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.     

The Sauvé-Kapandji procedure: a salvage operation for the distal radioulnar joint.

The Sauvé-Kapandji procedure, a distal radioulnar arthrodesis with surgical creation of a pseudoarthrosis in the distal ulna, was used to treat 11 patients. Although all patients had had at least one previous operation on the involved wrist, they were still having pain and functional limitations. Ten patients were available for follow-up, which averaged 33 months. Of the nine patients with posttraumatic arthritis, six had excellent results (a painless wrist that averaged 82 degrees of pronation and 83 degrees of supination). Three patients had good results (mild pain during activities with an identical range of forearm rotation). One patient who had rheumatoid arthritis had an excellent result for 3 years but recently had a radiocarpal wrist fusion because of radiocarpal arthritis. We have found the Sauvé-Kapandji procedure to be a reliable treatment option for intractable disorders of the distal radioulnar joint and recommend it as a salvage procedure when previous treatment has failed.     

Capitolunate arthrodesis with scaphoid and triquetrum excision

A retrospective two-center outcome study was designed to evaluate the results of capitolunate arthrodesis with scaphoid and triquetrum excision mainly for scapholunate advanced collapse patterns of arthritis. Fourteen wrists in 14 patients were evaluated objectively by standard parameters and subjectively by the Short Musculoskeletal Functional Assessment at an average of 28 months after surgery (range, 14-51 months). All patients were men between the ages of 20 and 70 years (average, 49 years). Two patients had a painful nonunion and one had persistent pain despite conversion to a solid wrist arthrodesis. One patient had x-ray evidence of progressive radiolunate narrowing, but only occasional pain. Postoperative wrist flexion-extension arc was 53 degrees and radioulnar deviation arc was 18 degrees. Grip and pinch strengths were 71% and 75%, respectively, of the normal contralateral wrist. The results of our study indicate that capitolunate arthrodesis with scaphoid and triquetrum excision is comparable to other motion-preserving operative procedures for scapholunate advance collapse.     

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.     

Treatment of chronic perilunate dislocations

Fifteen patients with 16 perilunate dislocations that had been untreated for a minimum of 6 weeks after the injury were evaluated after subsequent treatment at a mean of 6.4 years. The median time from injury to definitive treatment was 17 weeks. Ten wrists had completely ligamentous injuries and six had fracture-dislocations. Treatment consisted of open reduction and internal fixation in six patients, isolated carpal bone excision in four, wrist arthrodesis in two, proximal row carpectomy in two, and bilateral carpal tunnel release in one. In this series the results of excision of the lunate or scaphoid alone were uniformly poor. One of the two patients who had a proximal row carpectomy required secondary radial styloidectomy, and a pseudarthrosis developed in one of the two patients who had a wrist arthrodesis. All six patients treated by open reduction and internal fixation had satisfactory outcomes and none required additional surgery.     

Wrist arthrodesis using a Synthes wrist fusion plate

Thirty-nine patients were retrospectively reviewed after a wrist arthrodesis using a Synthes wrist fusion plate and iliac crest bone graft. Information was obtained from review of patient files, a questionnaire to assess pain, function and work status, and clinical assessment of grip strength, forearm rotation and fingers motion. All wrist fusions united except that the index carpometacarpal joint failed to unite in one patient. Thirty-seven patients were satisfied with the procedure, noting a reduction in wrist pain after fusion, but all reported some limitation of function. The wrist fusion plate was removed in six patients and a further four patients experienced minor symptoms over the dorsal aspect of the middle finger metacarpal.     

Posttraumatic ulnar translation of the carpus

Ulnar translation of the carpus is a rare posttraumatic carpal instability pattern, in which the entire carpus is displaced ulnarward on the radioulnar surface. No previous formal reports of this problem have been located although it has been described in general discussions of wrist instability. Seven men and one woman were diagnosed with this condition although the diagnosis was delayed from 2 to 23 months, an average of 7.3 months. Three patients were treated surgically before diagnosis; the other five patients were treated conservatively before diagnosis. At the time of definitive diagnosis the radiographs showed an ulnar translation of the carpus, which was quantified on the radiographs in all eight patients by the method of Chamay. Four patients had an attempt to repair the radiolunate and radiocapitate ligaments. One patient had a ligamentous augmentation of the radiocapitate ligament complex. Two patients had ligamentous repairs of a scapholunate dissociation; one of these had simultaneous radiocarpal ligamentous augmentation. The eighth patient had a radiolunate arthrodesis. Follow-up averaged 32 months. Three patients had formal wrist arthrodeses at 10, 13, and 26 months after initial ligamentous repair, which were considered treatment failures. In the remaining five patients, four had partial recurrent ulnar shift, which was seen radiographically. Of these, three patients rated the result as good, with near normal strength and returned to full activities while two obtained fair results, with minimal pain but decreased range of motion and decreased strength. One patient has shown progressive degenerative radiocarpal changes and may become a candidate for a limited or formal wrist arthrodesis.     

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.     

Pisotriquetral dysfunction following limited and total wrist arthrodesis

PURPOSE: We report a series of pisotriquetral arthritis cases following wrist and intercarpal arthrodesis, offer an anatomic and biomechanical rationale, and introduce intraoperative considerations to avoid this potential complication. METHODS: Nine patients with pisotriquetral arthritis requiring pisiform excision following wrist and intercarpal arthrodesis were retrospectively evaluated at 2 institutions. Five paired cadaver wrists were tested for alterations in pressure and kinematics of the pisotriquetral joint following four-corner and total wrist fusions. RESULTS: Nine patients were successfully treated with pisiform excision for pisotriquetral arthritis following wrist and intercarpal fusions. Biomechanical cadaver testing demonstrated profound alterations in pisotriquetral kinematics and pressure changes in measured degrees of wrist position following wrist and intercarpal fusions. CONCLUSIONS: Patients undergoing four-corner and/or wrist arthrodesis should be assessed for pisotriquetral discomfort before surgery, including a physical examination and a 30 degrees supinated radiograph to look for degenerative changes. Attempts should be made intraoperatively to ensure that the proximal row is not fused in an extended position. After surgery, if discomfort develops and conservative treatment fails, then pisiform excision can successfully alleviate the pain.     

Die Pisiformetransposition nach Beck zur Behandlung der Lunatumnekrose im Stadium 2 nach Kienböck

Summary BACKGROUND: Therapy for idiopathic necrosis of the lunate depends on the stage. The therapeutic strategy includes reconstruction and arthrodesis. The aim in stage II is the reconstruction of the wrist joint through a local or free vascularized bone graft. METHODS: In 13 patients, active range of motion (neutral-zero method), grip pinch (dynamometer), and pain were evaluated and compared to the uninvolved wrist. On standardized radiographs in posteroanterior projection, integration of the pisiform and development of carpal collapse in progressive degenerative arthritis were assessed. RESULTS: Sagittal wrist motion was reduced by 25 % and grip strength by 27 %. Pain improved from 1.6 points before surgery to 0.6 points after surgery. The pisiform showed osseous integration in 12 patients and separation by a hyperdense rim in one. Carpal collapse occurred in two patients. CONCLUSIONS: Following transposition of the pisiform to treat the necrotic lunate in stage II, good clinical results could be achieved and carpal collapse avoided in 84 % of the patients during the follow-up period.     

Silicone rubber carpal implants: a study of the incidence of late osseous complications

This clinical review of 53 silicone rubber carpal implants done by the senior author (P. R. C.) between 1976 and 1983 determines the incidence of so-called "silicone rubber synovitis." Although previously reported in small series, the true incidence of this complication of wear of the implant has not been documented. In this study late radiographic follow-up demonstrated lytic lesions adjacent to the carpal implants in 75% of the scaphoid implants, 55% of the lunate implants, and 75% of the scapholunate implants. In patients with x-ray film evidence of lytic lesions, more than half (56%) complained of pain, and more than one fourth (27%) have already had revision surgery. In every patient who had reoperation in this study, the histologic examination of the tissue in the wrist showed a chronic granulomatous process identical to that previously reported in cases of so-called "silicone rubber synovitis". These "lytic lesions" must be differentiated from "degenerative cysts" that are a part of the natural progression of degenerative arthritis. Four cases were submitted for mass spectrophotometric analysis, and the positive identification of the silica atom was made in all four. This study shows that the wear of carpal bone implants of silicone rubber and subsequent "silicone rubber synovitis" are common occurrences and not rare as has been previously inferred from isolated case report studies. This study suggests that implantation of these implants in young, healthy individuals is rarely indicated, and careful follow-up of patients who already have these implants in place is important.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Long-term results of silicone wrist arthroplasty in patients with rheumatoid arthritis

PURPOSE: The surgical treatment of the rheumatoid wrist is key in managing the affected hand. Wrist fusion is often the treatment of choice in cases of severe destruction and deformation although most patients would prefer a motion-preserving procedure. The implantation of a wrist prosthesis might be an alternative to partial arthrodesis for selected cases. In this series we analyzed the long-term results (minimum follow-up period, 10 y) of the Swanson silicone spacer for the wrist in patients with rheumatoid arthritis. METHODS: Sixteen patients with rheumatoid arthritis with 18 silicone spacers for the wrists were reviewed after a minimum follow-up period of 10 years (average, 15 y). Subjective evaluation, clinical examination, and radiographic analysis were included. An additional 9 patients (9 wrists) were interviewed by telephone. RESULTS: In 12 of the patients the subjective result was good or very good, mostly because of adequate pain relief. The average range of motion for flexion (average, 28 degrees )/extension (average, 15 degrees ) was 43 degrees with a wide variation within the series. Radiologically all wrists had diminished residual carpal height at follow-up evaluation and 9 of the wrists had evidence of osteolysis and foreign-body granuloma. The initial good correction of the ulnar translation of the wrist was lost partially in the follow-up period (1.1 vs 4.0 mm). Three of the patients needed surgical revision within the follow-up period; all were converted to wrist fusion. CONCLUSIONS: These long-term results suggest that the silicone wrist spacer still may be considered as an alternative to wrist fusion or more complex wrist joint prostheses in patients with rheumatoid arthritis, especially in severe cases and in patients with low demands. In the long term osteolysis caused by foreign-body granulation is to be expected and has to be considered.     

An approach to Kienböck's disease: Triscaphe arthrodesis

Sixteen patients with Kienb?ck's disease were treated with triscaphe arthrodesis (fusion of the scaphoid, trapezium, and trapezoid) with or without silicone rubber lunate arthroplasty. This approach removes compressive stress from the diseased lunate and treats the accompanying rotary subluxation of the scaphoid. Five patients were treated with triscaphe arthrodesis together with silicone rubber lunate arthroplasty. Three patients, who were symptomatic, after receiving silicone rubber lunate arthroplasty elsewhere, were treated with triscaphe arthrodesis. Eight patients were treated with triscaphe arthrodesis alone, without silicone rubber lunate arthroplasty. Two of these eight patients later required silicone rubber lunate arthroplasty. Radial styloidectomy and small lunate fragment excision were performed later on one patient. After an average follow-up of 20.5 months, relief of pain was satisfactory in all 16 patients. There was neither nonunion nor surgical infection. We believe that triscaphe arthrodesis with a silicone rubber lunate provides a means for load transference and heavy stress use capability of the hand. Triscaphe arthrodesis alone may suffice to bear the wrist load and can be used in an effort to preserve the diseased lunate. A silicone rubber lunate can easily be added at a later date if necessary.     

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.     

Wrist arthrodesis with intercalated iliac crest graft in mutilans rheumatoid arthritis

In mutilans rheumatoid arthritis (RA) patients with major wrist destruction, wrist arthrodesis is recommended. This type of arthrodesis needs carpal reconstruction and stable fixation. The goal of this study was to assess the functional and anatomical outcomes of an iliac crest graft and internal fixation with two medullary pins. Six wrists in three patients suffering from RA were reviewed clinically and radiologically at an average follow-up of 25 months. We assessed the fusion of the iliac graft with the radius and the metacarpus, the preoperative and postoperative carpal height, and the bone stock in front of the thumb. All the patients had improved functionally. The iliac graft fused with the radius in all cases and fused with the metacarpus in 5 out of 6 cases; the non-union occurred in the wrist where only one pin was used. Restoration of carpal height was associated with improvements in hand function. The bone stock was sufficient to allow implantation of a trapezial cup during a total arthroplasty of the thumb trapeziometacarpal (TMC) joint. No major complications occurred. An iliac graft and two pins through the 2nd and 3rd metacarpals were used to reconstruct the carpal height and to obtain wrist fusion. Internal fixation with only one pin is not recommended. Functional improvement can be attributed to the normal tension within the extrinsic flexors and extensors of fingers and thumb being restored because the carpal height was restored. A secondary TMC arthroplasty is theoretically possible.     

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.     

腕关节部分融合治疗退行性腕关节炎的疗效

目的评价头骨、月骨、三角骨及钩骨四关节融合治疗退行性腕关节炎的效果。方法1997年7月～2002年12月应用腕关节部分融合术创伤性腕关节炎治疗20例,术后随访15个月,随访检查包括术后腕关节疼痛程度、腕关节活动度、握力以及患侧X线检查。视觉模拟评分法评价疼痛程度。腕关节总体功能评价采用Krimmer腕关节评分表。结果腕疼痛值静息时为2.1,用力后为5.3;屈伸活动度为64°(对侧126°);尺桡偏为30°(对侧57°);平均握力为24kg(对侧40kg)。Krimmer腕关节评分值为67。X线检查头、月、三角及钩骨均融合。结论腕关节部分融合后能保存腕关节部分功能,是治疗退行性腕关节炎有效的方法。     

Resection of the distal pole of the scaphoid for scaphoid nonunion with radioscaphoid and intercarpal arthritis

PURPOSE: The treatment of scaphoid nonunion with degenerative arthritis poses a clinical problem that is particularly challenging in cases of associated dorsal intercalated segmental instability collapse, radiocarpal and intercarpal degenerative changes, and poor scaphoid bone quality. The purpose of this study was to report our clinical experience performing a distal scaphoid resection for symptomatic scaphoid nonunion in patients with either radioscaphoid or intercarpal arthritis who have had multiple surgeries. METHODS: Nine patients with recalcitrant scaphoid nonunion and associated degenerative arthritis treated by resection of the distal scaphoid fragment were evaluated both clinically and radiographically. Eight patients were male and one patient was female; the average follow-up period was 28.6 months (range, 12-52 mo). RESULTS: Seven patients reported pain with daily use and the remaining 2 patients reported mild pain with light work before surgery, whereas after surgery 4 of the 9 patients had no wrist pain and the remaining 5 patients had only mild pain with strenuous activity. The wrist range of motion improved from 70 degrees (51.4% of the opposite wrist) to 140 degrees (94% of the opposite wrist) and grip strength improved from 18 kg (40% of the opposite wrist) to 30 kg (77% of the opposite wrist). Clinical results were excellent in 6 patients and good in 3 patients based on a modified Mayo wrist-scoring chart. Radiographically neither additional degeneration nor progress of degenerative changes was noted after surgery in 8 patients. Newly developed degenerative arthritis occurred at the proximal scapholunate capitate articulation in the remaining patient who has a type II lunate, which had a facet (medial facet) articulation with the hamate. CONCLUSIONS: The results of this study showed that distal scaphoid resection produces a satisfactory clinical outcome, requires only a short period of immobilization, and should be considered one of the surgical options for long-standing scaphoid nonunion with either radioscaphoid or intercarpal degenerative arthritis. Nevertheless care must be taken in performing this procedure on patients whose preoperative radiograph show a type II lunate.     

Wide excision and ulno-carpal arthrodesis for primary aggressive and recurrent giant cell tumours

Twenty-five patients underwent wide resection of the distal radial giant cell tumours (GCTs) followed by ulno-carpal arthrodesis. There were 15 male and ten female patients, with an average age of 21.5 years. Tumours included ten primary aggressive and 15 recurrent GCTs. Mean follow up was 2.4 years. Pain, swelling and reduced range of movement (ROM) were noted. Average time to fusion was 7.6 months. Five patients had persistent pain in the proximal forearm. Grip strength was 65% compared to the uninvolved side. Two patients had superficial wound infection, two underwent additional bone grafting and three implant removals due to hardware prominence were carried out. There was no evidence of carpal instability or arthritis on clinical or radiological examination at the time of final follow up. Fusion of the carpus to the ulna is a simple method of producing a painless stable wrist, though at the expense of mobility. The procedure allows wide resection with a lower rate of recurrence. Pain in the proximal forearm seems to persist for 3 to 4 months only to improve at subsequent follow up. The procedure provides a valid option for the management of primary aggressive and recurrent GCTs of distal radius.