Distal radioulnar joint stabilization with open foveal reinsertion versus tendon graft reconstruction: an experimental study using radiostereometry.

PURPOSE: Symptomatic instability of the distal radioulnar joint (DRUJ) caused by lesion of the Triangular Fibrocartilage Complex (TFCC) can be treated with a number of surgical techniques. Clinical examination of DRUJ translation is subjective and limited by inter-observer variability. The aim of this study was to compare the stabilizing effect on DRUJ translation with two different surgical methods using the Piano-key test and a new precise low-dose, non-invasive radiostereometric imaging method (AutoRSA). METHODS: In a randomized experimental study we evaluated the DRUJ translation in ten human cadaver arms (8 males, mean age 78 years) after cutting the proximal and distal TFCC insertions, and after open surgical TFCC reinsertion (n = 5) or TFCC reconstruction using a palmaris longus tendon graft ad modum Adams (n = 5). The cadaver arms were mounted in a custom-made fixture for a standardized Piano-key test. Radiostereometric images were recorded and AutoRSA software was used for image analyses. Standardised anatomical axes and coordinate systems of the forearm computer tomography bone models were applied to estimate DRUJ translation after TFCC lesions and after surgical repair. RESULTS: The DRUJ translation after cutting the proximal and distal TFCC insertions was 2.48 mm (95% CI 1.61; 3.36). Foveal TFCC reinsertion reduced DRUJ translation by 1.78 mm (95% CI 0.82; 2.74, p = 0.007), while TFCC reconstruction reduced DRUJ translation by 1.01 mm (95% CI -1.58; 3.60, p = 0.17). CONCLUSION: In conclusion, foveal TFCC reinsertion significantly decreased DRUJ translation while the stabilizing effect of Adams TFCC reconstruction was heterogeneous. This supports the clinical recommendation of TFCC reinsertion in patients suffering from symptomatic DRUJ instability due to acute fovea TFCC lesions.

Splinting versus extension-block pinning of bony mallet finger: a randomized clinical trial.

Surgical treatment of bony mallet fingers is frequently recommended, but the evidence is sparse. This randomized clinical trial aimed to compare nonoperative splinting versus extension-block pinning of bony mallet fingers with involvement of more than one-third of the joint surface but without primary joint subluxation. Thirty-two patients were randomized and 28 fulfilled the protocol. At 6 months follow-up, there were no significant differences in active extension lag in the distal interphalangeal joint (the primary outcome) or in patient-reported function and pain scores. Flexion and active range of motion in the distal interphalangeal joint and finger-to-palm distance were better in the splinting group, but three patients developed secondary subluxation. We conclude from this study, that splinting these injuries is safe and efficient in restoring joint motion, but splinting does not sufficiently prevent secondary subluxation of the joint. Radiographic follow-up during splinting appears to be necessary. Level of evidence: I.

[Os epilunatum is a rare cause of atraumatic impaired motility and wrist pain].

In this case report a 28-year-old man had a six-year history of atraumatic wrist pain. X-ray and MRI showed an accessory ossicle dorsal to the lunate, near the scapholunate ligament: an os epilunatum. Os epilunatum is a rare ossicle of the hand, and only one clinical case and few cadaveric studies have previously been reported. Resection was performed through a dorsal approach, without damaging the scapholunate ligament. Three months post-operatively the patient had increased motility of the hand and no pain.

Wrist stability after experimental traumatic triangular fibrocartilage complex lesions.

PURPOSE: The aim of this study was to evaluate changes in stability of the wrist after experimental traumatic triangular fibrocartilage complex lesions. METHODS: Sixteen cadaver wrist specimens were included: 8 were fixed in neutral rotation of the forearm, 4 in maximal supination, and 4 in maximal pronation. The specimens were tested in a multiangle and torque measuring instrument. First the intact specimen was tested, second a dorsal arthrotomy was performed, and the third test was with 1 of 4 different experimental lesions according to Palmer's classification of traumatic triangular fibrocartilage complex lesions (1A-1D). Forced radioulnar deviation and internal/external rotation were recorded with a load of 0.75 Nm in the interval -60 degrees to +60 degrees of flexion. RESULTS: We found the 1C lesion to be highly significantly related to wrist stability. Forced radioulnar deviation and forced internal/external rotation were altered significantly in 35 degrees of wrist extension. The other lesions did not alter the stability of the wrist significantly and the rotation of the forearm had no influence on the outcome. CONCLUSIONS: The 1A lesion does not alter significantly wrist stability and hence the common treatment by a two-third excision of the central part of the disk will not affect wrist stability. A 1C lesion alters significantly the stability of the wrist. At 35 degrees of wrist extension forced radioulnar deviation and forced internal/external rotation were altered significantly; this might be used in a clinical test for a 1C lesion. The rotation of the forearm has no influence on the outcome.

Bone grafting the scaphoid nonunion: a systematic review of 147 publications including 5,246 cases of scaphoid nonunion.

In order to elucidate the history of scaphoid nonunion and to evaluate whether or not the problem has been solved, we have reviewed the literature from 1928 to 2003 for union rates, postoperative immobilization periods and complications of the different scaphoid bone grafting procedures. The outcomes of 5 246 scaphoid nonunions were evaluated in three treatment groups. In the first group involving nonvascularized bone grafting without internal fixation, we found a union rate of 80% (95% CI: 78-82) after an average immobilization period of 15 weeks. In the second group involving nonvascularized bone grafting with internal fixation, the figures were 84% (CI: 82-85) and 7 weeks, respectively. In the last group involving vascularized bone grafting with or without internal fixation, the figures were 91% (CI: 87-94) and 10 weeks, respectively. We found no prospective randomized studies comparing different operative treatments of scaphoid nonunion. We conclude that there still is a need for improvement in the treatment of scaphoid nonunion.

Long-term outcome of meniscal degeneration in the knee: poor association between MRI and symptoms in 45 patients followed more than 4 years.

Knee joint-related symptoms are frequent and the use of MRI as a diagnostic tool is common. About 25% of MRIs show meniscal degeneration (MD). As the natural history of MD has not been well described, we studied the long-term outcome of 50 MDs. 45 patients were initially evaluated by a MRI, and clinical examination and later by another MRI. After 5 years, 38 of the MDs were unchanged, 8 had progressed and 4 regressed. Progression of MD was associated with age over 40 years, trauma during the follow-up period and/or other knee lesions, such as osteoarthrosis and ligament rupture. The clinical findings were consistent with MDs only in 8 cases.