carpectomy (PRC) is a well-accepted procedure for the treatment of early post-traumatic degenerative disease of the wrist. Much less frequently, PRC has been advocated as an emergency procedure for irreparable fracture-dislocation of the wrist. Our objective was to compare the results of PRC in patients having undergone this procedure in the two contexts. We conducted a retrospective analysis of the clinical and radiographic results of six patients treated by emergency PRC as compared to six patients who underwent elective PRC. The mean follow-up was 36 months. Both the patient's satisfaction and the grasp of the wrist joint were significantly better in patients who underwent PRC emergency as compared to those having undergone elective PRC. Quick DASH score, radiographic results, and return to work were also more favourable in these patients, but the difference between the two groups was not significant. This study confirms that PRC is a valuable salvage technique indicated in early posttraumatic wrist collapse. Moreover, when performed in emergency, the procedure shows even better subjective and objective results, allowing a majority of patients to return to their previous job.     

Free fascia temporalis interpositioning as a treatment for wrist ankylosis

The fascia temporalis is a thin and well-vascularized tissue and, for this reason, its use in reconstructive surgery is versatile. It can be used as an island flap in defects of the head and neck or as a free flap in reconstructions of different anatomic regions. As a "living" spacer in the treatment of wrist ankylosis, its use has not yet been described. The authors present the transfer of the free fascia temporalis into the wrist as a treatment of wrist ankylosis in patients affected by severe rheumatoid arthritis. Four flaps in three patients were performed. Preoperative flexion/extension in the wrist was absent or almost absent and painful, resulting in severely impaired daily activities. After resection of the distal ulna, distal radius, and the proximal surfaces of the proximal row of the carpal bones was performed, the free fascia was used to replace the wrist joint. Postoperative wrist flexion/extension was 45 to 50 degrees on average. In all patients, this procedure allowed painless motion of the wrist, and in all patients, daily activities were improved. A 2-year follow up showed no recurrence of wrist problems and a maintained articular space. In the treatment of wrist ankylosis, the use of the free fascia temporalis offers a good alternative to arthrodesis, maintaining sufficient function for daily activities.     

Initial shortening and internal fixation in combination with a Sauvé-Kapandji procedure for severely comminuted fractures of the distal radius in elderly patients

We identified 11 women with a mean age of 74 years (65 to 81) who sustained comminuted distal radial and ulnar fractures and were treated by volar plating and slight shortening of the radius combined with a primary Sauvé-Kapandji procedure. At a mean of 46 months (16 to 58), union of distal radial fractures and arthrodesis of the distal radioulnar joint was seen in all patients. The mean shortening of the radius was 12 mm (5 to 18) compared to the contralateral side. Flexion and extension of the wrist was a mean of 54° and 50°, respectively, and the mean pronation and supination of the forearm was 82° and 86°, respectively. The final mean disabilities of the arm, shoulder and hand score was 26 points. According to the Green and O'Brien rating system, eight patients had an excellent, two a good and one a fair result. The good clinical and radiological results, and the minor complications without the need for further operations related to late ulnar-sided wrist pain, justify this procedure in the elderly patient.     

Silicone rubber arthroplasty of the wrist

The wrist is often referred to as the keystone of the hand. It is often affected in rheumatoid arthritis. Salvage procedures for patients with rheumatoid arthritis involving the wrist include silicone wrist arthroplasty, total joint arthroplasty, and wrist arthrodesis. In 1967, Swanson developed a double-stem, flexible-hinge implant for the radial carpal joint. In 1982, metal titanium bone liners (grommets) were added to help decrease the incidence of fractures. The authors feel that the gold standard is still wrist arthrodesis. However, they would use a flexible wrist arthroplasty in a patient who has bilateral wrist involvement with marked digital deformity and/or proximal interphalangeal stiffness. This is especially true in low-demand patients who have good alignment, good bone stock, and the associated proximal and distal disease. If these criteria are met and meticulous technique used, successful reconstruction of the wrist with a flexible wrist silicone implant can be performed in the patient with rheumatoid arthritis.     

Proximal row carpectomy: a minimum 10-year follow-up study

PURPOSE: To assess the long-term clinical and radiographic results after a proximal row carpectomy (PRC). METHODS: Twenty patients with various degenerative and posttraumatic disorders of the wrist were evaluated. The evaluation consisted of a physical examination, plain radiographs, and completion of a questionnaire that assessed patient satisfaction, return to work status, occupational and recreational activities and restrictions, and pain level. RESULTS: Two patients (10%) had persistent pain after a PRC requiring a radiocapitate arthrodesis. The remaining 18 patients were evaluated at an average follow-up of 13.1 years (range, 10.0-17.2 y). The average wrist range of motion was 63% and the average maximal grip strength was 83% of the opposite extremity, respectively. Seventeen patients were satisfied with their outcome. One patient complained of persistent pain and was not satisfied but did not want further surgery. All but 2 patients returned to their original occupation and activity level including all 5 patients involved in workers' compensation. Follow-up radiographs showed flattening of the proximal capitate in 6 patients. Radiocapitate arthrosis was absent/minimal in 13 patients and moderate/severe in 4 patients. The presence of radiographic changes did not correlate with patient satisfaction or degree of wrist pain. CONCLUSIONS: Proximal row carpectomy is a dependable and durable procedure that results in satisfactory pain relief in the majority of patients, maintenance of functional wrist motion and grip strength, high patient satisfaction, and ability to return to work. Progressive symptomatic deterioration of the radiocapitate articulation was not observed.     

Dorsal Wrist Extrinsic Carpal Ligament Injury Exacerbates Volar Radiocarpal Instability After Intra-Articular Distal Radius Fracture

Background: Volar radiocarpal instability is often seen after loss of fixation of volar lunate facet fragments. The pathogenesis of post-traumatic volar radiocarpal instability is poorly understood. The purpose of this study was to determine if injury to the dorsal wrist extrinsic carpal ligaments contributes to volar radiocarpal instability. Methods: Six matched pairs of cadaveric upper extremities were tested using a dynamic hand testing system. In group 1, the intact wrist, the wrist with a volar lunate facet fracture, and the fractured wrist after 500 cycles of grip were tested. In group 2, in addition to the intact and fractured wrist, the fractured wrist with the dorsal extrinsic carpal ligaments cut and the fractured wrist with the dorsal extrinsic carpal ligaments cut after 500 cycles of grip were also tested. Volar-dorsal displacement of the lunate was measured from 45° wrist flexion to 45° wrist extension in 22.5° increments with the wrist flexors/extensors loaded for each condition. Results: Volar lunate translation did not significantly increase after the volar lunate facet fracture alone, and was not evident to a significant extent until the dorsal wrist extrinsic carpal ligaments were cut. Further instability of the lunate occurred after grip cycling only with the dorsal extrinsic capsular ligaments cut. Conclusions: Injury to the dorsal wrist extrinsic carpal ligaments exacerbates volar radiocarpal instability. Unrecognized dorsal sided injury may be a contributing factor to why stable fixation of volar lunate facet fragments remains problematic after volar plating of intra-articular distal radius fractures with displaced volar lunate facet fragments.     

A three-dimensional quantitative analysis of carpal deformity in rheumatoid wrists

We have measured the three-dimensional patterns of carpal deformity in 20 wrists in 20 rheumatoid patients in which the carpal bones were shifted ulnarwards on plain radiography. Three-dimensional bone models of the carpus and radius were created by computerised tomography with the wrist in the neutral position. The location of the centroids and rotational angle of each carpal bone relative to the radius were calculated and compared with those of ten normal wrists. In the radiocarpal joint, the proximal row was flexed and the centroids of all carpal bones translocated in an ulnar, proximal and volar direction with loss of congruity. In the midcarpal joint, the distal row was extended and congruity generally well preserved. These findings may facilitate more positive use of radiocarpal fusion alone for the deformed rheumatoid wrist.     

Total wrist arthroplasty in patients with rheumatoid arthritis

PURPOSE: After very good midterm results with an uncemented total wrist arthroplasty we evaluated the long-term outcome in a retrospective study. METHODS: Forty uncemented anatomic physiologic (APH, Implant-Service Vertreibs-GmbH, Hamburg, Germany) wrist prosthesis implantations performed in 40 patients were reviewed. The mean follow-up period was 52 months (range, 24-73 mo) and the following parameters were examined: radiographs, grip strength, range of motion, and patient's satisfaction. RESULTS: After a good short-term outcome the results deteriorated with time. The following complications occurred: 2 infections, 3 implant failures, 2 prosthesis migrations, and 33 loosenings/dislocations. All patients (39 of 40) underwent revision surgery, and severe titanium wear in the soft tissues was found intraoperatively in all cases. It became clear that even in a non-weight-bearing joint such as the wrist, titanium alloy may wear and result in tissue metallosis when used as a bearing surface of the implant. As a salvage procedure the prosthesis was removed and an arthrodesis was performed in all patients. CONCLUSIONS: Because of the deterioration of the results including an unacceptable revision rate we currently do not consider the anatomic physiologic wrist prosthesis to be a suitable implant in patients with rheumatoid arthritis.     

Persistent posttraumatic wrist pain: complex regional pain syndrome? Mycobacterium tuberculosis infection should be in the differential diagnosis

It is a common algorithm for hand surgeons to diagnose and treat persistent post-traumatic wrist pain as complex regional pain syndrome (CRPS). Although it works for many patients, some conditions that affect the wrist don’t fall in this category and worsen with this treatment practice. We present a single-handed patient who had had a non-displaced distal radius fracture and was treated as CRPS for the next three months. He was eventually diagnosed with late tuberculous tenosynovitis of the wrist and a total wrist arthrodesis was performed. We believe that Mycobacterium tuberculosis infection should be in the differential diagnosis of persistent post-traumatic joint pain. This is especially important as Mycobacterium infections are becoming more common due to an increase in patients with chronic immunosuppression and definitive diagnosis and treatment of tuberculous tenosynovitis needs a high index of clinical suspicion.     

Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius

BACKGROUND: The purpose of the present study is to report on a cohort of patients with a volar shearing fracture of the distal end of the radius in whom the unique anatomy of the distal cortical rim of the radius led to failure of support of a volar ulnar lunate facet fracture fragment. METHODS: Seven patients with a volar shearing fracture of the distal part of the radius who lost fixation of a volar lunate facet fragment with subsequent carpal displacement after open reduction and internal fixation were evaluated at an average of twenty-four months after surgery. One fracture was classified as B3.2 and six were classified as B3.3 according to the AO comprehensive classification system. All seven fractures initially were deemed to have an adequate reduction and internal fixation. Four patients required repeat open reduction and internal fixation, and one underwent a radiocarpal arthrodesis. At the time of the final follow-up, all patients were assessed with regard to their self-reported level of functioning and with use of Sarmiento's modification of the system of Gartland and Werley. RESULTS: At a mean of two years after the injury, six patients had returned to their previous level of function. The result was considered to be excellent for one patient, good for four, and fair for two. The average wrist extension was 48 degrees, or 75% of that of the uninjured extremity. The average wrist flexion was 37 degrees, or 64% of that of the uninjured extremity. The one patient who underwent radiocarpal arthrodesis had achievement of a solid union. The four patients who underwent repeat internal fixation had maintenance of reduction of the lunate facet fragment. The two patients who declined additional operative intervention had persistent dislocation of the carpus with the volar lunate facet fragment. CONCLUSIONS: The stability of comminuted fractures of the distal part of the radius with volar fragmentation is determined not only by the reduction of the major fragments but also by the reduction of the small volar lunate fragment. The unique anatomy of this region may prevent standard fixation devices for distal radial fractures from supporting the entire volar surface effectively. It is preferable to recognize the complexity of the injury prior to the initial surgical intervention and to plan accordingly.