Clinical Outcomes of Arthroscopic Ligament-Sparing Dorsal Capsulodesis for Partial Scapholunate Ligament Tear.

Introduction Various wrist arthroscopy techniques can be used in the management of scapholunate ligament (SLL) partial tears but their success has not been proven. Arthroscopic techniques including thermal shrinkage are becoming more popular in the management of partial SLL injuries. We hypothesized that arthroscopic ligament-sparing capsular tightening yields reliable and satisfactory results for the management of partial SLL tears. Methods A prospective cohort study was conducted on adult (age ≥18 years) patients with chronic partial SLL tears. All patients failed a trial of conservative management consisting of scapholunate strengthening exercises. Patients underwent an arthroscopic dorsal capsular tightening of the radiocarpal joint capsule radial to the origin of the dorsal radiocarpal ligament and proximal to the dorsal intercarpal ligament by either thermal shrinkage or dorsal capsule abrasion. Demographic data, radiological outcomes, patient-rated outcome measures and objective measures of wrist range of motion (ROM), and grip and pinch strength were recorded. Postoperative outcome scores were collected at 3, 6, 12, and 24 months. Data are reported as median and interquartile range, and comparisons were drawn between baseline and last follow-up. Clinical outcome data were analyzed using a linear mixed model method, while radiographic outcomes were assessed with nonparametric analysis with p < 0.05 indicating statistical significance. Results Twenty-three wrists (22 patients) underwent SLL treatment by thermal capsular shrinkage (19 wrists) or dorsal capsular abrasion (4 wrists). Median age at surgery was 41 years (range: 32-48) and median follow-up time was 12 months (range: 3-24). Pain significantly decreased from 62 (45-76) to 18 (7-41) and satisfaction significantly increased from 2 (0-24) to 86 (52-92). Patient-Rated Wrist and Hand Evaluation and Quick Disabilities of the Arm, Shoulder, and Hand significantly improved from 68 (38-78) to 34 (13-49) and from 48 (27-55) to 36 (4-58), respectively. Median grip and tip pinch strength significantly increased at final review. Range of movement and lateral pinch strength were satisfactory and maintained. Four patients required further surgery for ongoing pain or reinjury. All were successfully managed with partial wrist fusion or wrist denervation. Conclusion Arthroscopic ligament-sparing dorsal capsular tightening is a safe and effective treatment for partial SLL tears. Dorsal capsular tightening demonstrates good pain relief and patient satisfaction while improving patient-reported outcomes, grip strength, and maintaining ROM. Longer term studies are required to determine the longevity of these results.

Proximal Trapezoidectomy and Scaphotrapezoid Joint Tendon Interposition at the Time of Ligament Reconstruction and Tendon Interposition for Pan Trapezial Osteoarthritis Does Not Increase Proximal Carpal Row Malalignment.

Background Surgical options for osteoarthritis (OA) of the first carpometacarpal include excision, replacement arthroplasty, and arthrodesis. However, in pan trapezial OA, optimal management of residual scaphotrapezoidal articulation has remained unclear. Purpose The purpose of this study was to evaluate whether removing the proximal trapezoid from the scaphotrapezoid joint (STJ) and interposing tendon when performing a ligament reconstruction and tendon interposition (LRTI) for pan trapezial arthritis resulted in any clinical or radiographic compromise compared with LRTI alone in isolated carpometacarpal joint arthritis. Methods In a prospective consecutive cohort, 122 thumbs were selected to generate two matched cohorts and a cross-sectional review was completed at an average of 24 months (range: 5-203 months). Fifty-six thumbs had LRTI alone and 66 thumbs also had resection of the proximal portion of the trapezoid with tendon interposition in the residual gap. Results The cohorts showed no significant differences in subjective and objective outcome measures and imaging. Excision of the STJ was not associated with poorer clinical outcomes or the development of a dorsal intercalated segment instability deformity. Conclusions The management of pan trapezial arthritis with LRTI and proximal trapezoid excision and STJ interposition appears satisfactory on short- to medium-term clinical and radiographic follow-up. Level of Evidence: This is a Level III, consecutive cross-sectional cohort study.

Traumatic Nondissociative Carpal Instability: A Case Series.

PURPOSE: We report 8 cases of acute or subacute unilateral nondissociative carpal instability (CIND) in the context of nondisplaced scaphoid fractures. METHODS: Eight patients from 3 centers developed abnormal volar intercalated segment instability (VISI) or dorsal intercalated segment instability (DISI) following the diagnosis of a nondisplaced scaphoid fracture. An operative inspection in each patient confirmed intact scapholunate and lunotriquetral interosseous ligaments. We outline the demographic characteristics of our patient cohort, radiologic and operative findings of CIND-DISI and CIND-VISI, and the outcomes of acute and delayed treatment. RESULTS: Two patients were diagnosed with CIND-DISI and 6 with CIND-VISI associated with ipsilateral nondisplaced scaphoid fractures. The average time from injury to diagnosis of CIND was 11 weeks, and the mean clinical and radiographic follow-up was 18 months. Rapid healing of the scaphoid fractures was achieved in all patients (4 open reduction internal fixation, 4 cast). All patients underwent surgery to improve proximal carpal row alignment: in 3 of the 4 patients who were diagnosed and treated surgically within 12 weeks of injury, the radiolunate angle (RLA) was successfully restored. A contracture release and ligament repair or reconstruction with tendon graft 12 or more weeks following injury was unsuccessful in restoring proximal row alignment in all 4 patients. Two patients in the delayed treatment group required secondary surgery for partial fusion. CONCLUSIONS: Based on the arthroscopic, imaging, and operative findings, we propose that the ligamentous restraints to CIND-VISI are dorsal at the radiocarpal joint and volar at the midcarpal joint. Conversely, the ligamentous restraints to CIND-DISI are dorsal at the midcarpal joint and volar at both the radiocarpal and midcarpal joints. In our series, a delayed diagnosis and late reconstructive surgery were associated with no improvement in RLA. We recommend early recognition of traumatic CIND and prompt treatment of injured ligaments prior to the development of a fixed deformity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

The use of 4D-CT in assessing wrist kinematics and pathology: a narrative view.

The wrist is a complex joint involving many small bones and complicated kinematics. It has, therefore, been traditionally difficult to image and ascertain information about kinematics when making a diagnosis. Although MRI and fluoroscopy have been used, they both have limitations. Recently, there has been interest in the use of 4D-CT in imaging the wrist. This review examines the literature regarding the use of 4D-CT in imaging the wrist to assess kinematics and its ability to diagnose pathology. Some questions remain about the description of normal ranges, the most appropriate method of measuring intercarpal stability, the accuracy compared with established standards, and the place of 4D-CT in postoperative assessment. Cite this article: Bone Joint J 2019;101-B:1325-1330.

Anticipatory and Reactive Response to Falls: Muscle Synergy Activation of Forearm Muscles.

We investigated the surface electromyogram response of six forearm muscles to falls onto the outstretched hand. The extensor carpi radialis longus, extensor carpi radialis brevis, extensor carpi ulnaris, abductor pollicis longus, flexor carpi radialis and flexor carpi ulnaris muscles were sampled from eight volunteers who underwent ten self-initiated falls. All muscles initiated prior to impact. Co-contraction is the most obvious surface electromyogram feature. The predominant response is in the radial deviators. The surface electromyogram timing we recorded would appear to be a complex anticipatory response to falling modified by the effect on the forearm muscles following impact. The mitigation of the force of impact is probably more importantly through shoulder abduction and extension and elbow flexion rather than action of the forearm muscles.

Positive magnetic resonance imaging findings in the asymptomatic wrist.

BACKGROUND: Magnetic resonance imaging (MRI) is being increasingly utilized to define pathology and guide treatment in patients presenting with wrist pain. The clinical relevance of MRI identified or confirmed pathology has not been established, and the prevalence of asymptomatic MRI pathology is not known. METHODS: Twenty volunteers with no previous wrist injury or symptoms underwent bilateral MRI wrist studies in this exploratory diagnostic study. The scans were reported by an experienced musculoskeletal radiologist and an experienced wrist surgeon, with a consensus reached on each report. RESULTS: There were 3.15 positive MRI findings per wrist. There were 126 positive findings (range 1-6 per wrist). Sixty-eight ganglia were identified. Eleven ligament tears or perforations were also identified. Increased joint fluid was seen at many sites, most frequently adjacent to the piso-triquetral joint. CONCLUSION: The accuracy of MRI in identifying triangular fibrocartilage complex tears, intercarpal ligament tears and carpal bone osteonecrosis is rapidly being refined. Positive MRI findings are common and may be coincidental in patients with wrist pain. MRI findings need to be correlated closely with clinical examination and history.

Defining residual radial translation of distal radius fractures: a potential cause of distal radioulnar joint instability.

BACKGROUND: Instability of the distal radioulnar joint (DRUJ) is a complication that can occur following distal radius fracture or malunion. We have observed that residual radial translation of the distal radius, relative to the radial shaft, may be a causal factor of DRUJ instability, even once the traditional radiographic parameters (volar tilt, radial inclination, and ulnar variance) have been restored. Residual radial translation of the distal fragment may cause detensioning of the distal interosseous membrane (IOM) and pronator quadratus with poor apposition between the ulnar head and sigmoid notch. This may potentially lead to persistent instability of the ulnar head following internal fixation. Residual radial translation deformity is at risk of being overlooked by the wrist surgeon as there is no existing radiographic parameter that accurately measures this deformity. PATIENTS AND METHODS: In this study, 100 normal wrist radiographs were reviewed by three fellowship-trained orthopedic surgeons to develop a simple and reproducible technique to measure radial translation. RESULTS: Utilizing the method described, the point of intersection between the ulnar cortex of the shaft of the radius and the lunate left a mean average of 45.48% (range 25­73.68%) of the lunate remaining on the radial side. In the majority of cases more of the lunate resided ulnar to this line. High levels of agreement with inter-rater (intraclass coefficients = 0.967) and intra-rater (intraclass coefficients = 0.79) reliability was observed. CONCLUSIONS: The results of this study can be used to define a normal standard against which residual radial translation can be measured to assess the reduction of distal radius fractures. This new parameter aids in the development of surgical techniques to correct residual radial translation deformity. In addition, awareness and correction of this potential malreduction at the time of surgery may decrease the need for other procedures on the ulnar side of the wrist to improve DRUJ stability, such as ulnar styloid fixation, TFCC repair, or ligamentous grafting [corrected].

Scapholunate ligament reconstruction.

Background Scapholunate reconstruction poses a challenge to orthopedic surgeons. Materials and Methods Prospective cohort. Description of Technique Our technique for scapholunate (SL) reconstruction involves ligament reconstruction utilizing a portion of the flexor carpi radialis tendon rerouted via transosseous tunnels across the scaphoid, lunate, and triquetrum (scapholunotriquetral tenodesis). The tendon graft is secured with interference screw fixation into the triquetrum. The philosophy of this new technique is to reduce subluxation and maintain the relationship between scaphoid and lunate by placing a graft through the center of the SL articulation. This graft is then tensioned by passing it centrally through the lunate and triquetrum and secured using an interference screw in the triquetrum. Secondary stabilizers, including the dorsal intercarpal ligament, are then augmented by passing the graft back to the scaphoid, crossing from the triquetrum over the proximal capitate. This further reinforces the translational relationship between the scaphoid and the triquetrum and, therefore, augments stability of the SL articulation. Results We have utilized this technique successfully in over 40 patients since 2009. We report on a prospective consecutive series of 11 patients with over 12 months follow-up (range 12 to 24 months) demonstrating good early radiological and clinical outcomes. Conclusions In developing this technique, we aimed to take the best features of previously described techniques and address the perceived shortcomings of each. We believe there are several benefits of our technique. Moreover, few other techniques address as many of the aspects of chronic SL instability as our technique does.