Lunate-capitate arthrodesis for scaphoid nonunion: a comparative study.

BACKGROUND: Scaphoid nonunion advanced collapse (SNAC) injuries are frequently associated with irreversible degenerative wrist arthritic changes that necessitate surgical intervention. Midcarpal fusion remains the mainstay of the management of SNAC II and III injuries. A successful four-corner fusion (4CF) relies on a stable lunate-capitate fusion (LCF). There have been reports of management relying solely on LCF. The outcomes of LC- and 4 C-fusions in SNAC injuries were not widely documented. The objective of this research is to provide valuable insights into the effectiveness of both fusion procedures in the management of SNAC II and III wrist injuries, with a focus on reporting associated complications, functional and radiological outcomes. PATIENTS AND METHODS: This retrospective study encompassed 65 patients diagnosed with SNAC II and III wrist injuries who underwent limited wrist fusion procedures between 2015 and 2024, with a minimum of 2 years of postoperative follow-up. Exclusion criteria encompassed patients with carpal instability, prior wrist surgical interventions, and scapholunate advanced collapse. Following the fusion procedure performed, patients were stratified into two groups: the LCF group consisting of 31 patients, and the 4CF group comprising 34 patients. Preoperative and intraoperative data were retrieved from the patient's medical records. At their final follow-up appointments, patients underwent comprehensive radiographic and clinical evaluations. Clinical outcomes including hand grip strength, range of motion, the Disabilities of the Arm, Shoulder, and Hand Score, and the Mayo Modified Wrist Score, were compared between groups. Any associated complications were reported. RESULTS: The average healing time was 74.7 ± 15.6 and 72.2 ± 13.2 days for the LCF and 4CF groups, respectively. At the final visit, all patients showed functional improvement relative to their preoperative status, with comparable wrist range of motions observed in both groups. The functional wrist scores were slightly better in the LCF patients (P > 0.05). The average grip strength was significantly greater in the LCF group (P = 0.04), with mean strength values of 86.8% and 82.1% of the contralateral side, for the LCF and 4CF groups, respectively. CONCLUSION: The LCF is not less efficient than the 4CF in the treatment of SNAC II and III wrist injuries. Through a less time-consuming procedure, LCF can efficiently provide comparable results to 4CF. LEVEL OF EVIDENCE: level IV evidence.

Ligamentoplasty in scapholunate instability: short-term results of the "all dorsal scapholunate repair" technique.

Injury to the scapholunate complex is the cause of scapholunate instability which can lead to radiocarpal and medio-carpal osteoarthritis. Several ligamentoplasty techniques have been reported for the treatment of chronic scapholunate instability before the osteoarthritis stage. The objective of this study was to assess the short-term results of an "all dorsal scapholunate repair" ligamentoplasty. We report the clinical, radiological and functional results of a retrospective study including 21 patients, operated between June 2019 and December 2020 for a stage 3 or 4 scapholunate instability according to the Garcia Elias classification. With a follow-up of 14.2 months, the pain was 0.1/10 according to the VAS at rest and 4/10 during exercise. Wrist strength was measured at 65% of the opposite side. The flexion-extension range of motion was 105°. Radiologically, there was a reduction of the diastasis and scapholunate angle. Osteolysis areas around the anchors were described in 47% of patients. The mean QuickDASH was 29.2/100, PRWE 24/100 and Mayo wrist score 67.8/100. Eighty-one percent of patients were satisfied. Seventeen patients had returned to work 5.2 months postoperatively. In the case of work-related injury, the functional scores were poorer, with a delayed return to work. This technique provides encouraging results in the short term. Most patients were improved compared to preoperative state. The work-related injury appears to be a poor prognostic factor. A longer-term study is imperative to confirm the maintenance over time of the correction of carpal malalignment and the evolution of the osteolysis areas.Level of evidence: Level IV Retrospective study.

Outcomes after radioscapholunate arthrodesis for intra-articular malunion of distal radius fractures.

PURPOSE: To study the clinical, radiological, and functional outcomes after of radioscapholunate (RSL) fusion for intra-articular malunion of the distal radius. METHODS: This retrospective study included 26 patients (17 males and 9 females) with intra-articular malunion of distal radius fractures who underwent RSL arthrodesis using locked miniplates (without distal scaphoid excision) between 2012 and 2020. Their mean age was 43 years (range, 32-56). Patients were assessed radiographically for union and clinically for range of motion, grip strength, and pain (assessed by Visual Analogue Scale (VAS) for pain). Functional evaluation was performed by using the Mayo modified wrist score (MMWS) and the Disabilities for the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS: All patients showed complete healing at the fusion site after a mean of 8.7 weeks (range, 8-12). The mean follow-up period was 72 months (range, 60-84). The pinch strength improved from a mean of 6.2 kg (range, 3-12) to a mean of 9.8 kg (range, 5-18) which represents 80% of the contralateral side. The mean pinch strength was 7 kg (range, 5-18) which presents 80% of the other side. VAS for pain showed a mean improvement of 72.6%. The DASH score improved to a mean of 19.2 (range, 14-24). The MMWS improved to a mean of 68 (range, 45-86). At the final follow-up period, no degenerative changes were detected in the midcarpal joint. CONCLUSION: RSL arthrodesis (using locked miniplates without distal scaphoid excision) is a reliable surgical procedure to manage cases of radiocarpal OA after intra-articular malunion of distal radius fractures with good clinical and radiological outcomes. LEVEL OF EVIDENCE: Level IV- therapeutic.

Surgical management and functional outcomes of perilunate dislocations and fracture dislocations through the dorsal approach.

BACKGROUND: Perilunate dislocations and perilunate fracture dislocations (PLD/PLFDs) are rare injuries of the wrist, with surgical management leading to acceptable functional results. PURPOSE: The purpose of this study was to assess the functional outcomes of the patients of our department who were treated with surgical management of PLDs/PLFDs through dorsal approach, as well as to report any complications on their follow-up. PATIENTS AND METHODS: In this retrospective study, 52 patients with PLD/PLFD, fulfilling the inclusion and exclusion criteria of the study, underwent surgical management of their injury. All patients were followed up at 6 weeks, 12 weeks, 6 months, 1 year postoperatively with radiographic imaging as well as functional scores measured with the modified mayo wrist score and the QuickDASH questionnaire. RESULTS: The mean postoperative modified Mayo score was 76.8 ± 8.8 and the mean QuickDASH score was 1.52 ± 2.18. Of the 52 cases, 20% had excellent results, 42% had good results, 29% had fair results and 9% had poor results as per the modified Mayo wrist score. No patient signed any symptoms of median nerve neuropathy. CONCLUSION: In conclusion, open reduction and internal fixation through dorsal approach is a reliable technique to manage perilunate injuries in spite of radiological evidence of wrist arthritis, as it also provides consistently good results in terms of functional outcomes. LEVEL OF EVIDENCE IV: Retrospective case series study.

Scapholunate Instability: Diagnosis and Management - Anatomy, Kinematics, and Clinical Assessment - Part I.

Injuries to the scapholunate joint are the most frequent cause of carpal instability. The sequelae of these injuries account for considerable morbidity, and if left untreated, may lead to scapholunate advanced collapse and progressive deterioration of the carpus. Rupture of the scapholunate interosseous ligament and its critical stabilizers causes dyssynchronous motion between the scaphoid and lunate. Additional ligament injury or attenuation leads to rotary subluxation of the scaphoid and increased scapholunate gap. Intervention for scapholunate instability is aimed at halting the degenerative process by restoring ligament integrity and normalizing carpal kinematics. In the first section of this review, we discuss the anatomy, kinematics, and biomechanical properties of the scapholunate ligament as well as its critical ligament stabilizers. We provide a foundation for understanding the spectrum of scapholunate ligament instability and incorporate meaningful new anatomical insights that influence treatment considerations. The purpose is to provide an update regarding the anatomy of the scapholunate ligament complex, importance of the critical ligament stabilizers of the proximal carpal row, introduction of safe technique to surgically expose the scaphoid and lunate, as well as pathoanatomy as it pertains to the treatment of scapholunate dissociation. In the second section of this review, we propose a novel ligament-based treatment algorithm based on the stage of injury, degree and nature of ligament damage, and presence of arthritic changes.

The tangential view described by Moneim to demonstrate scapholunate dissociation: an update.

PURPOSE: Scapholunate dissociation is a common and significant injury to the wrist. Radiographs are important in the diagnosis of this injury and in the planning of treatment. The tangential radiograph view was described almost 40 years ago as a method for accurately measuring scapholunate gaps. The hand is positioned on a 20° foam rubber block and the thumb on the cassette, which positions the scaphoid and lunate articular surfaces parallel, without patient discomfort or effort. The goal of this study was to review this method with more recent data and in a larger group of patients. METHODS: Radiographs of 31 patients who had scapholunate interosseous ligament tears and surgical repair over a 9 year period were retrospectively evaluated. Each of the four authors independently measured scapholunate gaps for posteroanterior and tangential views. RESULTS: The tangential view gaps were significantly greater than the posteroanterior gaps overall. Similar results were found for borderline cases where the posteroanterior gap was less than 3 mm. Every tangential view gap measurement was greater than its respective posteroanterior gap with good inter-rater reliability. CONCLUSION: The tangential view is a reliable radiographic method to identify scapholunate gaps. It should be obtained when there is clinical concern for scapholunate dissociation, especially in patients with borderline posteroanterior gaps.

Arthroscopic-Assisted Volar Scapholunate Capsulodesis: A New Technique.

Most current surgical techniques for scapholunate interosseous ligament injuries address the dorsal component only. Previously, volar capsulodesis has been described either as an open approach or an "all-inside" technique. In this article, we report an alternative arthroscopic technique to address volar scapholunate interosseous ligament injuries. Arthroscopic-assisted volar scapholunate capsulodesis may be considered in the treatment algorithm for volar scapholunate interosseous ligament injuries.

Bilateral bipartite lunate misdiagnosed as carpal fracture: a case report and brief review of literature.

Bilateral bipartite lunate is a very rare congenital anomaly of the lunate. A 36-year-old military European male was referred to our service diagnosed with a lunate fracture. Symptoms began 3 months before our encounter, after falling on his outstretched left hand. The patient was misdiagnosed with a lunate fracture, therefore treated with a cast and then transitioned to a removable splint over 2 months in total; When the patient presented to our facility, on physical examination, he referred pain over the dorso-ulnar side of the wrist, especially the ulnar snuff. Tenderness to palpation over the fovea and positive triangular fibrocartilage complex axial compression test was encountered. Bilateral wrist X-rays were taken, and a diagnosis of bilateral bipartite lunate was made by our team. The patient was treated for ulnar-sided wrist pain with steroid injection and physical rehabilitation. A literature review on bipartite lunate was conducted, and cases share three basic common features: unilateral involvement, incidentally diagnosed after a traumatic event, and absence of positive clinical findings related to the bipartition.

Perilunate injuries: biomechanics, imaging, and classification.

Perilunate injuries are uncommon injuries that are often misdiagnosed. Although conventional radiographs can underestimate the severity of the perilunate injuries, assessment with cross-sectional imaging can be complex, and terminology is inconsistent in the scientific literature. The aim of this paper is to describe the biomechanics, anatomy, and classification of perilunate trauma in order to provide a systematic approach to the description and diagnosis of these injuries.

The surgical outcomes of trans-scaphoid perilunate fracture-dislocations

1. Background/aim: Trans-scaphoid perilunate fracture-dislocation (TSPFD) is a rare injury. TSPFD is a fracture-dislocation that severely disrupts the anatomical structure of the carpal bones and may occur as a result of a high energy trauma of the wrist or a fall on an open hand. In this study, the aim is to provide midterm clinical and radiological evaluations of cases diagnosed and treated as TSPFD. Materials and methods: Eleven patients diagnosed with TSPFD as a result of wrist trauma were treated surgically and were analysed retrospectively. Clinical and radiological follow-up of the cases was evaluated. The mean age of the patients was 34 years. All patients were males with a dorsal dislocation according to Herzberg's perilunate fracture-dislocation classification. The mean follow-up time was 33 months. All of the cases were evaluated with preoperative and postoperative standard wrist anteroposterior and lateral radiographs. A dorsal approach was used in all cases. However, in 1 case a volar approach was also required. The Green and O'Brien evaluation scale modified by Cooney was used for the clinical assessment of pain, wrist range of motion, grip strength, and functional status as excellent, good, moderate, or poor. The wrist range of motion was evaluated goniometrically at the final check-up, and a mid-grade disability was observed compared with the uninjured side. A visual analogue scale was used to evaluate the pain. Results: Sufficient union was obtained in all cases with open reduction and internal fixation of the fractures. Grip strength was up to 77.5% of the other side. According to the modified Green and O'Brien clinical evaluation scale, 6 cases were evaluated as good, 3 cases were fair, and 2 cases were poor. No median nerve damage was determined preoperatively or postoperatively and there was no postoperative pin tract infection in any of the patients. Conclusion: This kind of injury represents complex biomechanical damage of the wrist anatomy. If it is diagnosed early and treated with open reduction and stable fixation, a functionally adequate and anatomically integrated wrist can be achieved.

Intermediate Cuneiform Resurfacing Arthroplasty for Combined Defects of the Sigmoid Notch and the Lunate Fossa of the Distal Radius.

Posttraumatic comminution and bone loss at the sigmoid notch and the lunate fossa of the distal radius result in substantial impairment. Established salvage methods do not meet the physical demands of young patients. Replacement of the articular cartilage is challenging owing to the loss of 2 articular surfaces in different planes and the lack of a defined autogenous source to replace them simultaneously. The use of an intermediate cuneiform osteoarticular autograft to reconstruct the sigmoid notch and the lunate fossa is a new surgical technique that restores joint congruity and stability while allowing early active motion. In this study, we report a cadaver study detailing the anatomy, the surgical technique, and the functional and radiographic outcomes of our index case. Unlike alternative salvage techniques, restoration of the articular surface of the sigmoid notch and the lunate fossa allows early active and stable forearm and radiocarpal joint motion.

Dorsal Extrinsic Ligament Injury and Static Scapholunate Diastasis on Magnetic Resonance Imaging Scans.

PURPOSE: Current biomechanical data suggest that static scapholunate (SL) ligament dissociation occurs only when there is loss of competence of the extrinsic ligaments either acutely or with attenuation over time. We aimed to identify whether patients with an SL gap greater than 2 mm demonstrated concomitant dorsal radiocarpal ligament (DRC) and dorsal intercarpal ligament (DIC) ligament changes on magnetic resonance imaging (MRI) scans that were identified as having an SL ligament tear. METHODS: We included 90 patients who had a posttraumatic MRI scan of the wrist diagnosed with an SL injury. We recorded basic demographics; 2 attending fellowship-trained musculoskeletal radiologists evaluated the integrity of the SL, DRC, and DIC ligaments and graded these as normal, low-grade injury (sprain or partial tear) or full-thickness tear. The association between the integrity of the DRC and DIC ligaments and the presence of a scapholunate gap of 2 mm or greater was analyzed. RESULTS: A total of 48 patients (53%) had an SL distance of 2 mm or greater on MRI. Of these patients, 28 (58%) had a partial or total tear of the DIC and/or DRC ligament. Compared with patients with an SL interval less than 2 mm, patients with an SL interval 2 mm or greater more often demonstrated DIC signal change (31% vs 12%), DRC signal change (52% vs 14%), or combined or isolated DIC and/or DRC signal change (52% vs 14%). CONCLUSIONS: Dorsal extrinsic ligaments demonstrate MRI signal change suggestive of acute or chronic injury in patients with an SL interval 2 mm or greater more often than in patients with an SL interval less than 2 mm. These results reinforce that MRI findings of SL ligament tear need to be interpreted in a larger context, perhaps with additional attention to the DIC and DRC appearance upon MRI. In addition, MRI evaluation of dorsal extrinsic ligaments may aid in clinical decision-making for patients with SL injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

3D printing lunate prosthesis for stage IIIc Kienböck's disease: a case report.

Stage IIIc Kienböck's disease is a clinical challenge to treat collapse of the lunate bone. A new reconstructive surgery was described in one patient using 3D printing lunate prosthesis. The prosthesis shape was designed by tomographic image processing and segmentation using technology compared with the intact side matched by mirror symmetry and 3D post-processing technologies. The patient recovered nearly full range of motion of the wrist after 12 months. The visual analog scale scores and Cooney scores were 2 points and 91 points. We demonstrated that an anatomical reconstruction to Kienböck's Disease is possible using 3D printing lunate prosthesis.

[Perilunate injuries]. / Perilunäre Verletzungen.

Perilunate injuries are one of the most severe injuries of the hand. They occur relatively rarely but necessitate that diagnostic procedures should be carried out thoroughly and as soon as possible. The therapeutic strategy must consider the age, exact type and full extent of the injury. The key for successful treatment is exact anatomic reduction and stable fixation of all injured structures.

Percutaneous elevation of depressed lunate fossa: A surgical technique.

Die-punch fractures or impaction fractures of distal radius articular surface are difficult to treat and hard to achieve satisfactory reduction. We present a unique, percutaneous and minimally invasive technique to elevate the depressed lunate fossa and maintain the reduction of the elevated fragment with no need of grafting in such fractures. This technique is simple, reproducible and can be executed with simple instrumentations. We think it deserves a variety of implications in the treatment of distal radius fractures.

Association of lunate morphology, sex, and lunotriquetral interosseous ligament injury with radiologic measurement of the capitate-triquetrum joint.

OBJECTIVE: Radiologic presentation of carpal instability at the radial side of the carpus, e.g. scapholunate diastasis following scapholunate interosseous ligament injury, has been studied extensively. By comparison, presentation at the ulnar-sided carpus has not. The purpose of this study was to assess the effects of lunate morphology, sex, and lunotriquetral interosseous ligament (LTIL) status on the radiologic measurement of the capitate-triquetrum joint (C-T distance). Further, we sought to evaluate the diagnostic accuracy of C-T distance for assessing LTIL injuries. MATERIALS AND METHODS: We retrospectively identified 223 wrists with wrist radiographs and MR arthrograms with contrast injection. Data collected included sex, lunate morphology and LTIL status from MR arthrography, and C-T distance from radiography. The effects of lunate morphology, sex, and LTIL injury status on C-T distance were evaluated using generalized linear models. Diagnostic performance of C-T distance was assessed by the area under receiver-operator characteristic curve (AUROC). RESULTS AND CONCLUSION: Lunate morphology, sex, and LTIL injury status all had significant effects on C-T distance; wrists with type II lunates, men, and wrists with LTIL injuries had greater C-T distances than wrists with type I lunates, women, and wrists without LTIL injuries, respectively (p < 0.01). The diagnostic value of the C-T distance for identifying patients with full-thickness LTIL tears was sufficient for women with type I (AUROC = 0.67) and type II lunates (0.60) and good for men with type I (0.72) and type II lunates (0.77). The demonstrated influence of LTIL status on C-T distance supports the use of C-T distance as a tool in assessing for full-thickness LTIL tears.

Comparative Outcome Analysis of Arthroscopic-Assisted Versus Open Reduction and Fixation of Trans-scaphoid Perilunate Fracture Dislocations.

PURPOSE: To compare union rates and clinical and radiological outcomes of arthroscopic-assisted reduction and fixation with those of open reduction and fixation in patients with trans-scaphoid perilunate fracture dislocations. METHODS: This retrospective study included consecutive patients with trans-scaphoid PLFDs who underwent arthroscopic-assisted reduction and fixation (group A) or open reduction and fixation (group O), and who were followed up for a minimum of 2 years between May 2005 and March 2013. We excluded initially missed patients. Each different surgeon who was on call had performed each experienced operation. These clinical outcomes were assessed: range of motion, grip strength, Mayo wrist score, and Disabilities of Arm, Shoulder, and Hand (DASH) score. For radiologic outcomes, the scapholunate angle, radiolunate angle, and lunotriquetral distance were measured. RESULTS: The total number of included patient was 20 (11 in group A and 9 in group O). Scaphoid union occurred in all patients except 1 individual (11 of 11 in group A, and 8 of 9 in group O). At the last follow-up, the mean flexion-extension arc was significantly greater in group A (125.0°) than in group O (105.6°) (P = .028). The mean grip strength was 81.1% that of the contralateral side in group A and 80.9% in group O (P = .594). The mean Mayo wrist score was 85.5 in group A and 79.4 in group O (P = .026), and the mean DASH score was 10.6 in group A and 20.8 in group O (P = .001); however, only the DASH score showed a minimum clinically important difference. The mean scapholunate angle, radiolunate angle, and lunotriquetral distance were similar between the 2 groups: 47.2°, 1.7°, and 2.0 mm in group A and 48.8°, 5.6°, and 2.1 mm in group O, respectively. CONCLUSIONS: Although both arthroscopic and open techniques achieved stability of the injured wrists in patients with trans-scaphoid PLFDs, it is shown that the arthroscopic-assisted technique showed a clinically meaningful better DASH score and greater flexion-extension arc with other parameters being similar. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

[Compression of the median nerve by chronic palmar dislocation of the lunate due to carpal collapse]. / Die Kompression des Nervus medianus durch ein luxiertes Mondbein aufgrund eines karpalen Kollapses.

Carpal tunnel syndrome is among the most frequently diagnosed forms of peripheral nerve compression. Carpal tunnel syndrome due to carpal collapse that had progressed over decades, with a palmarly dislocated lunate, is rare. Hints of past trauma to the wrist going back decades should prompt further radiological examination in case of recurrent median nerve compression. With sufficient preoperative evaluation, the causes can be accurately detected and treated. Therefore, precise and complete history-taking is mandatory. Conclusions on further diagnostics that can be drawn from the latter must be consistently implemented to enable adequate therapy.

Keyhole Revascularization for Treatment of Coronal Plane Fracture of the Lunate in Kienböck Disease.

Coronal plane fracture of lunate in Kienböck disease is a challenging problem with no proven treatment. We present a technique for the treatment. A vascularized bone graft from the distal radius employing the fourth and fifth extracompartmental artery pedicles is used as a mechanical support in order to enable fracture union. The technical pearls and pitfalls are described and a clinical case is presented.