Wrist Swelling in Kienböck's Disease.

Background and Purpose Wrist swelling is a frequent clinical manifestation of Kienböck's disease, but no study has reported the site and pathology of wrist swelling in this disease. The aim of this study is to elucidate the site and pathology of wrist swelling in Kienböck's disease. Materials and Methods Dorsal and palmar soft tissue thicknesses of the wrist were measured on standard lateral radiographs of the wrist in 26 patients with Kienböck's disease and 30 subjects without intra-articular lesion. Axial magnetic resonance imaging (MRI) views were examined to detect the site of swelling. The dorsal capsular ligament in three patients with Kienböck's disease underwent histological examination. Results Radiographic study confirmed dorsal wrist swelling in 24 of 26 (92%) patients examined compared with the contralateral unaffected wrists. MRI demonstrated thickening of the dorsal capsular ligament and extensor layer with synovial proliferation. Histological examination revealed nonspecific chronic inflammation. Conclusion Dorsal wrist swelling in Kienböck's disease is a common manifestation and constitutes a part of pathology of Kienböck's disease, although further study is required to clarify the relation between wrist swelling and etiology of Kienböck's disease. Level of Evidence This is a Level III study.

Efficacy and safety of novel collagen conduits filled with collagen filaments to treat patients with peripheral nerve injury: A multicenter, controlled, open-label clinical trial.

INTRODUCTION: The safety and efficacy of using artificial collagen nerve conduits filled with collagen filaments to treat nerve defects has not been fully studied in humans. We conducted a multicenter, controlled, open-label study to compare the safety and efficacy of artificial nerve conduit grafts with those of autologous nerve grafts. METHODS: We included patients with a sensory nerve defect of ≤30 mm, at the level of the wrist or a more distal location, with the first-line surgical methods selected according to a patient's preference. We compared sensory recovery using static two-point discrimination and adverse events between the artificial collagen nerve conduit and autologous nerve grafting. RESULTS: The artificial nerve conduit group included 49 patients, with a mean age of 42 years and nerve defect of 12.6 mm. The autologous nerve graft group included 7 patients, with historical data of an additional 31 patients, with a mean age of 36 years and nerve defect of 18.7 mm. The rate of recovery of sensory function at 12 months was 75% (36/49) for the artificial nerve conduit group and 73.7% (28/38) in the autologous nerve group. No serious adverse events directly associated with use of the artificial nerve conduit were identified. CONCLUSIONS: The treatment of nerve defects ≤30 mm using artificial collagen nerve conduits was not inferior to treatment using autologous nerve grafts. Based on our data, the new artificial collagen nerve conduit can provide an alternative to autologous nerve for the treatment of peripheral nerve defects.

Carpal tunnel syndrome associated with Kienböck disease.

We retrospectively reviewed 12 patients (3 men and 9 women, with a mean age of 72 years) who were surgically treated for carpal tunnel syndrome associated with Kienböck disease. All patients except 1 were incidentally diagnosed with Kienböck disease and had little or no wrist pain. Radiographic tests revealed advanced Kienböck disease in all patients. Intraoperative findings indicated that the site of maximum compression on the median nerve was located at the level of the carpal tunnel inlet in 11 patients, and the volar dislocated fragment of the lunate was located proximally adjacent to the floor of the carpal tunnel inlet. This disorder is most prevalent in elderly women, and even advanced Kienböck disease can present without wrist pain. Our findings suggest that palmar protrusion of the lunate may be the primary cause of carpal tunnel syndrome associated with Kienböck disease.

Ulnar shortening osteotomy for ulnar-sided wrist pain.

Background The purpose of ulnar shortening osteotomy is literally to shorten the ulna. It can tighten the triangular fibrocartilage complex (TFCC), ulnocarpal ligaments, and interosseous membrane. Nowadays, this method is used to treat ulnar-sided wrist pain, for which we have also started to use a treatment algorithm. The purpose of this study was to review the long-term and clinical results based on our algorithm. Materials and Methods We retrospectively reviewed 30 patients with ulnocarpal impaction syndrome after a minimum follow-up of 5 years (Group A) and then retrospectively evaluated 66 patients with recalcitrant ulnar wrist pain treated based on our algorithm (Group B). Description of Technique Ulnocarpal abutment was confirmed arthroscopically. The distal ulna was approached through a longitudinal incision between the extensor carpi ulnaris and flexor carpi ulnaris. We performed a transverse resection of the ulna fixed with a small locking compression plate. The contralateral side served as the reference for the length of shortening (mean, 2.4 mm; range, 1-5 mm). Disappearance of ulnar abutment was then confirmed again arthroscopically. Results (Group A) Most patients showed good long-term clinical results. About half of the patients showed a bony spur at the distal radioulnar joint (DRUJ), but the clinical results did not significantly correlate with presence of bony spurs. Radiological parameters wre not related to the presence of bony spurs. (Group B) Twenty-four of the 66 patients investigated prospectively underwent an ulnar shortening osteotomy, with all showing good clinical results at 18 months postoperatively. Conclusions Ulnar shortening osteotomy can change the load of the ulnar side of the wrist and appears useful for ulnar-sided wrist pain in the presence of ulnar impaction. Level of evidence IV.

Ulnar impaction syndrome: incidence of lunotriquetral ligament degeneration and outcome of ulnar-shortening osteotomy.

PURPOSE: We hypothesized that most patients with ulnar impaction syndrome have degenerative changes of the proximal lunotriquetral (LT) membrane and that ulnar-shortening osteotomy is an effective procedure in these patients. METHODS: We retrospectively reviewed 50 wrists of 49 patients with idiopathic ulnar impaction syndrome who underwent an arthroscopic evaluation at the time of ulnar-shortening osteotomy, and subsequently at plate removal. Based on the Geissler classification, patients were divided into group A, normal, and group B, grades I to IV. The degree of degeneration of the proximal LT membrane at first-look arthroscopy was compared with that at second-look arthroscopy. RESULTS: After ulnar-shortening osteotomy, both groups improved significantly in wrist range of motion and grip strength. According to the Mayo wrist score, 29, 18, and 3 patients showed excellent, good, and fair results, respectively. Of the 50 wrists, 25 had degenerative changes (group B) in the proximal LT membrane at the time of first-look arthroscopy. Of the 25 wrists in group B, 11 wrists improved based on the Geissler grade, 9 wrists showed no changes, and 2 wrists became worse. Clinically, patients demonstrated improvement after ulnar-shortening osteotomy regardless of the degree of degenerative LT ligament changes. CONCLUSIONS: Degenerative LT membrane changes that were seen in about half of our patients were mostly of a mild nature, and the clinical outcomes of ulnar-shortening osteotomy were acceptable. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Radial osteotomy for Kienböck disease.

Of various surgical treatments, radial shortening for patients with negative ulnar variance and radial wedge osteotomy (radial closing osteotomy) for patients with 0 or positive ulnar variance are widely accepted for the treatment of Kienböck disease. Long-term follow-up studies have shown more than 10 years lasting satisfactory pain relief, as well as an increase in wrist range of motion and grip strength. As representative surgical procedures, the techniques of radial shortening by transverse osteotomy, using a locking compression plate for internal fixation, and radial wedge osteotomy by step-cut osteotomy, using a small dynamic compression plate or locking compression plate, are described. One important point of radial wedge osteotomy is that resection of simple wedge bone yields a decrease in ulnar variance; therefore, we recommend trapezoidal bone resection with ulnar height of 1 mm for transverse osteotomy at the metaphysis and ulnar height of 2 mm for step-cut osteotomy at the distal fourth of the radius.

Importance of distal radioulnar joint arthroscopy for evaluating the triangular fibrocartilage complex.

BACKGROUND: The present study evaluated the importance of visualizing both sides of the triangular fibrocartilage complex (TFCC) when diagnosing ulnar wrist pain. METHODS: A total of 20 patients with ulnar wrist pain who underwent both radiocarpal joint (RCJ) and distal radioulnar joint (DRUJ) arthroscopy were studied retrospectively. TFCC was graded as normal or as having wear or tear. The definitive diagnosis was made by evaluating the TFCC from both joints. The medical records were reviewed to document the preoperative diagnosis, arthroscopic findings, postoperative diagnosis, and operative procedure(s) performed after the arthroscopic examinations. The patients' status at final follow-up was evaluated using the modified Green and O'Brien wrist scoring system. The TFCC grading on RCJ and DRUJ arthroscopies was compared. RESULTS: The final diagnosis was modified after arthroscopic examination in three cases (15%). In six patients (30%), DRUJ arthroscopy revealed pathological TFCC findings that could not be detected on RCJ arthroscopy. The DRUJ arthroscopy detected wear or degenerative changes seen only on the proximal aspect of the TFCC in four patients and tear in two patients. On the other hand, in only one patient (5%) were there no pathological findings observed from the DRUJ portal, although RCJ arthroscopy found wear. In eight patients (45%), the arthroscopic grading of TFCC was the same on RCJ and DRUJ arthroscopy; of these, the TFCC was graded as normal in one patient, showing wear in three patients, and with a tear in five patients. For diagnosing TFCC pathology, RCJ arthroscopy had a sensitivity of 68% and a negative predictive value (NPV) of 14%, whereas the sensitivity was 95% and the NPV was 50% for DRUJ. CONCLUSIONS: Adding DRUJ arthroscopy to RCJ arthroscopy enables more accurate diagnosis of TFCC pathology because the proximal aspect of the articular disk and the foveal insertion of the distal radioulnar ligament can be visualized.

Chondrotinase ABC enhances axonal regeneration across nerve gaps.

We evaluated the effects of chondroitinase ABC on axonal regeneration across peripheral nerve gaps. We compared axonal regeneration after 15-mm tibial nerve resection and repair with a silicone tube filled with type I collagen gel (negative control group), with a silicone tube filled with type I collagen gel containing chondroitinase ABC at three different concentrations (2.5 units/mL, 5 units/mL, 10 units/mL) (chondroitinase ABC groups), and with an autologous nerve segment (nerve autograft group). Electrophysiological and histological assessments were carried out 12 weeks after surgery. In the electrophysiological study, compound muscle action potentials (CMAPs) and nerve conduction velocities (NCVs) were recorded in all groups except the negative control group. Although both CMAPs and NCVs were highest in the nerve autograft group, there were no significant differences among the three chondroitinase ABC groups in either parameter. Histological findings were consistent with electrophysiological results. Based on these findings, we conclude that topical injection of chondroitinase ABC can significantly increase the critical length of nerve gap repair by tubulization or artificial nerve placement.

Arthroscopic visualisation of the distal radioulnar joint.

The diagnosis of chronic wrist pain is challenging and wrist arthroscopy has been recognised as the "gold standard". The present study investigated the efficacy of adding distal radioulnar joint (DRUJ) arthroscopy to routine wrist arthroscopy. The records of 67 patients who underwent DRUJ arthroscopy were reviewed, and the success rates for visualisation of intra-articular structures were determined. Pathological findings were correlated with ulnar-side wrist pain. In seven patients, pre-operative diagnoses were altered after DRUJ arthroscopy. The ulnar head and proximal surface of the triangular fibrocartilage complex (TFCC) were visualised in 100% and 99% of patients, respectively, while the foveal insertion of TFCC and sigmoid notch were visualised in 57% and 69%, respectively. Pathological findings of the proximal surface of TFCC tended to relate to ulnar wrist pain (p = 0.06). DRUJ arthroscopy should be included in routine wrist arthroscopy to enhance the accuracy of diagnosis.

Radial osteotomy for Kienböck's disease with displaced fracture of the lunate.

PURPOSE: Advanced Kienböck's disease often involves displaced fractures of the lunate; however, whether such fractures affect surgical outcomes remains unclear. The purpose of this study was to evaluate the results of radial osteotomy for Kienböck's disease with displaced fractures of the lunate and whether these fractures would achieve union. METHODS: We reviewed patients who had radial osteotomy for Kienböck's disease between 1975 and 2004. We included only displaced fractures of the lunate that were apparent on lateral radiography, and 31 patients (24 men, 7 women; mean age, 35 y) were then included in this study. Postoperative state of the lunate and clinical results were compared between cases of union and nonunion. RESULTS: Preoperatively, mean flexion/extension arc was 76 degrees , and mean grip strength was 22 kg. Postoperatively, mean flexion/extension arc was 84 degrees , and mean grip strength was 30 kg. Radiography revealed fracture healing in 16 wrists. No significant differences between union and nonunion were noted in any assessed clinical items. CONCLUSIONS: This study showed approximately 50% union after radial osteotomy. Fracture union did not affect clinical results. Clinical results were good considering the advanced stage of Kienböck's disease. Even with displaced fractures of the lunate, radial osteotomy yields results comparable with other treatments for same-stage patients and thus represents a reasonable approach.

Repair of the triangular fibrocartilage complex after ulnar-shortening osteotomy: second-look arthroscopy.

PURPOSE: Ulnar shortening is a widely used procedure for various conditions associated with ulnar wrist pain, including triangular fibrocartilage complex (TFCC) injury; however, few reports have examined the condition of the TFCC after osteotomy. The central avascular zone of the TFCC generally is considered to have no potential to heal. This study investigated whether the avascular zone of the TFCC has any potential for repair, and whether repair of the torn disc proper correlates with clinical findings. METHODS: Between 1987 and 2005, we performed 75 second-look arthroscopies after an ulnar-shortening osteotomy for ulnar wrist disorders. Of these, 32 wrists with a TFCC (disc proper) tear on first arthroscopy were included in this study. Data from patient charts, radiography, and video images of arthroscopy were reviewed retrospectively. Tears of the disc proper were classified as radial, central, or ulnar tears, and as either linear or round tears. RESULTS: Meticulous second-look arthroscopy showed repair of tears in 50% of studied wrists. Round tears tended to repair better than linear tears. Although the final clinical score was better in repaired wrists than in nonrepaired wrists, no marked differences were noted between groups in terms of age, gender, preoperative ulnar variance, follow-up period, or surgical procedures used. CONCLUSIONS: The avascular zone of the TFCC possesses some potential for repair; however, factors promoting spontaneous repair of this tissue were not identified. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Sonographic diagnosis of acute injuries of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb.

PURPOSE: To evaluate the significance of the ultrasonographic appearance of the aponeurosis for deciding the best treatment for ulnar collateral ligament (UCL) injuries of the thumb metacarpophalangeal joint. METHODS: Fourteen patients (11 men, 3 women; mean age, 41 years; range, 15-66 years) who had an acute UCL tear were included. All patients were examined by ultrasonography (US) with a 7.5-MHz transducer and subsequently underwent surgery. The ultrasonographic findings were compared to the intraoperative findings. RESULTS: UCL injuries were classified into two types by US according to the appearance of aponeurosis and its spatial relationship with the UCL: the intra-aponeurosis type (5 patients) and the extra-aponeurosis type (9 patients). In the 5 patients with intra-aponeurosis, ultrasonographic findings were well consistent with intraoperative findings. In contrast, extra-aponeurosis cases contained two different pathologies: of the 9 patients, 7 had so-called 'Stener lesions', one showed folding of a ruptured capsule, and one showed a ruptured aponeurosis. CONCLUSIONS: Because US is highly reliable in differentiating intra-aponeurosis from extra-aponeurosis types of injuries, the aponeurosis is a more reliable reference than Stener lesion for treatment decision by US.

Limited wrist arthrodesis versus radial osteotomy for advanced Kienböck's disease--for a fragmented lunate.

Thirty-eight patients with advanced Kienböck's disease treated by limited wrist arthrodesis (LWA: n = 10) or radial osteotomy (RO: n = 28) for a fragmented lunate were retrospectively examined after an average of 47.9 and 68.1 months, respectively. Compared with pre-operative values, the active flexion-extension range of motion decreased by about 16.0 degrees in LWA and increased approximately 9.7 degrees in RO and the grip strength improved by approximately 7.5 kg in LWA and 8.0 kg in RO. In both groups, radiographs showed no significant progression of carpal collapse. Although LWA caused some decrease in wrist flexion-extension, both procedures are appropriate for surgical treatment of advanced Kienböck's disease. Most patients experienced a reduction in pain and were able to return to work.

Arthroscopic mobilization for contracture of the wrist.

PURPOSE: We evaluated the clinical efficacy of arthroscopic mobilization of the wrist for release of persistent traumatic contracture. METHODS: We retrospectively reviewed 11 consecutive patients who had undergone arthroscopic mobilization after trauma. Patients included 9 men and 2 women who ranged in age from 16 to 65 years (mean, 40 years). Injuries causing contracture included 8 fractures of the distal radius, 1 Galeazzi fracture, 1 perilunate dislocation, and 1 carpal bone contusion. A single radiocarpal septum extended from the proximal fibrocartilage of the scapholunate ligament to the midradial ridge in all but 1 patient, in whom multiple fibrous bands bridged the radiocarpal joint. RESULTS: Arthroscopy disclosed 3 types of radiocarpal septum-a single fibromembranous structure that completely divided the joint (type A) in 9 cases, a membranous structure with a fenestration that partially divided the joint (type B) in 1 case, and multiple bands that completely divided the joint (type C); the latter situation occurred in the last patient described earlier. Preoperatively, the arc of motion averaged 76 degrees compared with an average of 98 degrees . Postoperatively, a 22 degrees increase was noted. CONCLUSIONS: Arthroscopic release of a radiocarpal septum was effective in improving range of wrist motion in patients with this finding. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Symptoms and radiographic findings in the proximal and distal ulnar stumps after the Sauvé-Kapandji procedure for treatment of chronic derangement of the distal radioulnar joint.

PURPOSE: We analyzed correlations between symptoms and radiographic findings with respect to the proximal and distal ulnar stumps after the Sauvé-Kapandji procedure for treating chronic derangement of the distal radioulnar joint. METHODS: A total of 26 patients were studied (13 men, 13 women) with a mean age of 46 years at examination. Clinical assessment included elicitation of postoperative symptoms related to the proximal and distal ulnar stumps. In the radiographic study the radioulnar distance in the neutral wrist position and the presence or absence of scalloping at the radius were determined from posteroanterior (PA) views. The total mobility distance of the proximal ulnar stump was measured on the PA and lateral views while the wrist moved from radial to ulnar deviation or from extension to flexion. RESULTS: Eleven patients complained of tenderness over the distal ulnar stump and 5 patients felt discomfort around the proximal ulnar stump during forearm rotation. The postoperative radioulnar distance in patients with tenderness was significantly smaller than in the group without tenderness. Scalloping at the radius was shown in 9 patients but it was not related to the radioulnar distance. The total mobility distance of the proximal ulnar stump on the PA view was significantly greater in patients with tenderness than in those without, and it also was significantly greater in patients with scalloping than in those without. The total mobility distance on the lateral view was significantly greater in the group with discomfort than in the group without discomfort. CONCLUSIONS: The radioulnar distance was related to tenderness over the distal ulnar stump but not to the scalloping. Tenderness and scalloping each were related to radioulnar instability of the proximal ulnar stump. Discomfort around the proximal ulnar stump was related to dorsovolar instability of the stump. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic, Level IV.

Ulnocarpal impaction syndrome restricts even midcarpal range of motion.

Ulnocarpal impaction syndrome is believed to be caused by abutment between the ulna and the ulnar carpus. We measured radiocarpal and midcarpal ranges of motion in 40 patients with ulnocarpal impaction syndrome by radiographic motion studies. The results showed that the radiocarpal and midcarpal ranges of motion were equally restricted in the affected wrist compared with the unaffected wrist. Therefore, motion of the radiocarpal joint and midcarpal joint contributed equally to total wrist motion bilaterally. No correlation between ulnar variance and the contribution of radiocarpal motion to overall wrist motion was found. Restriction of wrist motion in ulnocarpal impaction syndrome is not caused directly by abutment between the ulna and ulnar carpus, but a satisfactory explanation for restricted motion is still lacking.

Inhibitory, facilitatory, and excitatory effects of ATP and purinergic receptor agonists on the activity of rat cutaneous nociceptors in vitro.

Pathological pain is often associated with changed sympathetic nerve activities. It is known that sympathetic nerve endings release ATP as a co-transmitter of norepinephrine, but the effect of this ATP on the nociceptive system has not been properly studied in that the concentration range used in the previous studies was much higher than is expected in the surroundings of nociceptor terminals. We examined the effects of ATP, especially at low concentration (10(-5) M or less), on C-fiber polymodal receptor (CPR) activity using a rat skin-nerve preparation in vitro. We found for the first time that ATP inhibited the heat response of CPRs at low concentration (10(-5) M), but facilitated it at high concentration (10(-3) M). The former effect was mimicked by a P2X3 agonist, alpha,beta-methylene ATP, at 10(-5) M, while the latter was mimicked by 2-methylthio ADP (a P2Y1 agonist) or UTP (a P2Y2 agonist) at 10(-3) M, suggesting that the former is mediated by P2X receptors and the latter by P2Y receptors. After repetitive heat stimuli, ATP-induced CPR excitation was increased (10(-5) to 10(-3) M), but none of the purinergic agonists induced CPR excitation in a magnitude comparable to that by ATP. Possible mechanisms for these effects were discussed.

[Treatment of mallet finger accompanied by avulsional fracture with Ishiguro method].

OBJECTIVE: To evaluate the clinical results of mallet finger accompanied by avulsional fracture treated with Ishiguro method. METHODS: Twenty-seven patients suffering from mallet finger accompanied by avulsional fracture were treated with Ishiguro method or its modified method. During the operation, a blocking pin was inserted percutaneously with DIP flexed, then the DIP was fixed at a position of full extension with another Kirschner wire. When the fracture fragment was big with rotation displacement, a third Kirschner wire could be used to correct the displacement and fix fracture. RESULTS: The patients were followed up 2 months to 6 years and 6 months with an average of 9.3 months postoperatively. And the clinical results were evaluated with the modified Crawford's criteria, including DIP pain, range of motion and pinch power. The rate of bone union was 100%. The results were excellent in 7 patients, good in 11 patients, moderate in 8 patients and poor in 1 patient. After operation, the range of flexion was 54.19 degrees +/- 14.45 degrees, while the range of extension was -4.96 degrees +/- 9.27 degrees. The X-ray sign of slight osteoarthritis could be seen in one patient. CONCLUSION: Ishiguro method is simple, effective and less invasive. It is suitable for treatment of mallet finger accompanied by avulsional fracture.