Collapse after Carpal Bone Tunneling. An Underreported Complication?

PURPOSE: To report the complication of carpal bone tunnel collapse in scapholunate reconstruction. METHODS: The authors present six cases of carpal collapse or bone necrosis after bone tunneling for ligamentous reconstruction, three in the scaphoid bone and three in the lunate. RESULTS: All six cases were secondary to ligament reconstruction for chronic scapholunate dissociations, none of which had preoperative structural scaphoid or lunate deformities. CONCLUSIONS: Although the incidence of this occurrence is unknown, the consequences could be substantial; therefore, patients should be warned of this possibility when discussing complications of ligament reconstruction for chronic scapholunate instability requiring the creation of a bone tunnel. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of "0," "5," and "10" reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of "8" or higher for 80% or more of the panelists. RESULTS: Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds. CONCLUSIONS: Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC. CLINICAL RELEVANCE STATEMENT: MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries. KEY POINTS: • Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.

Postoperative Imaging of the Wrist and Hand.

In this article we will do an overview of the general and specific complications that occur after the most common wrist and hand surgeries. Knowledge of the different surgical techniques is essential for postoperative imaging evaluation. General complications include infection, complex regional pain syndrome, problems related with the surgical approach (open or arthroscopic) and bone healing problems. The most frequent fractures of the wrist with specific complications are distal radius fractures and scaphoid fractures as associated with tendon ruptures secondary to friction, nonunion or secondary malignment. We will briefly review the different approaches for triangular fibrocartilage injuries, including acute and degenerative lesions. Scapholunate instability is the most common instability and an important indication for surgery with pin fixation in the acute setting and arthroplasty or arthrodesis in the chronic irreparable injuries. One of the most common surgeries of the wrist is carpal tunnel release, although complications are uncommon, radiologists should be familiar with the normal appearance and pathological changes after surgery. Trapeziometacarpal joint osteoarthritis is frequent especially in postmenopausal women and has several treatment options depending on the stage.

Postoperative MRI of the Ankle and Foot.

Many surgical procedures and operations are used to treat ankle and foot disorders. Radiography is the first-line imaging for postoperative surveillance and evaluation of pain and dysfunction. Computed tomography scans and MR imaging are used for further evaluation. MR imaging is the most accurate test for soft tissues assessments. MR imaging protocol adjustments include basic and advanced metal artifact reduction. We chose a surgical approach to select the common types of procedures and discuss the normal and abnormal postoperative MR imaging appearances, highlighting potential complications. This article reviews commonly used surgical techniques and their normal and abnormal MR imaging appearances.

Evaluation and management of ischiofemoral impingement: a pathophysiologic, radiologic, and therapeutic approach to a complex diagnosis.

Ischiofemoral impingement syndrome (IFI) is an underrecognized form of atypical, extra-articular hip impingement defined by hip pain related to narrowing of the space between the ischial tuberosity and the femur. The etiology of IFI is multifactorial and potential sources of ischiofemoral engagement include anatomic variants of the proximal femur or pelvis, functional disorders as hip instability, pelvic/spinal instability, or abductor/adductor imbalance, ischial tuberosity enthesopathies, trauma/overuse or extreme hip motion, iatrogenic conditions, tumors and other pathologies. Magnetic resonance imaging (MRI) is the diagnostic procedure of choice for assessing IFI and may substantially influence patient management. The injection test of the ischiofemoral space (IFS) has both a diagnostic and therapeutic function. Endoscopic decompression of the IFS appears useful in improving function and diminishing hip pain in patients with IFI but conservative treatment is always the first step in the treatment algorithm. Because of the ever-increasing use of advanced MRI techniques, the frequent response to conservative treatment, and the excellent outcomes of new endoscopic treatment, radiologists must be aware of factors that predispose or cause IFI. In addition, focused treatment in these conditions is often more important than in secondary impingement. In this article, we briefly describe the anatomy of the IFS, review the clinical examination and symptoms, assess the diagnostic imaging criteria and pathophysiological mechanisms, and develop an understandable classification of IFI, with particular focus on its etiology, predisposing factors, and associated musculoskeletal abnormalities. We also assess the role of the radiologist in the diagnosis, treatment, and preoperative evaluation of both primary and secondary IFI.

Usefulness of MR arthrography of the hip with leg traction in the evaluation of ligamentum teres injuries.

PURPOSE: To retrospectively evaluate the diagnostic accuracy of magnetic resonance (MR) arthrography of the hip with leg traction in the evaluation of ligamentum teres lesions and to evaluate whether there is increased articular distraction, possibly indicating secondary instability, in hips with ligamentum teres injuries. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained for this retrospective study. MR arthrograms of the hip with leg traction of 184 consecutive patients, including 108 men (mean age, 32.6 years; range, 19-53 years) and 76 women (mean age, 38.5 years; range, 18-56 years), who underwent hip arthroscopy were assessed for the presence of ligamentum teres lesions. The MR arthrographic findings were independently assessed by two radiologists who were blinded to the arthroscopic results. The inclusion criteria stipulated no previous surgery, arthroscopy within 1 month after MR arthrography, and availability of a detailed surgical report with ligamentum teres findings. The arthroscopy findings served as the reference standard. Sensitivity, specificity, accuracy, and K statistics for interobserver and intraobserver agreement were calculated. RESULTS: At arthroscopy, 32 ligamentum teres injuries were found. The ligamentum teres was normal in 152 (82.6%) patients and had suffered low-grade partial tears in 15 (8.1%) patients, high-grade partial tears in 10 (5.4%) patients, and complete ruptures in 7 (3.8%) patients. MR arthrography with axial traction demonstrated moderate sensitivity and high specificity for both low-grade (62/93%) and high-grade (66/96%) partial tears. Grouping low- and high-grade partial tears increased the diagnostic performance of MR arthrography, yielding a sensitivity of 87% and a specificity of 95%. For complete ligamentum teres tears, MR arthrography with leg traction demonstrated high sensitivity (92%) and specificity (98%). Articular distraction was significantly increased in patients with complete ruptures of the ligamentum teres (p = 0.001). CONCLUSION: MR arthrography with leg traction offers accurate diagnosis of ligamentum teres injuries. Patients with complete tears of the ligamentum teres exhibit increased articular distraction that may indicate secondary hip instability.

Deep gluteal syndrome: anatomy, imaging, and management of sciatic nerve entrapments in the subgluteal space.

Deep gluteal syndrome (DGS) is an underdiagnosed entity characterized by pain and/or dysesthesias in the buttock area, hip or posterior thigh and/or radicular pain due to a non-discogenic sciatic nerve entrapment in the subgluteal space. Multiple pathologies have been incorporated in this all-included "piriformis syndrome," a term that has nothing to do with the presence of fibrous bands, obturator internus/gemellus syndrome, quadratus femoris/ischiofemoral pathology, hamstring conditions, gluteal disorders and orthopedic causes. The concept of fibrous bands playing a role in causing symptoms related to sciatic nerve mobility and entrapment represents a radical change in the current diagnosis of and therapeutic approach to DGS. The development of periarticular hip endoscopy has led to an understanding of the pathophysiological mechanisms underlying piriformis syndrome, which has supported its further classification. A broad spectrum of known pathologies may be located nonspecifically in the subgluteal space and can therefore also trigger DGS. These can be classified as traumatic, iatrogenic, inflammatory/infectious, vascular, gynecologic and tumors/pseudo-tumors. Because of the ever-increasing use of advanced magnetic resonance neurography (MRN) techniques and the excellent outcomes of the new endoscopic treatment, radiologists must be aware of the anatomy and pathologic conditions of this space. MR imaging is the diagnostic procedure of choice for assessing DGS and may substantially influence the management of these patients. The infiltration test not only has a high diagnostic but also a therapeutic value. This article describes the subgluteal space anatomy, reviews known and new etiologies of DGS, and assesses the role of the radiologist in the diagnosis, treatment and postoperative evaluation of sciatic nerve entrapments, with emphasis on MR imaging and endoscopic correlation.

Minimally invasive fixation of fractures of the phalanges and metacarpals with intramedullary cannulated headless compression screws.

PURPOSE: To present the technique, indications, and outcomes of metacarpal and phalangeal fractures fixed with intramedullary cannulated headless screws (CHS). METHODS: We retrospectively reviewed all charts of patients whose metacarpal and phalangeal fractures had been treated with intramedullary CHS in our practice. A total of 69 fractures (48 metacarpal and 21 phalangeal) were identified in 59 patients. Seventeen were open fractures. Eleven patients had multiple fractures (29 in total); of those, 21 were managed with CHS. In 4 other fractures the method was abandoned intraoperatively. The defect created by the entrance of the screw in the proximal phalanx was identified by computed tomography in 20 patients. RESULTS: In 63 fractures a single screw was used; in 6 fractures 2 screws were used to provide stronger fixation. All patients returned to full duties or sport activities at an average of 76 days (range, 3 wk to 15 mo). At the latest follow-up (range, 5-54 mo; average, 19 mo) total active motion was on average 247° (range, 150° to 270°) for all fractures, 249° (range, 210° to 270°) for metacarpal, and 243° (range, 150° to 270°) for proximal phalangeal fractures. All fractures were healed and within acceptable radiological parameters. A comminuted basilar phalangeal fracture displaced secondarily yielding a poor functional result. Two patients required tenolysis and further procedures before the final result was achieved. The screw hole represents around 20% of the proximal phalanx distal articular surface. CONCLUSIONS: Unstable transverse fractures in the phalanx and metacarpal are amenable to single intramedullary CHS fixation. Comminuted fractures require more complex configurations. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Vascularized graft from the metatarsal base for reconstructing major osteochondral distal radius defects.

PURPOSE: To present our experience of reconstructing distal radius articular defects with a vascularized osteochondral graft from the metatarsal base and to present the mid-term outcomes. METHODS: Seven patients (average age, 36 y; range, 26-55 y) who had reconstruction of major defects of the articular surface of the radius are presented. In 5, the lunate facet and sigmoid notch were reconstructed; in 1, an isolated defect on the surface of the lunate facet was reconstructed; and in 1, the scaphoid facet was reconstructed. In 6, the base of the third metatarsal was transferred, and in 1, the base of the second was transferred. RESULTS: All flaps survived without complications. At the latest follow-up (range, 20 mo to 8 y), the flexion-extension arc improved an average of 50°, and the pain on a visual analog scale decreased from 8 to 1 on average. Disabilities of the Arm, Shoulder, and Hand score improved from 54 to 11 on average. One patient did not improve. No major complaints related to the donor site were mentioned (average American Orthopedic Foot and Ankle Society score of 96/100). CONCLUSIONS: Our mid-term results are promising; however, the decision-making process and the operation are complex. The operation is not indicated when the carpals are devoid of cartilage or when the defect involves the whole radius surface.

Anatomy, biomechanics, imaging, and management of ligamentum teres injuries.

The ligamentum teres has traditionally been viewed as an embryonic remnant with no role in the biomechanics or vascularity of adult hips. However, the ligamentum teres is a strong intraarticular ligament that is anatomically and biochemically similar to the anterior cruciate ligament of the knee. It is composed of two bands that originate from the acetabular transverse ligament and the pubic and ischial margins of the acetabular notch. Among other functions, the ligamentum teres is an important stabilizer of the hip, particularly in adduction, flexion, and external rotation. Abnormalities of the ligamentum teres account for 4%-15% of sports-related injuries and should be considered in the differential diagnosis of patients with hip pain. Lesions of the ligamentum teres include partial or complete traumatic tears, degenerative tears, avulsion fractures of the ligament at its insertion into the fovea capitis femoris, and a congenital absence of the ligament. Magnetic resonance arthrography and computed tomographic arthrography are the preferred modalities for precise preoperative diagnosis of ligamentum teres injuries and may be used to rule out other associated intraarticular injuries. Treatment of these lesions is still evolving; at present, treatment of most injuries is limited to arthroscopic débridement.

Direct MR arthrography of the hip with leg traction: feasibility for assessing articular cartilage.

OBJECTIVE: Hip arthrography is an accurate diagnostic method for evaluation of the peripheral compartment, but its depiction of cartilage lesions is moderate. The purpose of this study was to add leg traction to MR arthrography of the hip to test its effect on visualization of cartilage surfaces. CONCLUSION: Hip MR arthrography with leg traction is a technically feasible and safe procedure that improves visualization of the femoral and acetabular cartilage surfaces.

Correction of malunited intra-articular distal radius fractures with an inside-out osteotomy technique.

PURPOSE: To present an inside-out osteotomy technique under arthroscopic guidance to correct an intra-articular malunion. METHODS: The joint is explored with a 2.7-mm arthroscope through the standard portals without infusing any water. To allow room to introduce the curettes and the osteotomes (4-mm wide), the instrumentation portals are made slightly larger than usual. Malunited fragments are cut with the osteotomes from inside the joint and advanced out. Fragments are mobilized, and granulating tissue and/or new bone is removed with curettes and synoviotomes. After disimpaction and reduction, fixation with plates or screws via the appropriate open approach is performed under arthroscopic control. No water is used throughout the procedure except at the end of the surgery to clear out debris. RESULTS: Steps were corrected to 0 mm in all patients. Gaps of less than 1 mm were common. CONCLUSIONS: This procedure allows us to define each cartilage-containing fragment and to re-create the original articular fracture line without the fear of creating new fracture lines on the articular surface. This technique can be used for patients with irregularly defined fragments that are not amenable to classic techniques. The key to the procedure is to perform the arthroscopic exploration without water infusion (dry technique).

Ankle MR arthrography: how, why, when.

MR arthrography has become an important tool for the assessment of a variety of ankle disorders. MR arthrography may facilitate the evaluation of patients with suspected intra-articular pathology in whom conventional MR imaging is not sufficient for an adequate diagnosis and be useful for therapy planning. MR arthrography is valuable in the evaluation of ligamentous injuries, impingement syndromes, cartilage lesions, osteochondral lesions of the talus, loose bodies, and several synovial joint disorders. Indirect MR arthrography is a useful adjunct to conventional MR imaging and may be preferable to direct MR arthrography in cases in which an invasive procedure is contraindicated or when fluoroscopy is not available.

Arthroscopic Keller technique for Freiberg disease.

Freiberg disease is a disorder that has a predilection for the second metatarsal head. Keller excision of the base of the proximal phalanx is a procedure described for the treatment of late-stage Freiberg disease. We describe a case of a 60-year-old man, with a stage IV lesion according to Smillie's classification, treated by debridement, removal of the free body, and arthroscopic Keller excision. Arthroscopic treatment allows the patient to begin and maintain an aggressive postoperative physical therapy program immediately after surgery, thus decreasing the risk of scarring and contracture. At last evaluation, 2 years postoperatively, he is symptom-free. A suggested pattern of minimally invasive surgery management of this disease is proposed.

The radial portal for scaphotrapeziotrapezoid arthroscopy.

The scaphotrapeziotrapezoidal (STT) joint is a complex joint in which the arthroscope and instruments can be used through the radial midcarpal and STT-ulnar portals. This report describes a new arthroscopic portal at the STT joint to complete and improve the evaluation and treatment of this joint by arthroscopy: The STT-radial (STT-R) portal is situated immediately radial to the abductor pollicis longus at the STT level. Five cadaveric wrist specimens were dissected immediately after the portal was established, and photographed to determine the proximity of neurovascular structures. Magnetic resonance imaging evaluation of 15 hands was performed to measure the proximity of the radial artery. A cadaveric distal scaphoid excision was also created arthroscopically to show the real usefulness of this portal. Results of the anatomic study showed that no lesions of nerves or vessels were seen at this portal. Magnetic resonance imaging showed that the radial artery was located at a safe distance from the portal. The distal scaphoid excision was performed 15 minutes after the STT portals were established. Our results suggest that this new portal is safe and effective.

Acute hand compartment syndromes after closed crush: a reappraisal.

Severe crush to the hand is associated with a poor prognosis. The authors investigated the hypothesis that compartment syndrome complicates such injuries. From 1996 to 2000, the authors retrospectively identified 11 patients who, after sustaining a closed crush injury, developed acute hand compartment syndrome. Diagnosis was made on clinical grounds in two patients (the intracompartmental pressure was not measured) and after clinical examination plus measurement of intracompartmental pressure in nine patients. In all cases, the muscle burst out once the fascia was released from the affected compartment. Clinical clues to elicit the diagnoses were massive hand swelling and tenseness to palpation. Classic symptoms, such as excruciating pain, were absent or their intensity was attributed to the trauma event (in six patients). Classic signs such as intrinsic muscle minus position and pain on stretching were absent in six and three patients, respectively. In addition, the latter stretch test could not be properly judged in five more patients because of interference by the associated injuries. None of the patients developed contracture or sequela that could be attributed to compartment syndrome. On the basis of this experience, it was concluded that crush injury does not in itself carry a poor functional prognosis, provided that attention is paid to the often-concomitant compartment syndrome. Elevated subfascial pressure may be present despite the absence of classic signs and symptoms.

Imaging findings in ulnar-sided wrist impaction syndromes.

Impaction syndromes related to ulnar-sided pain include ulnar impaction syndrome, ulnar impingement syndrome, ulnocarpal impaction syndrome secondary to nonunion of the ulnar styloid process, ulnar styloid impaction syndrome, and hamatolunate impingement syndrome. The most common of these, ulnar impaction syndrome, is a degenerative condition of the ulnar side of the wrist related to excessive load bearing across the ulnar carpus, triangular fibrocartilage (TFC) complex, and ulnar head. In an adequate clinical setting, characteristic osseous findings at radiography include positive ulnar variance in ulnar impaction syndrome, a short ulna in ulnar impingement syndrome, nonunion of the ulnar styloid process in ulnar impaction syndrome secondary to ulnar styloid nonunion, an excessively long ulnar styloid process in ulnar styloid impaction syndrome, and type II lunate bone in hamatolunate impingement syndrome. Nevertheless, confirmation of clinical and conventional radiographic findings with magnetic resonance (MR) imaging is often necessary to exclude other entities with similar clinical manifestations. MR imaging allows earlier detection of an abnormality in the TFC complex, cartilage, or bone marrow of carpal bones and is helpful in formulating the extensive differential diagnosis in patients with ulnar wrist pain and limitation of motion.