Capitate shortening osteotomy with or without vascularized bone grafting for the treatment of early stages of Kienböck's disease.

PURPOSE: The study evaluates the procedures of capitate shortening osteotomy with or without vascularized bone grafting (VBG) for the treatment of stage II or IIIA Kienböck's disease with neutral ulnar variance. METHOD: Forty-five patients with stage II (n = 21) and IIIA (n = 24) Kienböck's disease were included in the study. Patients were classified into two groups; isolated capitate shortening (ICS) group included 21 patients (stage II [n = 10] and stage IIIA [n = 11]) treated by capitate shortening without VBG of the lunate. Combined capitate shortening (CCS) group includes 24 patients (stage II [n = 11] and stage IIIA [n = 13]) who treated by capitate shortening combined with VBG of the lunate from the dorsal distal radius based on the fourth + fifth extensor compartment artery. All patients were evaluated pre- and post-operative for pain as measured by visual analogue scale score (VAS), range of motion (ROM), grip strength, modified Mayo wrist score (MMWS), lunate height index (LHI) ratio, and carpal height index (CHI) ratio. RESULTS: The mean operative time for CCS procedure was 85 min (76 to 120) and for ICS was 58 min (47 to 65). The mean follow-up period for all patients was 33 months (29 to 47). Patients with stage IIIA Kienböck's disease treated by CCS procedure had better post-operative VAS, ROM, grip strength, MMWS, LHI, and CHI ratio than patients treated by ICS procedure. ICS procedure reported 28% failure rate versus 8% for CCS. No differences were found between CCS and ICS procedures in patients with stage II Kienböck's disease in the term of clinical, radiographic outcomes, or failure rate. CONCLUSION: Using CCS procedure for the treatment of stage IIIA Kienböck's disease (lunate height collapse) with neutral ulnar variance can restore height and dimensions of the collapsed lunate and subsequently improve the final outcomes with lower failure rate. However, in patients with stage II Kienböck's disease (maintained lunate height), no advantages were noticed for CCS over ICS procedure. Lunate height index might be considered a prognostic factor for the treatment outcomes of Kienböck's disease.

Structural Versus Nonstructural Bone Grafting for the Treatment of Unstable Scaphoid Waist Nonunion Without Avascular Necrosis: A Randomized Clinical Trial.

PURPOSE: We evaluated the impact of structural versus nonstructural bone grafting on the time to union, scaphoid deformity correction, and clinical outcomes in adults with unstable scaphoid waist nonunion without avascular necrosis. We hypothesized that nonstructural grafting would provide earlier time to union, restoration of scaphoid anatomy, and equivalent clinical outcomes compared with structural grafting. METHODS: We prospectively randomized 98 patients to undergo open reduction, iliac crest bone grafting with either corticocancellous (CC group) or cancellous bone only (C-only), and internal fixation using a Herbert screw. The lateral intrascaphoid angle (LISA) and scaphoid height length ratio (HLR) were measured on wrist computed tomography scans along the scaphoid longitudinal axis before surgery and an average of 84 weeks afterward. Pain, range of motion, grip strength, and Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score were measured before surgery and an average 84 weeks afterward. RESULTS: The trajectory of scaphoid union showed a higher union rate of the C-only group at 12, 14, and 16 weeks after surgery. However, at 24 weeks after surgery, there was no difference between the groups, The union rate was 94% in patients treated with C-only and 90% with CC grafting. In patients with preoperative LISA less than 70° and/or HLR less than 0.80 (n = 53), there were no differences between the CC and C-only grafting techniques for radiographic and clinical outcomes, QuickDASH scores, and malunion rate. In patients who had preoperative LISA greater than 70° and/or HLR greater than 0.80 (n = 45), radiographic outcome measures, range of motion, and QuickDASH scores were significantly better in the CC than in the C-only group. Scaphoid malunion was observed in 9 of 22 of C-only patients (41%) and 4 of 23 of CC patients (18%). CONCLUSIONS: The severity of the scaphoid deformity may be a factor in determining the best graft type, because this may affect the rate of successful deformity correction. Corticocancellous grafting in patients who had a high degree of scaphoid deformity provided consistent deformity correction and superior QuickDASH scores. Otherwise, C-only grafting provides earlier time to union and equivalent clinical and radiographic outcomes compared with CC grafting. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Intraneural Ganglions of the Hand and Wrist.

PURPOSE: To review 15 patients who were treated for intraneural ganglions of the hand and wrist. METHODS: Between 1990 and 2012, 15 patients were treated for intraneural ganglions of the hand and wrist. There were 9 women and 6 men, averaged age 42 years. Ten patients presented with a mass and 5 with symptoms of entrapment neuropathy. The ganglions involved the ulnar nerve at the wrist in 5 patients, the dorsal branch of the ulnar nerve in 2, the superficial radial nerve in 2, a digital nerve in 4, and the dorsal branch of a digital nerve in 2. Eight patients had magnetic resonance imaging evaluations that showed cystic masses that did not confirm intraneural ganglions. In all patients diagnosis was made intraoperatively. Ganglions were treated by intraneural dissection and excision of the cyst in 10 patients, excision of the articular branch and decompression of the cyst in 4, and excision of the ganglion and the nerve in 1. RESULTS: Postoperative follow-up averaged 57 months. There were no complications or recurrences. Five patients had transient paresthesias that improved after an average of 2 months. Preoperative symptoms improved in all patients. Patients returned to normal daily and work activities at an average of 10 days. CONCLUSIONS: Intraneural ganglions should be considered in the differential diagnosis of a mass in the vicinity of a nerve. Surgical excision is usually curative but simple excision of the articular branch and decompression of the cyst seems simpler and equally effective. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Functional outcome of open reduction of chronic perilunate injuries.

PURPOSE: Perilunate injuries are complex and occasionally go unrecognized acutely. Open reduction and internal fixation is a valid treatment option for these injuries. The purpose of this study was to evaluate the functional outcome of treating chronic perilunate injuries with open reduction and internal fixation. METHODS: Between 1998 and 2007, we treated 24 patients for chronic perilunate injuries. We excluded 5 patients from this study because they underwent proximal row carpectomy or limited wrist arthrodesis. We treated the remaining 19 patients with open reduction and internal fixation. Mean time from injury to surgery was 29 weeks. All patients were men, with a mean age of 27 years. A total of 13 patients had fracture dislocations (group 1); of these, 11 were transscaphoid and 2 were transscaphoid transcapitate fracture dislocations. Six patients had perilunate dislocations (group 2). RESULTS: Postoperative follow-up averaged 58 months. All carpal fractures healed at an average of 18 weeks. At final evaluation, the average pain scores during rest, daily activities, and manual work on a 20-point visual analog scale were 0, 2, and 3, respectively, with no significant difference between groups. The active extension and flexion of the wrist averaged 39% and 52% of the uninjured side, respectively. Grip strength averaged 87% of the uninvolved extremity. According to the Mayo wrist scoring system, 58% of all patients (69% of group 1 and 33% of group 2) achieved good to excellent results. A total of 18 patients returned to their original work activities; 14 patients (74%) were very satisfied. No patients required secondary procedures. CONCLUSIONS: Despite late presentation, patients with chronic perilunate injuries can be treated with open reduction internal fixation, with satisfactory results. Patients with lesser arc injuries have less successful outcome. Patients with irreducible dislocations or major articular damage may require wrist salvage procedures.