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.

Kienböck's disease in 2021.

The cause of Kienböck's disease is still unclear. It was initially considered as osteomalacia, before being recognized as avascular necrosis of the lunate. Its functional prognosis is doubtful, given that the progression often leads to wrist degeneration. Conservative treatment does not provide good results in adults; thus surgery is often needed. Certain anatomical factors such as the ulnar variance, configuration of the lunate or orientation of the radial glenoid have turned out not to contribute to necrosis but may contribute to lunate fracture. The lunate's vascularization can be precarious and mostly depends on the capsular arterioles. The lunate is a very mobile bone that participates in wrist movements, both in the radiocarpal joint and especially in the mid-carpal joints during activities of daily living. Radiographs are not the only diagnostic tools. The lunate makes contact with the radius and triangular fibrocartilage complex and is often subjected to high shear loads at the edge of the radius that can cause it to fracture. MRI and arthroscopy can contribute to the assessment. Kienböck's disease is likely an inflammatory, biological venous thrombosis disorder that leads to local damage due to intraosseous compartment syndrome. The basis of surgical treatment is to decompress the lunate to shield it from shear and compression loads. Existing osteotomy procedures will be described and compared to better understand their biomechanical effects. Some osteotomies do not reduce the loads transmitted to the lunate but can reduce the risk of intra-osseous shear. Some osteotomies may place excessive pressure on the lunate on its ulnar side. Some techniques are extra-articular and preserve the capsule's vascularization along with the anatomy of the mid-carpal joint. When the lunate damage is so severe that the bone's viability is compromised, bone grafting or replacement have been proposed. The palliative techniques typically used for wrist degeneration are indicated in the terminal stages. There are currently no effective biological treatments. While the origin of Kienböck's disease is still unknown, we now know that decompression osteotomies, while they do not heal the necrosis, protect the lunate from collapse, which hopefully provides enough time for biological healing to occur.

Interdisciplinary consensus statements on imaging of scapholunate joint instability.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-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 panellists. RESULTS: Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available. CONCLUSIONS: Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability. KEY POINTS: • Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability. • Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability. • Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

Lunate loads following different osteotomies used to treat Kienböck's disease: A 3D finite element analysis.

BACKGROUND: One of most accepted principles for treating Kienböck's disease before wrist degeneration settles in is to decompress the lunate by an osteotomy. Several osteotomies have been proposed since 1935. However, they are based on biomechanical hypotheses that are sometimes conflicting: This study compares the decompression effect of radius transverse shortening, radius lateral closing and medial closing wedge osteotomies, capitate shortening - with and without hamate shortening - and a Camembert-type radius wedge osteotomy with and without ulnar head shortening according to Sennwald. METHODS: We built a 3D wrist model using finite elements that included the metacarpal, carpal and forearm bones. All wrist ligaments and Triangular Fibrocartilage Complex were incorporated in the simulation. Load was applied on the metacarpals with the forearm bones fixed. We then applied the different osteotomies to the model. FINDINGS: When load was applied to the wrist, the osteotomies that best unloaded the lunate were the capitate shortening osteotomy combined with hamate shortening and the Camembert osteotomy combined with ulna shortening; the latter was the only osteotomy that completely unloaded the lunate. INTERPRETATION: We think the association of the radius Camembert osteotomy and ulna Sennwald's shortening osteotomy is the most effective procedure to propose in Kienböck's disease.

Evaluation of Kienböck's Disease Treated by Camembert Osteotomy at Seven Years.

In Kienböck's disease, radius shortening osteotomy is the most common treatment. The Camembert procedure is a wedge osteotomy that shortens only the radius facing the lunate. Its aim is to offload the lunate by redirecting the compression stress of the grip forces toward the scaphoid. The purpose of this study was to determine if the Camembert osteotomy is effective in improving clinical symptoms and limits lunate collapse. The series include 10 patients who underwent a Camembert osteotomy for Kienböck's disease between 2002 and 2012 (one bilaterally). They are six men and four women, aged 40.6 years. Five patients had an additional ulnar shortening osteotomy if ulnar variance was neutral or positive. The mean follow-up is 7 years. Preoperatively, range of motion, grip strength, pain, and functional scores were poor. All osteotomies healed within 3 months. Extension, ulnar deviation, grip, functional scores improved significantly. In 10 cases, there were improvement in the T1 and T2 signals on the magnetic resonance imaging (MRI). There was no lunate collapse. This series shows good results with no worsening of the lunate shape. There was no ulnocarpal impingement. The Camembert osteotomy proposes to offload the lunate and redirect strains toward the scaphoid. The supposed interest is to protect the lunate from collapse. In this small series, the Camembert osteotomy improved function in patients with early stage Kienböck's disease. MRI aspects improve in most cases and no patients collapsed. Camembert can be used in combination with a Sennwald's ulnar shortening when ulnar variance is neutral or positive. Authors propose this procedure for Lichtman's stages 1-2-3A if there are no cartilage or ligament lesions. This is a Level IV, case series study.

Treatment of the distal radius fractures with percutaneous pinning: evolution to the HK2 system.

Displaced fractures of the distal radius often require reduction and fixation to improve outcome in active patients. The volar locking plate gained ground over pinning, which was the first surgical solution described. But pinning methods have since evolved with fewer complications. The authors present a clinical study of distal radius fracture fixation using the HK2 technique, where subchondral pins are connected to intra-focal pins. The results are satisfactory with a lower complication rate compared to other pinning methods. This technical improvement relaunches the pinning technique, with its two advantages, being faster and significantly cheaper than locking plates, with similar long-term functional results.

Arthroscopic Classification of the Lesions of the Dorsal Capsulo-Scapholunate Septum (DCSS) of the Wrist.

The dorsal capsulo-scapholunate septum (DCSS) is an anatomic structure linking the scapholunate ligament and the dorsal capsule of the wrist. It should be a predynamic scapholunate stabilizer. The authors, using their experience for the extrinsic ligaments testing, suggest an arthroscopic testing of the DCSS. The status could be graded in 4 stages according to the trampoline aspect and to the fiber attachment. They report a preliminary study on a series of 53 arthroscopies made between January 2014 and December 2015 with evaluation of scapholunate ligament instability and DCSS laxity. There is a significant correlation between the lesional stage of the DCSS and the arthroscopic predynamic scapholunate instability stage (P<0.01).

The role of extrinsic ligaments in maintaining carpal stability - A prospective statistical analysis of 85 arthroscopic cases.

Several biomechanical studies have shown that the scapholunate (SL) and lunotriquetral (LT) ligaments are not the only stabilizers of the proximal carpal row. However, no study has yet analyzed the range of ligament lesions leading to instability in vivo. Arthroscopy has been used to assess the condition of the wrist's extrinsic ligaments by palpating and tensioning the various ligament and capsule structures. In this prospective study, this arthroscopic method was used in 85 cases of wrist sprain without static instability to evaluate the correlation between lesions of the intrinsic and extrinsic carpal ligaments and carpal instability. In SL instability, a scapholunate interosseous ligament (SLIL) lesion was statistically correlated with lesions of the long radiolunate ligament (P<0.05). There also was a statistically significant correlation between lesions of the SLIL and the radioscaphocapitate, scaphotrapezial and dorsal intercarpal ligaments. There was a correlation between the stage of SL instability and the number of lax extrinsic ligaments (P<0.05) but not with the severity of the extrinsic ligament lesions. In LT instability, a LT interosseous ligament lesion was statistically correlated with lesions of the dorsal intercarpal ligament (P<0.05). There also was a correlation between the stage of LT instability and the number (P<0.005) and severity (P<0.001) of the extrinsic ligament lesions. Arthroscopy can reveal hidden radiographic instability and can also be used to define the number and severity of injured ligaments. In carpal instability, a lesion of one intrinsic carpal ligament was associated with a lesion of one or more extrinsic ligaments.

A systematic method of arthroscopic testing of extrinsic carpal ligaments: implication in carpal stability.

Several biomechanical studies have shown that the scapholunate and lunotriquetral ligaments are not the only stabilizers of the proximal carpal row. However, no study has yet analyzed the spectrum of ligamentous lesions in vivo, leading to instability. We describe an arthroscopic technique for evaluating the extrinsic carpal ligaments. The testing relies on visualization and palpation of different ligaments. Their integrity is assessed with a 4-stage scale. Radiocarpal arthroscopy enables assessment of the following ligaments: the radiocarpal part of the radio-scapho-capitate, the long radiolunate, the short radiolunate, the ulnolunate, the ulnotriquetral, and the dorsal radiocarpal. Midcarpal arthroscopy enables assessment of the mid part of the radio-scapho-capitate, the triquetrocapitate, the scaphotrapezial, and the dorsal intercarpal. Above assessment is proposed in addition to assessing the articular cartilage, scapholunate, and lunotriquetral ligaments. This method allows a precise arthroscopic assessment of the extrinsic ligaments of the wrist. It could give an important help in the understanding of carpal instability.

Anatomical Description of the Dorsal Capsulo-Scapholunate Septum (DCSS)-Arthroscopic Staging of Scapholunate Instability after DCSS Sectioning.

Background The dorsal capsuloligamentous scapholunate septum (DCSS) is a confluence of the dorsal capsule, the dorsal intercarpal ligament (DIC), and the scapholunate interosseous ligament (SLIOL). It appears to play a role in the stability of the scapholunate articulation. The purpose of this study was to describe the anatomical basis for this structure and to investigate its role in scapholunate instability through sectioning of this structure followed by an arthroscopic and fluoroscopic analysis. Material and Methods In the anatomical part of the study we dissected 3 fresh cadaver wrists to examine the anatomy of the DCSS. In the arthroscopic part of the study we assessed the EWAS grade of SL instability before and after sectioning the DCSS and measured the scapholunate and radiolunate angles fluoroscopically. Results Sectioning the DCSS increased the EWAS grade of SL instability but did not affect the scapholunate gap, the scapholunate angle or radiolunate angle. Conclusion We have demonstrated that there is a distinct structure that is separate from the dorsal capsule, which we have labeled the Dorsal Capsuloligamentous Scapholunate Septum. We believe that the DCSS is a previously unreported secondary stabilizer of the SL joint which may have therapeutic and prognostic implications.

Surgical technique of a radial wedge "camembert" osteotomy in Kienböck disease.

The main accepted principle to treat Kienböck disease is to decompress the lunate. Radius shortening is the most used technique. Three transverse osteotomies of the radius are described: neutral shortening osteotomy, lateral closing wedge osteotomy, and medial closing wedge osteotomy. Shortening the radius decompress the lunate and more or less the scaphoid. This deviates axial constraints toward ulna and triangular fibrocartilage complex. But the ulnar wrist is not able to support important axial constraints. The authors propose a solution to decompress only the lunate and not the scaphoid. This solution deviates axial constraints toward the scaphoid, which is naturally the most capable bone to support it. The authors describe a new radial nontransverse decompression wedge osteotomy. It allows to shorten the radius in front of the lunate. The fixation is done with a dorsal staple. To complete lunate decompression, authors propose to associate a metaphysal ulnar oblique shortening, essentially if ulnar variance is neutral or positive. The preliminar results on 10 cases are presented.

[The double-cup carpus: a demonstration of the variable geometry of the carpus]. / Le carpe à double cupule: illustration de la géométrie variable du carpe.

OBJECTIVES: The variable frontal geometry of the carpus has been known for many years, however there is no unanimity as to whether to describe the dynamic model of the carpus as comprising row or columnar functional units. The place of the scaphoid is also discussed. This study attempts to understand the organization and the composition of the functional units of the carpus. METHODS: We took radiographs of 40 normal right wrists in radial and ulnar deviation and measured the displacement in the coronal plane of each carpal bone except the pisiform. We measured the angular movements of each carpal bone compared to a vertical axis passing through the geometric centre of the carpus. This axis is parallel to the radial axis which is defined as the line joining the midpoints of the radius at 2 and 5 cm proximal to the radial articular surface. We studied the movement of each row and each column. RESULTS: Recorded angular movements were the followings: scaphoid 26 degrees, lunate 28 degrees, triquetrum 29 degrees, trapezium 44 degrees, trapezoid 50 degrees, capitate 50 degrees, hamate 56 degrees. Average angular movement within the first row is 27 degrees, within the second row is 50 degrees. Average angular movement within the radial column is 38 degrees, middle column is 39 degrees, ulnar column is 42 degrees. CONCLUSIONS: The amplitude of movement are similar for the bones of each row, and different for the bones of each column. The bones of each row tend to move together and can alone account for all movements of the wrist. The movements measured between each column are torsional intrarow movements, allowing congruence between the two rows and the glenoid surface of the radius. The scaphoid movements are superposable with those of lunate and triquetrum. Scaphoid kinematics joins the first row. Radio-ulnar deviation of the wrist is shared equally between the radiocarpal and midcarpal joints. This sharing of wrist movement between the two rows constitutes for us a double cup carpal model.