Giant Cell Tumor of the Triquetrum: Clinical Case and Literature Review.

Giant cell tumor (GCT) is a benign, locally aggressive neoplasm with little incidence at the carpal bone level. We present a case of pyramidal bone GCT that required open biopsy for diagnosis. As a definitive treatment, en bloc resection of the pyramidal bone and luno-capitate arthrodesis were performed to avoid frequent relapses of these neoplasms and ensure proper functionality of the anatomical segment.

Posttraumatic Arthrosis and Triquetral Nonunion Associated With Pisotriquetral Subluxation in Adolescent Female Softball Players.

Impaction fracture subluxation of the pisotriquetral joint producing arthrosis and ulnar triquetral osteochondral nonunion is a cause for ulnar wrist pain in batting athletes. Two cases of adolescent female softball players managed successfully with pisiform and triquetral fragment excision are reported.

Biomechanical Effects of Radioscapholunate Fusion With Distal Scaphoidectomy and Triquetrum Excision on Dart-Throwing and Wrist Circumduction Motions.

PURPOSE: Distal scaphoid and triquetrum excisions can improve the range of wrist motion after radioscapholunate (RSL) fusion, but little is known about the kinematics of dart-throwing and global circumduction motions. We hypothesized that these excisions could increase the range of motion without causing midcarpal instability. METHODS: Seven fresh-frozen cadaver upper extremities were mounted on a testing apparatus after isolation and preloading of the tendons of the flexor carpi radialis, flexor carpi ulnaris, extensor carpi radialis, and extensor carpi ulnaris. Sequential loadings of the flexor carpi ulnaris and extensor carpi radialis simulated active dart-throwing motion. Passive circumferential loading produced the wrist circumduction motion. We measured the range of wrist motions with an electromagnetic tracking system in 4 experiments: intact, simulated RSL fusion, RSL fusion with distal scaphoid excision, and RSL fusion with distal scaphoid and total triquetrum excisions. To evaluate midcarpal stability, we conducted passive mobility testing of the distal carpal row in the radial, volar, ulnar, and dorsal directions. RESULTS: Radioscapholunate fusion decreased the dart-throwing motion to a mean of 46% of the baseline value; distal scaphoid and triquetrum excisions increased the mean arc to 50% and 62%, respectively. Radioscapholunate fusion diminished the wrist circumduction to a mean of 43% of the baseline value, which increased to a mean of 58% and 74% after distal scaphoid and triquetrum excision, respectively. A significant increase in radial deviation was noted after distal scaphoid excision, and subsequent triquetrum excision significantly increased motion in the ulnar-palmar direction. Regarding midcarpal stability, dorsal translation significantly increased after distal scaphoid and triquetrum excisions. CONCLUSIONS: Distal scaphoid and triquetrum excision after RSL fusion improved both dart-throwing and circumduction motions, but dorsal midcarpal instability occurred. CLINICAL RELEVANCE: Subsequent carpal excisions may improve short-term outcome by increasing motions in a RSL-fused wrist; however, a potential risk of midcarpal instability should be considered.

Radioscapholunate fusion for posttraumatic osteoarthritis with consecutive excision of the distal scaphoid and the triquetrum: A comparative study.

The aim of this study was to assess the clinical and radiographic outcomes after radioscapholunate (RSL) fusion for posttraumatic osteoarthritis. This was a retrospective, dual-center study of all patients who underwent RSL fusion between 1995 and 2015 for posttraumatic radiocarpal osteoarthritis. Patients were assessed at the final review to determine clinical (pain, wrist range of motion and strength), self-reported (QuickDASH, PRWE and MWS scores) and radiological (degenerative osteoarthritis in the scaphotrapeziotrapezoid (STT) or midcarpal joint and radiocarpal fusion) outcomes. We analyzed three groups: RSL fusion alone, RSL fusion with distal scaphoid excision (DSE) and RSL fusion with DSE and triquetrum excision (TE). Eighty-five patients were included; 10 were lost to follow-up and 11 required conversion to total wrist fusion before the final review. Finally, 64 patients had both clinical and radiographic evaluations. The mean follow-up was 9.1 years (range 1-21.4). RSL fusion alone was performed in 29 patients, RSL fusion with DSE in 23 and RSL fusion with DSE and TE in 12. At the final follow-up, the three groups did not differ in their pain or wrist motion. Overall, 47 (73%) patients were satisfied or very satisfied with the procedure. DSE significantly decreased STT osteoarthritis and radiocarpal non-union. The total wrist osteoarthritis rate after RSL fusion was 55%. RSL fusion is an effective procedure to preserve some motion in wrists with posttraumatic radiocarpal osteoarthritis. DSE prevents STT osteoarthritis by removing bony impingement and increases the fusion rate. LEVEL OF EVIDENCE: Level IV, Case series, Therapeutic studies.

Surgical Management of Triquetral Osteoid Osteoma with Adjunct Tetracycline for Intraoperative Visualization: A Case Report.

CASE: We report the case of a 15-year-old male patient presenting with persistent wrist pain after surgical treatment of a triquetral osteoid osteoma. The patient was found to have a persistent nidus. These tumors are difficult to observe intraoperatively or through fluoroscopy, limiting adequate resection and resulting in continued pain. CONCLUSION: The nidus was excised successfully through an unusual technique using tetracycline for intraoperative identification. The patient remains asymptomatic without recurrence at 31 months postoperative. Difficulties visualizing and removing carpal lesions leading to recurrence are described.

Ten-year radiological and clinical outcomes of capitolunate arthrodesis with scaphoid and triquetrum excision for advanced degenerative arthritis in the wrist: Single-center, retrospective case series with 10patients.

The aim of this study was to evaluate the long-term outcomes of capitolunate arthrodesis for treating advanced wrist osteoarthritis. The arthrodesis procedures were performed in three women and seven men having a mean age of 59years (range, 20-70). Eight of the patients were manual laborers. The dominant hand was operated on in seven patients. The osteoarthritis was attributed to scapholunate dissociation (SLAC) in six patients and scaphoid nonunion (SNAC) in four patients. The arthrodesis site was stabilized with two vertical compression screws. Patients were reviewed after an average follow-up of 122months (80-172). The clinical and radiological outcomes consisted of measuring pain on a visual analog scale (VAS), determining the QuickDASH and PRWE scores, the patients' satisfaction, the radiolunate and capitolunate angles, carpal height, radiolunate joint condition, and fusion of the arthrodesis site. The mean pain level was reduced from 5 to 1 (P<0.05). The range of motion improved by 20° in flexion-extension and 10° in radioulnar deviation, while strength improved by 8kg relative to the preoperative measurements (P<0.05). The QuickDASH was 15points (±12) and the PRWE was 20 (±32). Relative to the preoperative values, the radiolunate angle was reduced by 4.5° and the capitolunate angle by 6.5°. Carpal height was 6.5mm less on average (P<0.05). None of the patients had a nonunion or deterioration of the radiolunate joint. One patient developed Type II complex regional pain syndrome. The nine other patients were able to return to work. Capitolunate arthrodesis provided pain relief and good function in 9 of the 10patients in our case series. The results was maintained over time, both in terms of mobility and pain relief, which were clearly improved after the surgical treatment. We found no signs of deterioration of the radiolunate joint over 10years. There are very few published studies describing the long-term outcomes of this procedure. Our findings are consistent with those in the literature, which makes capitolunate arthrodesis with scaphoid and triquetrum excision a highly satisfactory and reliable technique in the long term for the treatment of advanced osteoarthritis in the wrist. LEVEL OF EVIDENCE: IV.

Triquetrum Excision in Radioscapholunate Arthrodesis for Posttraumatic Radiocarpal Osteoarthritis With Ulnar Impaction Syndrome.

Dependent on fracture type, concomitant carpal injuries, and operative treatment, distal radius fractures can lead to symptomatic radiocarpal osteoarthritis. In addition, radial shortening can cause ulnar impaction syndrome. Radiocarpal arthrodesis and ulnar shortening osteotomy are known and frequently applied surgical procedures for each of those pathologies. There are limited data concerning treatment options for a combined disorder. The presented technique in this article demonstrates that radioscapholunate arthrodesis with distal pole scaphoidectomy and total triquetrum excision successfully treats both symptomatic radiocarpal osteoarthritis and ulnar impaction syndrome without further surgery on the ulna.

The Effect of Radioscapholunate Fusion With and Without Distal Scaphoid and Triquetrum Excision on Capitolunate Contact Pressures.

PURPOSE: To determine the effects of motion-increasing modifications to radioscapholunate (RSL) arthrodesis on capitolunate contact pressure in cadaveric wrist specimens. METHODS: Ten fresh-frozen cadaveric wrists were dissected of all superficial soft tissue, potted in polymethyl-methacrylate, and the carpus exposed via a ligament-sparing capsulotomy. An RSL arthrodesis was simulated using 2 2.4-mm distal radius plates with locking screws. The distal scaphoid pole and triquetrum were removed with an osteotome and rongeur, respectively. Contact area, pressure, and force were measured in the capitolunate joint during the application of a 35-N uniaxial load using pressure-sensitive film. Measurements were obtained before and after simulated RSL fusion, following distal scaphoidectomy and after triquetrectomy. RESULTS: The combination of RSL fusion with distal scaphoid excision (DSE) increased contact forces in the capitolunate joint by 50% over controls. An RSL fusion, and RSL fusion with DSE and triquetrum excision (TE), exhibited intermediate levels of contact force between controls and RSL fusion with DSE. Capitolunate contact pressures were similar between all experimental groups. Contact area in the capitolunate joint increased by 43% after RSL fusion with DSE over intact specimen controls. Lastly, contact area in wrists with RSL fusion, and RSL fusion with DSE and TE, were elevated, but not significantly different from intact controls. CONCLUSIONS: A DSE performed at the time of RSL fusion results in increased midcarpal joint contact force and area, with resultant contact pressures unchanged. Triquetrectomy, which has been previously shown to improve range of motion, did not increase contact forces in the capitolunate joint. CLINICAL RELEVANCE: If a surgeon is contemplating performing an RSL arthrodesis with DSE, we recommend adding a triquetrectomy to improve motion because this does not add to the potentially deleterious effects of increased midcarpal contact force.

Lunate Grafting Into the Radius for Lunate Fossa Reconstruction in Madelung Deformity.

A 40-year-old woman presented with Madelung deformity and severe arthritic changes at both the radiocarpal and the distal radioulnar joints. She was treated by using her lunate as an osteochondral graft into the radius allowing reconstruction of the lunate fossa. The scaphoid and triquetrum were removed concomitantly and a Sauve-Kapandji procedure was performed. Complete bone healing was achieved. Ten years later, an excellent functional result was maintained, with a pain-free wrist, an acceptable wrist joint range of motion, as well as a favorable aesthetic appearance. This procedure may be indicated for patients with severe Madelung deformity with painful radiocarpal and distal radioulnar joints associated with severe arthritis changes.

Radioscapholunate fusion with triquetrum and distal pole of scaphoid excision: long-term follow-up.

The purpose of this study was to assess the long-term outcomes of radioscapholunate fusion, with and without distal pole of scaphoid excision and excision of the triquetrum. These compromised three operative groups. Seventeen patients were identified with a minimum of 10 years follow-up, with a mean of 15 years (range 10-19). Fifteen of the 17 patients were satisfied with their outcome. Two were converted to total wrist fusion. The mean outcomes scores were; pain visual analogue scale score 2.1/10, Quick Disabilities of the Arm, Shoulder, and Hand 29 and Modified Mayo Wrist score 60. Patients with excision of the triquetrum had a mean radial-ulnar arc increase of 10° compared with the other two groups, but this was not statistically significant. The mean space for the scaphocapitate joint was 1.7 mm and lunocapitate joint was 1.3 mm at latest follow-up. Close adherence to the indications and surgical technique provided a sustainable good clinical outcome. Patients who obtained a good result at 2 years were likely to achieve a good long-term outcome. LEVEL OF EVIDENCE: IV.

Management of Pisotriquetral Instability.

Pisotriquetral instability is an often-overlooked condition that can lead to ulnar-sided wrist pain and dysfunction. Various case series and biomechanical studies have been published regarding the diagnosis and treatment of this condition. We review current methods for examining, diagnosing, and treating pisotriquetral instability.

Biomechanical Analysis of Palmar Midcarpal Instability and Treatment by Partial Wrist Arthrodesis.

PURPOSE: To create a biomechanical model of palmar midcarpal instability by selective ligament sectioning and to analyze treatment by simulated partial wrist arthrodesis. METHODS: Nine fresh-frozen cadaver arms were moved through 3 servohydraulic actuated motions and 2 passive wrist mobilizations. The dorsal radiocarpal, triquetrohamate, scaphocapitate, and scaphotrapeziotrapezoid ligaments were sectioned to replicate palmar midcarpal instability. Kinematic data for the scaphoid, lunate, and triquetrum were recorded before and after ligament sectioning and again after simulated triquetrohamate arthrodesis (TqHA) and radiolunate arthrodesis (RLA). RESULTS: Following ligament sectioning, the model we created for palmar midcarpal instability was characterized by significant increases in (1) lunate angular velocity, (2) lunate flexion-extension, and (3) dorsal/volar motion of the capitate during dorsal/volar mobilizations. Simulated TqHA caused significantly more scaphoid flexion and less extension during the wrist radioulnar deviation motion. It also increased the amount of lunate and triquetral extension during wrist flexion-extension. Simulated RLA significantly reduced scaphoid flexion during both wrist radioulnar deviation and flexion-extension. CONCLUSIONS: Both simulated arthrodeses eliminate wrist clunking and may be of value in treating palmar midcarpal instability. However, simulated RLA reduces proximal row motion whereas simulated TqHA alters how the proximal row moves. Long-term clinical studies are needed to determine if these changes are detrimental. CLINICAL RELEVANCE: Palmar midcarpal instability is poorly understood, with most treatments based on pathomechanical assumptions. This study provides information that clinicians can use to design better treatment strategies for this unsolved condition.

Joint Space Narrowing in Patients With Pisotriquetral Osteoarthritis.

BACKGROUND: Patients with suspected pisotriquetral osteoarthritis may show joint space narrowing. However, the extent of joint space narrowing and its deviation from the joint space width (JSW) in normal anatomy is unknown. In this pathoanatomic study, we therefore compared the JSW in the pisotriquetral joint between osteoarthritic patient wrists and healthy wrists. METHODS: We reviewed preoperative computed tomography (CT) scans of 8 wrists of patients with ulnar-sided wrist pain who underwent a pisiformectomy with confirmed pisotriquetral osteoarthritis at surgery. We also reviewed CT scans of 20 normal wrists from healthy volunteers serving as control group. Three-dimensional CT models of the pisiform and triquetrum were obtained from both affected and normal wrists, after which the minimum JSW was calculated in an automated fashion. RESULTS: In the patient group, the median (interquartile range) of the minimum JSW was 0.1 mm (0.0-0.2), and in the control group, 0.8 mm (0.3-0.9) ( P = .007). CONCLUSIONS: We showed that the pisotriquetral joint space in osteoarthritic patient wrists was significantly narrowed compared with healthy wrists. These results suggest that JSW evaluation has a potential diagnostic value in the work-up of patients with suspected pisotriquetral osteoarthritis. This is an interesting area for future clinical research, especially because no gold standard for diagnosing pisotriquetral osteoarthritis has been established yet.

Triquetrohamate Impaction Syndrome: An Unrecognized Cause of Ulnar-Sided Wrist Pain; Its Presentation Further Defined.

BACKGROUND: The aim of this review was to further define the clinical condition triquetrohamate (TH) impaction syndrome (THIS), an entity underreported and missed often. Its presentation, physical findings, and treatment are presented. METHODS: Between 2009 and 2014, 18 patients were diagnosed with THIS. The age, sex, hand involved, activity responsible for symptoms, and defining characteristics were recorded. The physical findings, along with ancillary studies, were reviewed. Delay in diagnosis and misdiagnoses were assessed. Treatment, either conservative or surgical, is presented. Follow-up outcomes are presented. RESULTS: There were 15 male and 3 females, average age of 42 years. Two-handed sports such as golf and baseball accounted for more than 60% of the cases, and these cases were the only ones that involved the lead nondominant hand, pain predominantly at impact. Delay in diagnosis averaged greater than 7 months, with triangular fibrocartilage (TFCC) and extensor carpi ulnaris (ECU) accounting for more than 50% of misdiagnoses. Physical findings of note included pain over the TH joint, worse with passive dorsiflexion and ulnar deviation. Radiographic findings are described. Instillation of lidocaine with the wrist in radial deviation under fluoroscopic imaging with relief of pain helped to confirm the diagnosis. Conservative treatment was successful in 9 of 18 patients (50%), whereas in the remaining, surgical intervention allowed approximately 80% return to full activities without limitation. CONCLUSION: Triquetrohamate impaction syndrome remains an underreported and often unrecognized cause of ulnar-sided wrist pain. In this report, the largest series to date, its presentation, defining characteristics, and treatment options are further elucidated.

Management of lunotriquetral instability: a review of the literature.

UNLABELLED: Lunotriquetral ligament injury is a relatively common cause of ulnar-sided wrist pain. Injury ranges from partial stable ligament tears to extensive perilunate instability. Clinical decision-making largely depends on the chronicity, instability and cause of the ligament injury. Conservative treatment is generally regarded as first choice of treatment of mild lunotriquetral instability; however, outcome studies on conservative treatment are lacking. Temporary arthroscopic pinning and/or debridement are minimally invasive procedures of preference. In the case of more dissociative injury, surgical interventions may be performed. The literature suggests that soft tissue reconstruction is an effective procedure in this group. Arthrodesis of the lunotriquetral joint is associated with high rates of non-union (up to 57%) and the indications for surgery should therefore be very clear. Methodological issues make it hard to draw firm conclusions from the data. Studies on the effectiveness of conservative management and prospective comparative studies will further improve clinical decision-making in lunotriquetral instability. LEVEL OF EVIDENCE: N/A.

Three-Corner Arthrodesis With Scaphoid and Triquetrum Excision for Wrist Arthritis.

PURPOSE: To report the clinical and radiographic results of a consecutive series of patients who underwent the 3-corner arthrodesis (3CA) (arthrodesis of capitate, hamate, and lunate with scaphoid and triquetrum excision) procedure for wrist arthritis. METHODS: This was a retrospective study of 30 consecutive patients who underwent a 3CA between 1994 and 2008. The indications were painful wrist osteoarthritis due to stage 2 or 3 scapholunate advanced collapse, scaphoid nonunion advanced collapse, or scaphoid chondrocalcinosis advanced collapse wrists. The clinical assessment consisted of range of motion, grip strength, and the Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores. The radiographic assessment parameters consisted of bone fusion, carpal height and translation, lunate tilt, and appearance of the radiolunate joint space. RESULTS: The average follow-up was 6 years (± 4 years). The arthrodesis was performed with staples, 2 screws, or a plate and screws. Grip strength was 72% of the contralateral side. The mean range of motion in flexion-extension arc and ulnar-radial deviation arc was 70° and 36°, respectively. The mean Disabilities of the Arm, Shoulder, and Hand and the Patient-Rated Wrist Evaluation scores were 17 (± 11) and 22 (± 24), respectively. The fusion incidence was 90% (27 of 30). The mean difference of radiolunate angle on preoperative and postoperative radiographs was 8° (16°-8° in dorsal direction). The radiolunate joint space had narrowed in 1 patient. Six surgical revisions (20%) were necessary owing to dorsal pain in patients operated using plates, staples, or excessively long screws. CONCLUSIONS: Three-corner arthrodesis results are comparable with 4-corner arthrodesis and proximal row carpectomy. We feel that it is simpler technically than 4-corner arthrodesis. Although 3CA is more complex than proximal row carpectomy, it preserves the native radiolunate joint. Complications that can be attributed to the dorsal fixation hardware (particularly staples and plates) were noteworthy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

[Ligament reconstruction for lunotriquetral instability using a distally based strip of the extensor carpi ulnaris tendon]. / Die Bandersatzplastik bei lunotriquetraler Instabilität mit einem distal gestielten Streifen der Extensor-carpi-ulnaris-Sehne.

OBJECTIVE: Stabilization of the lunotriquetral junction. INDICATIONS: Dynamic and static chronic instability without fixed dislocation of the carpals. CONTRAINDICATIONS: Chronically fixed dislocation of the carpals, ulnar impaction syndrome, osteoarthritis of the joint between hamate and triquetrum and other parts of the wrist joint, rheumatoid arthritis, chondrocalcinosis. SURGICAL TECHNIQUE: Restoration of the palmar portion of the lunotriquetral ligament using a distally based strip of the extensor carpi ulnaris tendon with temporary fixation of the lunotriquetral junction with K-wires. POSTOPERATIVE MANAGEMENT: Immobilization for 8 weeks with a radial cast that includes the first metacarpophalangeal joint. Removal of the K-wires after 8 weeks and exercise. RESULTS: The procedure with rare complications reliably restores stability of the lunotriquetral junction. Reduction of grip strength, pain during exercise, and a reduced range of motion persist. Overall, the results are predominantly good and excellent.

A rare coronal fracture of the medial carpal column: Case report.

Carpal coronal fractures are rare. We report the case of a 15 year-old male who fell from a balcony and suffered a displaced coronal fracture of the capitate, hamate and triquetrum. The diagnosis, which was initially made based on the X-rays, was confirmed by CT scan. Open reduction and internal fixation using Herbert screws was performed. To the best of our knowledge, this is the first published case of a coronal fracture of these three bones. The patient returned to normal activities after six months.

Radiographic evaluation of the modified Brunelli technique versus a scapholunotriquetral transosseous tenodesis technique for scapholunate dissociation.

PURPOSE: To compare reduction of the scapholunate articulation using a transosseous tenodesis through the scaphoid, lunate, and triquetrum (SLT) with the modified Brunelli technique (MBT) in a cadaver model, as measured by scapholunate (SL) angle and diastasis on radiographs. METHODS: Twelve fresh-frozen cadaveric wrists were radiographically examined in a neutral posture, ulnar deviation, and clenched fist position. The SL angle and diastasis were recorded in each position with the SL ligament intact, after sectioning the ligament and secondary restraints, and after reconstruction by either the MBT (6 wrists) or SLT technique (6 wrists). Wrists were cycled through their maximum flexion and extension arc 100 times to simulate wrist motion after ligament sectioning and reconstruction. RESULTS: After sectioning and cycling, all wrists demonstrated radiographic evidence of SL diastasis. After ligament reconstruction and cycling, there was no statistically significant difference in diastasis in the MBT reconstructions compared with the SLT reconstructions (3.0 vs 2.4 mm). The SLT group demonstrated better maintenance of the restored SL angle than the MBT reconstructions. CONCLUSIONS: In this cadaveric model, both MBT and SLT reconstructions restored anatomic parameters in the SL joint, with correction of SL diastasis and SL angle. Future studies to assess the clinical outcomes of SLT tenodesis in patients with chronic SL disruptions are important. CLINICAL RELEVANCE: The SLT tenodesis, with a central biologic tether along the SL axis and dorsal reinforcement, may prove clinically useful.