Use of an iliac crest growth plate for the development of a neo-articulation for congenital transverse deficiencies at the wrist.

PURPOSE: Terminal congenital transverse deficiencies of the wrist and hand are rare malformations. They are usually treated with prosthetic devices. We describe here a surgical technique to create a neo-articulation that could provide mobility distal to the forearm and help children with terminal transverse deficiencies use orthotic devices. METHODS: This procedure involved an autologous, nonvascularized graft from the immature iliac crest. The graft was placed with its cartilaginous side facing the radial and ulnar articular surfaces. We studied the clinical, radiological, and functional outcomes of this technique in 2 pediatric cases 5 and 14 years after this procedure. RESULTS: The x-rays showed a mobile graft distally in the forearm. Magnetic resonance imaging showed a space between the graft and the radius and an intermediate signal on either side of the space highly suggestive of articular cartilage. These various elements were organized into a neo-articulation between the forearm and the graft. The functional ability at follow-up was greater compared with the absence of a graft. CONCLUSIONS: The results of basic research work on cartilage and chondrocytes may help explain the presence of persistent cartilaginous tissue on the articulated part of the graft. The good functional outcome provided by our surgical procedure may translate into reduced need for prosthesis acceptance. Our surgical procedure does not restore limb length, but does add a new functional ability. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Anatomy and biomechanics of healthy and arthritic trapeziometacarpal joints.

Understanding the biomechanics of the trapeziometacarpal (TMC) or first carpometacarpal (CMC1) joint, the pathophysiology of basal thumb arthritis, the design and performance of surgical procedures require a solid anatomical basis. This review of literature summarizes the most recent data on the descriptive, functional, and comparative anatomy of healthy and arthritic TMC joints.

Reproducibility of X-rays and CT arthrography in SLAC, SNAC, SCAC wrists.

The purpose of this study was to assess the inter-observer and intra-observer reproducibility of the interpretation of CT arthrography and plain X-rays for scapholunate advanced collapse (SLAC), scaphoid non-union advanced collapse (SNAC) and scaphoid chondrocalcinosis advanced collapse (SCAC) wrist conditions, as well as the clinical relevance of these imaging modalities. The CT and X-rays images were reviewed twice in a blinded and randomized manner by two experienced orthopedic surgeons specialized in hand surgery, two orthopedic surgery residents and two experienced radiologists specialized in bone and joint imaging. Cohen's kappa and Fleiss' kappa coefficients were used to analyze the reproducibility of interpretation of the radiological examinations. With CT arthrography, the overall diagnosis was often a problem, in terms of both inter- or intra-observer reproducibility. The assessment of the joint line appeared to be fairly reproducible for each observer but was poorly reproducible between different observers. Plain X-rays are not sufficient to assess cartilage quality in degenerative wrist disease. CT arthrography is a reliable examination, but its interpretation is not always standardized. Diagnostic arthroscopy may be justified in doubtful cases.

Anatomical study of the ligamentous attachments and articular surfaces of the trapeziometacarpal joint. Consequences on surgical management of its osteoarthrosis.

In the goal to optimize conservative surgical techniques of the trapeziometacarpal joint in cases of moderate osteoarthritis, we have defined the relationships between the ligamentous attachments and the articular surfaces onto the trapezium and the first metacarpal bone on the one hand, and the dorsovolar and the transverse diameters of the articular surfaces on the other hand. Thirty-six trapeziometacarpal joints (from 18 fresh cadavers) were studied. They were separated into two groups depending on the macroscopic assessment of chondral disease. Group A included stages I to III (no osteoarthritis or moderate osteoarthritis), group B included stages IV (major cartilage destruction). The dorsovolar and transverse sizes of the articular surfaces were measured. Dorsoradial ligament (DRL), posterior oblique ligament (POL), intermetacarpal ligament (IML), ulnar collateral ligament (UCL) and anterior oblique ligament (AOL) were dissected and the distance between their attachments and the articular surfaces were measured. Group A included 17 joints (71% males) and group B included 19 joints (95% females). For the first metacarpal bone, the average ratio between the dorsovolar diameter and the transverse diameter of metacarpal articular surfaces was significantly higher in group B and the average distance between the ligamentous attachments and the articular surface was more than two millimeters, except for the DRL in group B. For the trapezium, only the posterior ligaments (DRL and POL) of group A were inserted at a mean distance more than two millimeters from the articular surfaces. Dorsovolar length of the metacarpal articular surface was higher for osteoarthritis cases. This difference can be explained by the existence of a palmar osteophyte that was always found in stage IV. Describing a map of the ligamentous attachment distance from the articular surface could help surgeons to avoid the ligamentous injury during minimal osteochondral resection.

Amandys(®) implant: novel pyrocarbon arthroplasty for the wrist.

OBJECTIVES: Post-traumatic, arthritic or degenerative destruction of the midcarpal and radiocarpal joints are difficult to treat. A new arthroplasty with a free interposition pyrocarbon implant, Amandys(®), is proposed for the treatment of extensive destruction of midcarpal and radiocarpal joints. Preliminary results are reported. METHODS: The prospective series included 25 patients, 15 males and 10 females with a mean age of 60. The indications were degenerative, post-traumatic or rheumatoid destruction of the wrist. Sixty percent of the patients had already had surgery on their wrist before the operation. The mean follow-up was 24months. RESULTS: Three patients had a reoperation: two for a repositioning of the implant and one for a styloidectomy. At the last follow-up, the mean grip strength was 16kg (51% of the contralateral side), the mean range of motion in flexion-extension was 68°. Mean strength and range of motion did not change significantly with the operation. Pain and function showed significant improvement. The mean pain score decreased from 6.7/10 to 3.7/10 postoperatively. The mean PRWE score decreased from 61/100 to 32/100.The mean QuickDash score decreased from 63/100 to 36/100. Ninety-six percent of the patients were satisfied or very satisfied. No dislocation or subsidence of the implant was noticed. CONCLUSIONS: This minimally invasive pyrocarbon interposition increases the possibilities for the treatment of extensive articular destructions of the wrist. Indications must be limited to a well-aligned wrist with competent capsuloligamentous structure. This new arthroplasty is a reliable alternative to other surgical options, which are more radical or invasive such as total arthrodesis or total wrist prosthesis.