Partial interosseous ligament tears of the wrist: difficulty in utilizing either primary or secondary MRI signs.

PURPOSE: Prior reports on scapholunate ligament (SLL) and lunotriquetral ligament (LTL) tears have evaluated complete tears. As these complete tears have markedly different biomechanical manifestations and surgical considerations than do partial tears, we evaluated the accuracy of MR and the usefulness of secondary MR signs to diagnose partial interosseous ligament tears. METHOD: Fifty wrists in 50 patients underwent arthroscopy following 1.5 T MR. Images were evaluated by two independent blinded observers for normal or partially torn SLL and LTL and for three secondary signs potentially seen as mechanical sequelae of tears: osseous offset, arc disruption, or focal osteoarthritis. RESULTS: Arthroscopically, there were 16 SLL and 14 LTL partial tears. Accuracy of primary MR signs of partial tears was lower than that described in the literature for complete tears [sensitivity/specificity (kappa) = 0.56/0.56 (0.12)-SLL, 0.31/0.76 (0.13)-LTL]. Secondary signs showed low sensitivity but high specificity, particularly for LTL tears: arc disruption [0.17/0.83 (0.43)-SLL, 0.0/1.00 (1.0)- LTL], focal osteoarthritis [0.32/0.78 (0.18)-SLL, 0.11/0.91 (0.12)-LTL], and focal osseous offset [0.39/0.75 (0.10)-SLL, 0.26/0.93 (0.39)-LTL]. Additionally, there was poor interobserver consistency for both primary and secondary signs. CONCLUSION: The sensitivity of morphologic evaluation for diagnosing partial intercarpal ligament tears, particularly those of the LTL, is limited. Secondary signs increase specificity but have low sensitivity, and with the exception of arc disruption, all signs had poor interobserver agreement.

The role of arthroscopy in evaluating and treating trapeziometacarpal disease.

Thumb trapeziometacarpal arthroscopy offers unique opportunities for improving evaluation and treatment in patients with basal joint disease. For patients with early disease, arthroscopic synovectomy and electrothermal shrinkage of the capsule can provide symptomatic improvement. For patients with more advanced disease, arthroscopic hemitrapeziectomy and complete trapeziectomy can be performed, combined with electrothermal shrinkage of the anterior oblique ligament. This article reviews the surgical technique and the early follow up of this rapidly advancing, minimally invasive technique for treatment of trapeziometacarpal disease.

Treating fractures of the distal radius with arthroscopic assistance.

The role and technique of arthroscopy when used in the treatment of fractures of he distal radius are reviewed. Arthroscopy, if properly modified, assists in the evaluation and reduction of displaced intra-articular fractures of the distal radius in treating associated injuries within the carpus. Technical details important to the successful use of this technique are discussed. Favorable outcomes have been reported after the use of this technique for the reduction of displaced intra-articular fractures of the distal radius.

Proximal row carpectomy for the treatment of scaphoid nonunion.

Nonunion of the scaphoid bone may occur even with early diagnosis of fracture and modern internal fixation techniques. A pattern of degenerative instability termed scaphoid nonunion advanced collapse may lead to collapse of the carpus with irreversible articular damage initially isolated to the radiostyloid joint. Proximal row carpectomy (PRC), which removes the intercalary proximal row and creates a radiocapitate articulation, is a motion preserving salvage procedure which unloads the areas of articular pathology, and creates a new articulation that allows motion and is able to bear compressive forces over time. Although results of PRC specifically for scaphoid nonunion are clearly not reported in the article, several studies demonstrate that PRC provides a pain relieving and motion-sparing salvage option particularly suited for this condition.

Complications of wrist arthroscopy.

Wrist arthroscopy has become an essential tool in the evaluation and treatment of a variety of wrist injuries and disease processes. As such, an understanding of complications related to wrist arthroscopy is critical to overall outcome. Complications are based on the unique anatomy of the wrist, portal locations, surgical technique, and type of procedure performed. This article describes techniques that may decrease the likelihood of each of these complications.

Is a subset of wrist ganglia the sequela of internal derangements of the wrist joint? MR imaging findings.

PURPOSE: To determine if there is an association between wrist ganglia and internal derangements of the wrist joint by reviewing magnetic resonance (MR) images. MATERIALS AND METHODS: Two observers retrospectively reviewed MR images of the wrist obtained in 625 patients at 1.5 T for the presence of ganglia and associated triangular fibrocartilage complex, scapholunate ligamentous, or lunotriquetral ligamentous tears that were within 3 mm of the ganglion. When available, surgery and/or pathology records were reviewed. RESULTS: There were 122 ganglia and 37 internal derangements. Of the 22 ulnar-sided ganglia, 10 (45%) demonstrated associated triangular fibrocartilage complex tears. Of the 97 radial-sided ganglia, 27 (28%) demonstrated ligamentous tears related to the site of the ganglion. The radial-sided tears involved the radial aspect of the triangular fibrocartilage complex in 12 ganglia; the scapholunate ligament, in isolation, in eight ganglia; and both the triangular fibrocartilage complex and the scapholunate ligament in six ganglia. Only one of the ganglia demonstrated an associated lunotriquetral ligamentous tear. Surgical findings confirmed the ligamentous tears in 25 patients. CONCLUSION: Wrist ganglia are associated, not infrequently, with internal derangements of the wrist.

MR imaging of the type II lunate bone: frequency, extent, and associated findings.

OBJECTIVE: Type II lunate bones have an "extra" facet that articulates with the hamate bone, which frequently leads to arthritis. Because the only prior studies, to our knowledge, on this common and clinically significant variant involved dissection of cadavers, we performed an MR imaging study of the type II lunate. MATERIALS AND METHODS: We retrospectively reviewed MR images obtained at 1.5 T of 186 wrists for frequency of type II lunates, size of the extra facet, amount of hamatolunate apposition, and presence of hamate subchondral edema. Of the 186 wrists, 28 also had correlation with findings on wrist arthroscopy. RESULTS: One hundred seven wrists (57.5%) had type II lunates with an average extra facet size of 4.6 mm (range, 1.2-12.0 mm). Apposition (articulation) of the extra lunate facet with the hamate averaged 77.4% (range, 0-100%). Hamate edema was seen in only nine wrists (4.8%), all of which had type II lunates. Arthroscopic evidence of focal hamate chondromalacia and MR imaging evidence of marrow edema were seen in six of these nine wrists; marrow edema was seen only in wrists with frank cartilage changes on arthroscopy. CONCLUSION: An extra facet (type II lunate) was seen in approximately half of 186 wrists. On MR imaging, type II lunates usually have an innocuous appearance. A large percentage of patients with type II lunates also have chondromalacia, which often is occult on MR imaging. When visible, such chondromalacia is the cause of marrow edema similar to that seen in patients with carpal fractures.

Intra-articular fractures of the distal aspect of the radius.

Intra-articular distal radius fractures are a heterogeneous group of injuries with different fracture patterns. The existing classification systems are helpful for describing the fractures but not for assessing their stability or for deciding which surgical approach to use. Patients who have a fracture with at least 1.0 mm of displacement of the articular surface may benefit from open surgical treatment. Improved diagnostic imaging with CT is helpful for fracture classification and surgical planning. The options for surgical treatment include limited open reduction and internal fixation, arthroscopically assisted internal fixation, and open reduction and internal fixation. The surgical approach is determined on the basis of the initial displacement of the fracture. Patients who have a displaced fracture of the volar rim may benefit from a volar approach; those who have a dorsally displaced fracture, from a dorsal approach; and those who have an impacted fracture such as a die-punch fracture, from a dorsal approach that provides better visualization of the articular surface. The long-term functional outcome is determined in part by the severity of the fracture as defined by the amount of comminution, the initial severity of displacement, and the number of fracture fragments. The accuracy of the reconstruction of the articular surface, with the goal of establishing congruency to within 1.0 mm, is also important in order to minimize the risk of late osteoarthrosis. Of all of the extra-articular parameters, restoration of the length of the radius is the most important for enhancing recovery of motion and grip strength and for preventing problems involving the distal radioulnar joint--the so-called forgotten joint in distal radial fractures.

Revision of the ununited one-bone forearm.

Between 1975 and 1995, 7 patients were surgically treated for persistent forearm pain following previously unsuccessful attempts of constructing a radioulnar synostosis using interosseous bone grafting with either cross screw or pin fixation. These prior reconstructive procedures were salvage operations to address symptomatic radioulnar instability. The time interval between index operation and revision surgery was a mean of 12.6 months (range, 4-36 months). The postoperative follow-up period averaged 29.7 months (range, 11-61 months). To address these failed radioulnar arthrodeses, plate osteosynthesis and aggressive bone grafting were used in 5 of 7 patients (group 1) (4 with autologous graft and 1 with demineralized bone matrix). Union was achieved in all 5 patients after a single revision operation. Radiographic evidence of solid union was seen at approximately 4 months. In the remaining 2 patients (group 2), revision synostosis procedures were performed; these involved local bone grafting and repeat transverse screw fixation in 1 patient and iliac crest bone grafting alone in the other. One of these 2 patients progressed to union; the other had a persistent symptomatic fibrous union. The 5 patients in group 1 reported symptomatic relief, while the 2 patients in group 2 were dissatisfied. There were no postoperative complications in our series. Based on our findings, we advocate abundant bone grafting and plating for rigid internal fixation in failed radioulnar synostosis procedures.

Reconstruction of the scapholunate ligament in a cadaver model using a bone-ligament-bone autograft from the foot.

This study is an investigation of a new procedure in which the scapholunate interosseous ligament (SLIL) is reconstructed using a bone-ligament-bone autograft from the foot. After investigation, the dorsal medial portion of the navicular-first cuneiform ligament (NFCL) was chosen for testing as a potential donor since it is similar in length and thickness to the SLIL and it is easily harvested with minimal potential donor site morbidity. Eight SLILs and NFCLs were harvested from fresh-frozen cadavers. Biomechanical extensometry testing was performed using an Instron 1000 machine. A 5-mm-wide central portion of the NFCL was tested since this width was compatible with the technical aspects of reconstructing the SLIL. Both ligaments were tested for elastic properties, including stiffness, load to failure, and deformation to failure. Mean length of the NFCL was 7.6 mm (range, 5.5-8.5 mm). Stiffness of the NFCL was 10.6 x 10(5) Nm (range, 8.0-13.0 Nm) compared with 14.4 x 10(5) Nm for the SLIL (range, 10.0-19.5 Nm). Peak load to failure for the NFCL was 1,980 N (range, 1,530-2,940 N) compared with 2,940 N for the SLIL (range, 1,780-4,050 N). Total elongation to failure for the NFCL was 2.50 mm (range, 1.7-3.2 mm) compared with 3.2 mm for the SLIL (range, 2.1-5.2 mm). Thus, the biomechanical characteristics of the NFCL were found to be very similar to those of the SLIL. Having established the biomechanical similarities of the 2 ligaments, we are currently using the NFCL to reconstruct the sectioned SLIL in a fresh-frozen cadaver model. Early results suggest that this procedure is feasible for restoration of normal kinematics of the wrist.

Wide excision of the distal ulna: a multicenter case study.

Excision of the distal ulna to treat degenerative disease or instability has fallen into disfavor following reports of radioulnar impingement, carpal instability, and distal ulnar instability. Alternative procedures for reconstruction of the painful distal ulna have been developed to address these problems; the results have been generally favorable. When faced with distal ulnar reconstruction that has failed after multiple surgical procedures, or a distal ulnar neoplasm, the surgeon is left with few treatment options. Creation of a one-bone forearm, free fibular transfer, and allograft replacement have been attempted, with mixed outcomes. We report the results of 5 men and 7 women who underwent wide excision of the distal ulna, defined as surgical excision of 25% to 50% of the ulnar length. The diagnosis was failed distal radioulnar reconstruction or excision in 8 patients, osteomyelitis in 1, congenital pseudoarthrosis of the radius in 1, and neoplasm in 2. No soft tissue reconstruction was performed. Patients were examined at an average of 22 months after surgery for radiocarpal and radioulnar instability, functional outcome, pain relief, grip strength, and range of motion. Nine of the 12 procedures resulted in good or excellent results; 1 patient had a fair result after resection for osteosarcoma, and the procedure in 2 patients failed, requiring conversion to a one-bone forearm. Grip strength was restored to 75% of the normal side and range of motion was restored to 86% of the normal side. Wide excision of the distal ulna without soft tissue reconstruction is a simple and durable treatment of neoplasms of the distal ulna or salvage of the failed reconstruction of the distal radioulnar joint. We do not recommend its use in patients with incompetency or disruption of the interosseous membrane.

Arthroscopic reduction and internal fixation of distal radius fractures.

Despite recent advances in the treatment of complex distal radius fractures, problems of stiffness, carpal instability, and posttraumatic arthritis remain in a significant number of cases. Associated soft-tissue and ligamentous injuries are being recognized with increasing frequency. Arthroscopic reduction and internal fixation not only allow for anatomic reduction of the distal radius fracture with minimal surgical trauma, but provides a valid diagnostic and treatment alternative for the often missed associated injuries.

The effect of ice application versus controlled cold therapy on skin temperature when used with postoperative bulky hand and wrist dressings: a preliminary study.

Skin temperature of the hands of 12 volunteers was monitored. The hands were placed in bulky dressings and treated with a standard ice bag (group I) or a new cooling blanket (group II). The contralateral hands served as controls. The mean difference in skin temperatures between group I and controls was 1.5 degrees F, while the difference between group II and controls was 13 degrees F. Temperatures of the controls did not decrease with time. Newer cooling devices appear to be more efficacious than standard ice bags in accurately and significantly lowering skin temperature when used with traditional bulky hand dressings.

Repeat Russe bone grafting after failed bone graft surgery for scaphoid non-union.

We report the long-term outcome of repeat Russe bone grafting after failure of a previous Russe graft for scaphoid non-union. 15 patients were followed for a mean of 71 months after their last surgical procedure. 11 patients had undergone a single previous Russe graft and four patients had two previous graft attempts. Internal fixation was used in only three patients. Eight out of 15 (53%) patients achieved union after a single repeat graft and one out of four united after a third attempt. When union was achieved, range of motion was unchanged, grip strength was increased 10% and pain was slight to none, allowing return to full employment in seven out of the nine patients. All patients who did not achieve union have either undergone a salvage procedure or are contemplating one. Based on the literature and our relatively low rate of union without internal fixation (53%), we recommmend supplementary internal fixation if repeat Russe bone grafting is undertaken. When union is achieved, satisfactory results can be expected.

A complex free toe transfer after a reverse radial forearm flap.

A case is reported of the difficulties associated with late free toe transfer for thumb reconstruction after an initial reverse radial forearm flap.

Complications of common carpal injuries.

Interest in the diagnosis and treatment of common disorders of the carpus has intensified in recent years. Although newer nonoperative and surgical procedures have developed to improve outcome, complications and their treatment remain a challenging problem. To address complications of the more common carpal injuries, we have chosen fractures of the scaphoid, scapholunate ligament injuries, carpal fracture dislocations, and fractures of the hook of the hamate for discussion.