Trapeziometarpal joint arthritis in the young patient.

Initial management of symptomatic trapeziometacarpal joint arthritis is generally non-operative. Though the aetiology of trapeziometacarpal arthritis remains controversial, unrecognized joint incongruity in early-stage arthritis (Eaton stage 1 or 2) is likely to lead to progression of joint degeneration. In established arthritis, salvage procedures can successfully alleviate symptoms and return of function; however the long-term outcome of these procedures has not been determined, and this is of particular concern in the younger patient. Recognition of the joint incongruity in these patients with early-stage disease can lead to measures which may prevent or delay the progression of joint degeneration.Level of evidence: V.

Ulnar-sided wrist pain: a prospective analysis of diagnostic clinical tests.

BACKGROUND: Identifying the cause of pain on the ulnar side of the wrist can be challenging. The outcome and recovery following surgery can be unpredictable. The aim of this study was to document and analyse the clinical tests used to evaluate the cause of ulnar-sided wrist pain and determine their diagnostic relevance. METHODS: This is a prospective evaluation of 110 patients who presented with pain on the ulnar side of the wrist. The clinical evaluation and results from radiological investigations were documented and analysed. RESULTS: There were 17 different diagnoses. Eighty-five percent of the diagnoses were triangular fibrocartilage complex (TFCC) injuries, ulnocarpal abutment syndrome (UCAS), pisotriquetral arthritis (PTA), triquetral fracture or non-union, distal radioulnar joint arthritis (DRUJ OA) and extensor carpi ulnaris (ECU) pathology. The ulnocarpal stress test and ulnar foveal sign were positive in several diagnoses. The ulnar foveal sign had a sensitivity and specificity of 89% and 48% for TFCC injuries, and 85% and 37% for UCAS, respectively. The sensitivity and specificity of pisotriquetral shear test for PTA was 100% and 92%, respectively. Patients with PTA or ECU pathology localised their pain better on the patient's pain localisation chart. CONCLUSION: Diagnosis of TFCC injuries, UCAS, DRUJ OA and ECU injuries are challenging as the clinical symptoms and signs for the four diagnoses were similar and required either magnetic resonance imaging or computed tomography for diagnostic confirmation after clinical examination. The ulnocarpal stress test and the ulnar foveal sign were not sufficiently specific.

Measurement of Scaphoid Bone Microarchitecture: A Computed Tomography Imaging Study and Implications for Screw Placement.

PURPOSE: High bone density and quality is associated with improved screw fixation in fracture fixation. The objective of this study was to assess bone density and quality in the proximal and distal scaphoid to determine optimum sites for placement of 2 screws in scaphoid fracture fixation. METHODS: Twenty-nine cadaveric human scaphoid specimens were harvested and scanned using micro-computed tomography. Bone density (bone volume fraction) and bone quality (relative bone surface area, trabecular number, and trabecular thickness) were evaluated in 4 quadrants within each of the proximal and distal scaphoid. RESULTS: The proximal radial quadrant of the scaphoid had significantly greater bone volume than the distal ulnar (mean difference, 33.2%) and distal volar quadrants (mean difference, 32.3%). There was a significantly greater trabecular number in the proximal radial quadrant than in the distal ulnar (mean difference, 16.7%) and in the distal volar quadrants (mean difference, 15.9%) and between the proximal ulnar and the distal ulnar quadrants (mean difference, 12%). There was a significantly greater bone surface area in the proximal radial and distal radial quadrants than in the distal ulnar and distal volar quadrants. There were no significant differences in trabecular thickness between the 8 analyzed quadrants CONCLUSIONS: Although there are differences in bone volume, trabecular number, and bone surface area between the proximal pole of the scaphoid and that of the distal pole, there were no significant differences in the bone quality (trabecular thickness, trabecular number, and relative bone surface area) and density (bone volume fraction) between the 4 quadrants of the proximal or distal pole of the cadaveric scaphoids studied. CLINICAL RELEVANCE: Insertion of 2 headless compression screws can be determined by ease of surgical access and ease of screw positioning and not by differences in bone quality or density of the proximal or distal scaphoid.

Medial Femoral Trochlea Graft for Scaphoid Waist Nonunion: A Case Report and Review of the Literature.

The medial femoral trochlea (MFT) of the knee is a donor site for convex osteochondral vascularized bone that has been used for the salvage of fractures of the proximal pole of the scaphoid. Chronic nonunited fractures of the scaphoid may lead to a sequence of degenerative change often referred to as scaphoid nonunion advance collapse. The vascularized MFT osteochondral graft has been reported as a salvage procedure for fractures of the proximal pole of the scaphoid, in situations where fixation is not an option. In this "Special review," we describe the technique of free vascularized MFT graft in a case in which the nonunited scaphoid fracture was associated with segmental loss of the articular surface of the scaphoid waist. Given the likely progression of arthritis, if left untreated, we elected to treat this by replacing the lost articular surface using a vascularized intercalary osteochondral MFT graft between the nonunited scaphoid segments.

Fixation of the Fractured Lunate in Kienböck Disease.

PURPOSE: To describe an uncommon subset of fractured lunates in Kienböck disease that is salvageable by internal fixation. METHODS: We performed a retrospective review for patients with Kienböck disease treated by internal fixation. Demographic data, objective and radiographic measurements, patient-reported outcome measures (Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation) and pain (visual analog scale) scores were collected. RESULTS: Of the 7 patients treated, 5 were available for review. At an average follow-up of 7.1 years (range, 1.5-15 years), all patients had activity-related wrist pain but were pain-free at rest. Radiographic assessment showed union in all lunates and a normal radioscaphoid angle and Stahl index. The modified carpal height ratio was reduced in 4 patients and normal in one. There was no observed narrowing or irregularity of the radiocarpal or midcarpal joints. Patient-reported outcome measures in 2 patients were unsatisfactory. CONCLUSIONS: Computed tomography of the lunate in Kienböck disease is an important investigative tool. A coronal split fracture of these lunates can be salvageable by internal fixation. Revascularization of the lunate can be performed when the fragment is of sufficient size. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

A blinded, randomized trial comparing bicolumnar arthrodesis to radioscapholunate arthrodesis in scapholunate advanced collapse II arthritis: a pilot study.

The purpose of this study was to compare the outcome of scaphoid excision with capitolunate and triquetrohamate arthrodesis (bicolumnar arthrodesis) to radioscapholunate arthrodesis in patients with scapholunate advanced collapse (SLAC) II wrist arthritis. Twelve patients with symptomatic SLAC II arthritis were recruited and randomized to receive either bicolumnar arthrodesis or radioscapholunate arthrodesis. The primary outcome was wrist function as assessed by the patient rated wrist evaluation. Secondary outcomes included range of motion, grip strength and the Mayo wrist score. A linear mixed-effects model was used to evaluate the effects of bicolumnar arthrodesis and radioscapholunate arthrodesis in treating SLAC II arthritis. Patients receiving bicolumnar arthrodesis had more improvement in their wrist function compared with patients receiving radioscapholunate arthrodesis. A high rate of re-operation was observed in patients receiving radioscapholunate arthrodesis. In SLAC II arthritis, the expected benefit of preserving the midcarpal joint was not observed. Scapholunate ligament disruption makes radioscapholunate arthrodesis a technically challenging operation. LEVEL OF EVIDENCE: I.

Osteotomy for sigmoid notch obliquity and ulnar positive variance.

Background Several causes of ulnar wrist pain have been described. One uncommon cause is ulnar carpal abutment associated with a notable distally facing sigmoid notch (reverse obliquity). Such an abnormality cannot be treated with ulnar shortening alone because it will result in incongruity of the distal radioulnar joint (DRUJ). Case Description A 23-year-old woman presented with ulnar wrist pain aggravated by forearm rotation. Ten years earlier she had sustained a distal radius fracture that was conservatively treated. Examination revealed mild tenderness at the DRUJ and decreased wrist flexion and grip strength on the affected side. Radiographic examination demonstrated 1 cm ulnar positive variance, ulnar styloid nonunion, and a 37° reverse obliquity of the sigmoid notch. The patient was treated with ulnar shortening and rotation sigmoid notch osteotomy to realign the sigmoid notch with the ulnar head. Literature Review Sigmoid notch incongruity is one of several causes of wrist pain after distal radius fracture. Traditional salvage options for DRUJ arthritis may result in loss of grip strength, painful ulnar shaft instability, or reossification and are not acceptable options in the young patient. Sigmoid notch osteotomy or osteoplasty have been described to correct the shape of the sigmoid notch in the axial plane. Clinical Relevance We report a coronal plane osteotomy of the sigmoid notch to treat reverse obliquity of the sigmoid notch associated with ulnar carpal abutment. The rotation osteotomy described is particularly useful for patients in whom a salvage procedure is not warranted.

Ligament reconstruction of the Trapezial-metacarpal joint for early arthritis: a preliminary report.

PURPOSE: To evaluate the results and determine the efficacy of an alternative ligament reconstruction technique in patients with a symptomatic trapezial-metacarpal joint associated with subluxation and early or limited chondral damage. METHODS: This retrospective, nonrandomized study was composed of 6 patients, all women with ages between 31-46 years, treated by arthroscopic evaluation and reconstruction of the intermetacarpal and reverse anterior oblique ligament of the trapezial-metacarpal joint, using a strip of flexor carpi radialis tendon. Evaluation at an average follow-up of 18 months (range,12-28 mo) consisted of interview, examination, and computed tomography. RESULTS: The visual analog pain score, preoperative rest pain, and activity pain improved significantly after surgery. Tip and lateral pinch strength measured 92% compared to the contralateral thumb, and computed tomography showed improved alignment of all joints. CONCLUSIONS: Our results indicate that ligament reconstruction using the technique described reduced pain, increased strength, and improved the trapezial-metacarpal joint alignment in patients with early symptomatic trapezial-metacarpal joint osteoarthritis associated with joint subluxation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Sigmoid notch osseous reconstruction.

The purpose of this article is to describe a technique of restoring stability or congruency to the distal radioulnar joint (DRUJ) by osteoplasty or osteotomy of the sigmoid notch, where abnormalities in the osseous anatomy have resulted in DRUJ instability. This technique addresses the osseous cause to DRUJ instability and avoids the need for complex soft tissue procedures to treat chronic volar instability or salvage procedures to treat dorsal instability of the DRUJ associated with an impacted fracture of the dorsal rim of the sigmoid notch.

Sigmoid notch osteotomy for posttraumatic dorsal dislocation of the distal radioulnar joint: A case report.

Instability of the distal radioulnar joint (DRUJ) is associated most commonly with injury to the soft-tissue restraints of that joint, particularly the triangular fibrocartilage complex. The dorsal rim of the sigmoid notch, however, also plays an important role as a bony restraint to dorsal subluxation. We report a case of posttraumatic dorsal dislocation of the DRUJ associated with a depressed fracture of the dorsal rim of the sigmoid notch. This was treated with soft-tissue release and corrective osteotomy of the dorsal rim of the sigmoid notch to restore DRUJ stability and congruency.

Chondrocyte apoptosis in response to dislocation of the hip in the rat model.

BACKGROUND: Joint dislocation is a traumatic event that can lead to osteoarthritis. The purpose of this paper is to study cartilage changes following prolonged joint dislocation for 1, 2 or 8 h. METHODS: Sprague-Dawley rats (n = 27) were used in this study. Surgical dislocation of the hip under anaesthesia was carried out on the animals. The joints remained dislocated for 1, 2 or 8 h. The joints were subsequently harvested and terminal deoxnucleotidyl transferase-mediated dUTP nick-end labelling testing was carried out to show chondrocyte apoptosis in the femoral head and acetabulum. Using this test, the apoptotic index, which is the proportion of apoptotic chondrocytes to total number of chondrocytes, was calculated. A comparison of apoptotic indices was made among the three groups. RESULTS: The mean apoptotic indices for the femoral head for the 1-, 2- and 8-h groups were 0.065 +/- 0.025, 0.162 +/- 0.031 and 0.201 +/- 0.030, respectively. There was a significant difference (P < 0.05) in the mean apoptotic indices between each of the three groups. For the acetabulum, the mean apoptotic indices were 0.046 +/- 0.012, 0.051 +/- 0.023 and 0.057 +/- 0.031 for the 1-, 2- and 8-h groups, respectively. There was no significant difference (P > 0.05) between each of the three groups. CONCLUSIONS: Dislocation of a joint causes chondrocyte apoptosis. There is a progressive increase in the apoptotic index with prolonged dislocation of the rat hip.

Scaphotrapezial joint arthroscopy: a palmar portal.

PURPOSE: Arthroscopy of the scaphotrapezial trapezoid (STT) joint is performed traditionally through a dorsal radial midcarpal portal. This portal allows visualization of the dorsal rim of the STT joint but is difficult to approach owing to lack of surface landmarks and it passes close to the radial artery and nerve. The purpose of this study was to assess the safety, ease of access, and visualization of the STT joint through a palmar portal. METHODS: Five cadaveric wrists were dissected initially to identify the anatomy around the palmar aspect of the STT joint and to identify a safe route for an arthroscopic portal. A further 5 cadaveric wrists then were used to confirm the efficacy of the portal. RESULTS: A palmar portal to the STT joint can be established 3 mm ulnar to the abductor pollicis longus tendon, 6 mm radial to the scaphoid tubercle, and midway between the radial styloid and base of the first metacarpal. CONCLUSIONS: A palmar arthroscopic portal to the STT joint can be identified readily because of the palpable surface landmarks, improves the visualization of its articular surface compared with a dorsal portal because of the orientation of the joint, is safe, and provides a second portal through which therapeutic interventions may be considered.