Description of WALANT technique in open bone and ligament wrist surgery.

The gold-standard for bone, ligament and joint surgery in the wrist is locoregional anesthesia in most countries. Wide-Awake Local Anesthesia No Tourniquet (WALANT) is commonly used for simple soft-tissue hand surgery procedures such as carpal tunnel or trigger finger release, and can now also be safely used in procedures such as proximal row carpectomy, scapholunate ligament repair or partial wrist fusion, to name but a few. This article describes the use of WALANT for complex surgery in the wrist. WALANT surgery offers many known benefits, such as enhanced patient safety and comfort, simplified perioperative process and avoidance of anesthesia-related risks, and also allows the surgeon to perform intraoperative testing of the repaired structures. Thus, the surgeon can tailor the rehabilitation program and shorten recovery time. We describe detailed guidelines for performing WALANT procedures safely and effectively, making it a favorable option for complex surgeries in the wrist.

Radiolunate arthrodesis and scaphoidectomy combined to Sauvé-Kapandji procedure as treatment of wrist osteoarthritis: Clinical and radiological results.

OBJECTIVE: The aim of this study was to analyze clinical and radiological results for 1-stage radiolunate arthrodesis and scaphoidectomy associated to the Sauvé-Kapandji procedure, to alleviate pain and conserve wrist motion. METHODS: Seven patients (8 wrists) with symptomatic osteoarthritis of the radiolunate and distal radioulnar joints were treated from 1999 to 2016. Mean age at surgery was 49 years and M/F sex ratio was 6/1. Etiologies were distal radial intra-articular malunion for 6 patients and bilateral gouty arthritis for 1. The procedure was performed by a dorsal approach in a single step. Pain was assessed on visual analogue scale (VAS). Pre- and post-operative active flexion-extension and pronation-supination were compared. The secondary endpoint was onset of postoperative complications. RESULTS: At a mean 71 months' follow-up (range, 30-168 months), there was significant reduction in pain (VAS, 0.5/10; p < 0.0001). Motion results were satisfactory, with 32° flexion, 39° extension, for a non-significant decrease of 11° and 5° respectively; pronation and supination were significantly increased, by a mean 23° and 30° respectively. Three wrists (37.5%) required a second surgery. There were no cases of surgical site infection or non-union. CONCLUSION: Radiolunate arthrodesis and scaphoidectomy combined to Sauvé-Kapandji procedure was an effective solution for the treatment of symptomatic radiolunate and distal radioulnar osteoarthritis. LEVEL OF EVIDENCE: IV.

Osteoid osteoma of the wrist: Recent advances.

Osteoid osteoma is a benign bone tumor usually arising in the diaphysis and metaphysis of the long bones, with male predominance (sex ratio, 2:1). Despite being the most common bone tumor in the wrist, it is still an atypical location for this lesion. The usual presentation is pain that is exacerbated at night and relieved by aspirin or non-steroidal anti-inflammatory drugs. This presentation is not always the case in the wrist, which leads to numerous differential diagnoses and often a delay in definitive diagnosis and treatment. Various imaging modalities can confirm the presence of the tumor and guide the surgical approach. Resection is the gold-standard, with radiofrequency gaining popularity in recent years.

Proximal row carpectomy versus four-corner arthrodesis in the treatment of SLAC and SNAC wrist: meta-analysis and literature review.

A systematic literature review was performed on 84 articles from 2000 to 2020 on proximal row carpectomy (PRC) or four-corner arthrodesis (FCA) in patients with posttraumatic wrist osteoarthritis. Qualitative assessment was conducted on 14 articles. Pain, range of motion (ROM), grip strength and complications were analyzed using weighted average means. Meta-analysis with a random effects model was performed for the flexion-extension arc and grip strength. A total of 1,066 PRCs and 2,771 FCAs were analyzed, with a mean follow-up of 9 and 7 years respectively. Mean flexion after PRC and FCA respectively was 36.2 ° and 31.1 °, mean extension 41.4 ° and 32.4 °, and mean grip strength 26.4 kg and 27.5 kg. PRC had a larger flexion-extension arc than FCA, with a standard mean difference (SMD) of 0.41 (range, 0.02-0.81). No significant difference was found for grip strength. Osteoarthritis occurred in 42.2% of PRC cases, independently of capitate shape. Conversion to wrist arthrodesis was performed in 10.1% of failed PRCs. Revision was chosen in 4.7% of FCAs and conversion to wrist arthrodesis in 4.6%. We conclude that the functional results of both techniques are similar, but prefer PRC to FCA because of the lower complications rate.

Tenosynovial chondromatosis of the wrist: A case report.

We report the case of an 80-year-old woman who presented with an asymptomatic slowly growing mass in the dorsal aspect of her right wrist. Radiographs revealed a snail-shaped radiopaque structure. Surgical exploration and excision revealed a calcified lesion over the extensor digitorum communis. Histopathological analysis confirmed the diagnosis of tenosynovial chondromatosis. At the last follow-up, four years after surgery, the patient was asymptomatic and free of recurrence. Practitioners and hand surgeons should be aware of the dorsal involvement and evocative radiological calcifications of tenosynovial chondromatosis, which is a rare benign soft tissue neoplasm that affects all tendon sheaths of the hand.

Symptomatic bifid insertion of the Flexor Carpi Radialis Brevis.

A 35 year-old right-handed female presented with persistent wrist pain lasting two years. Imaging disclosed an accessory tendon-shaped structure, identified as a Flexor Carpi Radialis Brevis, strangling the Flexor Carpi Radialis tendon at the wrist during effort. Surgical exploration found the insertion of the Flexor Carpi Radialis Brevis to be bifid. Resection of the stenosing branch and the fibrotic tendon sheath restored strength in the right wrist and painless symmetrical motion compared to the left wrist ten weeks postoperatively.

Intercarpal arthrodesis: A systematic review.

Intercarpal arthrodesis is a well-established option to treat various disorders of the carpus, such as localized osteoarthritis, carpal instability, and Kienböck's disease. This is a non-conservative procedure aimed at obtaining a stable and congruent interface between the radius and the proximal carpal row, which restores wrist function by minimizing pain and restoring grip strength. These procedures generally yield good predictable results that are maintained over time. However, all intracarpal arthrodesis procedures cause a loss of wrist range of motion. To optimize outcomes and minimize complications, especially nonunion, this surgery may require a learning curve. A precise surgical technique for preparing the bone surfaces, bringing enough bone graft, and using reliable fixation is essential. Since the late 1960s, several intracarpal arthrodesis procedures have been described. Commonly used fusions target the scaphotrapeziotrapezoid, scaphocapitate, four corners, capitolunate or capitohamatolunate regions. Lesser used fusions focus on specific lesions such as the scapholunate, scapholunocapitate, lunotriquetral and triquetrohamate. Here, we propose a systematic review of the various types of intercarpal arthrodesis procedures described in the literature. After having described each arthrodesis, we specify their indications, the variations of the surgical techniques, and then present an overview of the results and complications. Finally, we discuss how these surgeries affect wrist biomechanics. LEVEL OF EVIDENCE: III.

Denervation of the thumb carpometacarpal joint for symptomatic osteoarthritis in 46 patients.

We investigated the effect of an extended denervation procedure in the thumb carpometacarpal (CMC) joint in patients suffering from CMC osteoarthritis. Between 2006 and 2018, 46 patients underwent the procedure in our clinic and were included in this retrospective study. Pain, strength, range of motion, DASH score, complications and overall satisfaction were determined. Assessment showed a significant decrease in pain and excellent physical function at a median 5 years' follow-up. Twelve patients needed secondary surgery due to persistent pain. Overall, 28 of the 46 patients were satisfied with the results of the denervation. Even though the results of CMC denervation are poorer than with simple trapeziectomy, considerable pain relief can be achieved in selected young, physically active patients by exclusively soft-tissue surgery, conserving the biomechanical properties of the joint. In case of failure of the procedure, all other options remain available.

3D-planned corrective osteotomy of metacarpal arch disruption after Motec® wrist prosthesis.

We report two cases of metacarpal arch disruption after Motec® total wrist arthroplasty, with hyperextension of the third metacarpal and dorsal protrusion of the head. Correction osteotomies of the adjacent metacarpals using preoperative 3D surgical planning were successful. This report seeks to shed light on the origin of this deformation and to recommend some operative precautions. It is important that surgeons should be aware of the existence of this complication, as disruption of the transverse metacarpal arch affects both grasp and hand esthetics. LEVEL OF EVIDENCE: IV.

Factors affecting contralateral wrist surgery after one carpal tunnel release in bilateral carpal tunnel syndrome.

Carpal tunnel syndrome (CTS) can be bilateral, with varying incidence. Carpal tunnel release (CTR) in one wrist may relieve the symptoms of the contralateral wrist, avoiding the need for second surgery; conversely, the symptoms may persist or worsen, requiring contralateral surgery in some cases. The present study investigated whether surgical treatment was finally required for the non-operated CTS wrist, and in what cases non-operative treatment was possible. We compared baseline characteristics, risk factors and electrodiagnostic data between CTS patients who underwent only unilateral CTR and those who subsequently underwent bilateral surgery at various time intervals. This single-center retrospective study included 188 patients with bilateral CTS managed between 2010 and 2020; 137 patients (group 1, 73%) underwent only unilateral CTR, and 51 (group 2, 27%) subsequently underwent contralateral CTR. In group 1, contralateral CTS symptoms were assessed in 4 categories and compared to the presenting symptoms in the index wrist. There were no significant differences in age, gender, preoperative symptom duration, body status, addictive behavior, electrodiagnostic study or comorbidities, other than a higher rate of dialysis in group 2. The contralateral wrist showed partial or complete symptom relief in 57% of patients undergoing unilateral CTR. High BMI and history of diabetes were risk factors for persistent severe CTS or subsequent contralateral CTR.

Long-term functional outcomes after total wrist arthrodesis.

Current literature surrounding functional outcomes after total wrist arthrodesis is limited by short follow-up or limited use of validated patient reported outcome measures (PROMs). The primary aim of this study was to describe long-term functional outcomes following wrist arthrodesis. Secondary aims were to describe the incidence of complications and patient satisfaction. This was a retrospective single-center study. Patients with a minimum of 10-year follow-up completed a questionnaire including the Patient-Rated Wrist Evaluation (PRWE), the Quick version of the Disabilities of the Arm, Shoulder and Hand (Quick-DASH) score, the EQ-5D-5L score, and a question assessing satisfaction. Presence of a complication was also assessed. During the study period 66 patients underwent total arthrodesis. At a median follow-up of 15 years, complete patient reported outcomes were available for 34 patients. Thirty-two patients were lost to follow-up. Mean age at surgery was 49 and 16 patients were female. Mean PRWE and Quick-DASH scores were 44.8 (SD 27.7; range 0-96) and 41.9 (SD 23.6; range 2.3-97.7) respectively. Twenty-eight patients were satisfied. Nine patients reported complications. There were six cases of hardware removal and two cases of prominent metalwork. One patient underwent revision surgery for non-union. Presence of a complication did not affect the Quick-DASH or PRWE scores. Median EQ-5D-5L score was 0.7. This long-term follow-up suggests high levels of patient satisfaction and health related quality of life, despite significant functional disability. The complication rates are not insignificant, although the presence of a complication did not affect functional outcomes.

Results of isolated ulnar shaft shortening osteotomy in the treatment of idiopathic ulnocarpal impaction syndrome.

The objective of this study was to evaluate the results of isolated ulnar shaft shortening osteotomy (USSO) in the treatment of idiopathic ulnocarpal impingement syndrome. This was a two-center retrospective study. All patients older than 18 years who underwent isolated USSO for idiopathic ulnocarpal impingement syndrome between 2006 and 2016 were included. The outcome measures were: patient satisfaction, decrease in pain intensity, change in occupation, QuickDASH and PRWE functional scores, secondary palliative surgery suggesting failure of the ulnar shaft shortening osteotomy, and postoperative ulnar variance. The main complications were analyzed. Thirty-one patients were included. Twenty-six (84%) were satisfied with the procedure. At an average follow-up of 62 months, there was no secondary palliative surgery. Mean pain intensity on VAS was 7/10 (range, 2-10) and 1.7/10 (range, 0-6) preoperatively and postoperatively, respectively, for a mean decrease of 5.3 ± 2.6 points; this decrease was statistically significant (p < 0.001). None of the manual workers had to alter their work. Mean postoperative QuickDASH score was 19.6/100 (range, 0-79.55) and mean postoperative PRWE score was 23/100 (range, 1-85). Mean postoperative ulnar variance was -0.5 mm. As for complications, 61% of patients (n = 19/31) had discomfort related to the plate; 9.7% (n = 3/31) had distal radioulnar osteoarthritis; 4% (n = 1/19) had a fracture after hardware removal; 13% (n = 4/31) had non-union. Despite a high rate of complications, the study confirmed the effectiveness, in terms of pain, of isolated USSO in the treatment of idiopathic ulnocarpal impingement syndrome. LEVEL OF EVIDENCE: IV; retrospective cohort.

Anatomical and radiological description of ligament insertions on the radial aspect of the scaphoid bone.

Anatomical studies on the radial side of the scaphoid mention inter-ligamentous connections, but without detailed description of their relations to one another. The purpose of this study was to provide an anatomical and radiological description of the ligamentous structure on the radial side of the scaphoid. High-field 3-Tesla 3D MRI scans of 7 cadaveric formaldehyde-fixed wrists were performed to assess the presence and location of each ligament. Dissection was performed in 10 wrists under microscopy on the radial side to assess the dimensions, anatomical variations and angles between ligaments in various wrist positions during in intracarpal pronation/supination, flexion/extension and ulnar/radial deviation. This study confirmed that the same ligament configuration was found on MRI and on dissection. The scaphotrapezial ligament, dorsal intercarpal ligament and radial collateral ligament fibers merge along the dorsal ridge of the scaphoid. The fibers of the radial collateral and radioscaphocapitate ligaments could be distinguished in only 4/10 specimens. Wrist position changes from intracarpal pronation to supination produced major changes in angle between the scaphotrapezial and dorsal intercarpal ligaments, while other position changes affected this angle only slightly. 3D MRI sequences allow these structures to be systematically analyzed in case of scapholunate instability. Further studies should be conducted to assess the biomechanical properties of these ligaments and the clinical consequences of isolated injury in this region.

Repair of the dorsal capsuloligamentous scapholunate septum during arthroscopic resection of painful dorsal wrist ganglion cyst: Comparative analysis of two techniques.

We compared arthroscopic cyst resection (ACR) of dorsal ganglia of the wrist, either associated to reconstruction of the dorsal capsuloligamentous scapholunate septum (ACR-DCSS) in 66 cases in which the ganglia were painful on exertion, or isolated ACR in 15 pain-free cases. A single-center retrospective study analyzed data for the period April 2013 to May 2021. The main aim was to compare pre- and post-operative functional results (pain at rest (on a numerical rating scale: NRS), pain under effort (NRS), range of motion (°), grip strength (kg)) and recurrence rate between the two techniques. The study hypothesis was that DCSS repair improves recurrence of dorsal ganglion cyst and functional outcome. The ACR-DCSS group showed significant improvement in extension, pronation, supination, radial inclination, ulnar inclination, grip strength, pain at rest and pain on exertion. The ACR group showed significant improvement in pronation, ulnar inclination and pain on exertion. There was a significant difference in recurrence rate, in favor of ACR-DCSS. Recovery was also significantly better for the ACR-DCSS group in terms of extension, supination and pain at rest. Arthroscopic treatment of wrist ganglion cyst is a reliable, minimally invasive and reproducible technique that produces good results in terms of pain and recovery of range of motion, with significantly lower recurrence rate in case of DCSS repair. Level of evidence: Therapeutic III.

Complications of Scheker semiconstrained distal radioulnar joint arthroplasty in a low-volume unit.

Semiconstrained arthroplasty of the distal radioulnar joint (DRUJ) (Scheker prosthesis, Aptis Medical, Glenview, KY, USA) is a treatment option in case of irreparable destruction of the DRUJ. In our unit, a Scheker endoprosthesis was implanted in 5 wrists in 4 patients. 3/5 wrists (60%) in 3/4 patients (75%) underwent revision surgery. Reasons for revision surgery were implant loosening, periprosthetic fracture of the radius and suspicion of periprosthetic infection. Asymptomatic loosening of the screw of the radial head cover was detected in one wrist. Scheker arthroplasty is technically demanding. The prosthesis is prone to failure over the long term. Before implantation, all patients should be informed of the high risk of revision surgery.

Hamatolunate impingement syndrome in golfers: results of arthroscopic burring of the apex of the hamate.

Hamatolunate impingement syndrome is an uncommon cause of ulnar-sided wrist pain in the general population. Often misdiagnosed and untreated by non-specialized physicians, it is an important source of chronic ulnar wrist pain in golfers. The purpose of this retrospective study was to report results of arthroscopic burring of the apex of the hamate for hamatolunate impingement, whether isolated or not, in golf players, with a minimum of six months follow-up. Fifteen golf players (10 amateur, 2 semi-professional and 3 professional players), aged 40-61 years, with ulnar carpal pain implicating hamatolunate impingement with Viegas type-II carpal configuration, were included. Treatment consisted in arthroscopic burring of the apex of the hamate. At an average follow-up of 11 months (range, 6-24 months), all patients were satisfied with functional results, except 1 with persistent pain and stiffness; 93% returned to sport to their prior level. Mean range of motion was improved by 17 ° for wrist flexion (range, 15 ° to 30 °) and 15 ° for wrist extension (range, 10 ° to 25 °). All patients except 1 recovered grip strength, improving from 27 kg (range, 12-53) preoperatively to 35 kg (range, 17-61) at last-follow-up, and ulnar-sided pain was alleviated during golf practice. Return to prior sport level was possible by 5.5 months for professional players and by 9 months for amateurs. Arthroscopic burring of the apex of the hamate provided good clinical results for function and pain, with fairly rapid return to sport. Hamatolunate chondritis does not always mean pathology but represents the natural progression of Viegas type II wrists.

Comparison of outcome between operative treatment and constraint-induced movement therapy for forearm and wrist deformities in cerebral palsy. A randomized controlled trial.

Several treatment strategies for upper extremity deformities in cerebral palsy have been studied for their effectiveness in terms of function and quality of life. There are a few comparative studies between nonoperative and operative management for upper extremity deformities. This study aimed to compare the outcomes between conservative methods using constraint-induced movement therapy (CIMT) and operative methods using pronator teres rerouting, flexor carpi ulnaris transfer to extensor carpi radialis brevis (FCU transfer to ECRB) and fractional lengthening in cerebral palsy patients with forearm pronation and wrist flexion contracture. A total of 19 participants aged 7-15 years were randomized to either CIMT or surgery. The primary endpoint was changes in Shriners Hospital Upper Extremity Evaluation (SHUEE) functional score. Secondary endpoints comprised range of motion, Volkmann's angle, and the Pediatric Outcomes Data Collection Instrument (PODCI). At 1-year follow-up, there was no significant difference between the nonoperative and operative groups in any SHUEE dimensions, range of motion or PODCI. However, there was significant improvement in Volkmann's angle in the operative group compared to the CIMT group: CIMT = 11.11 ± 9.92, surgery = -13.00 ± 4.72: p = 0.04 (95% CI = 1.68-46.54). Operative treatment provided more improvement in wrist posture, represented by Volkmann's angle, in cerebral palsy patients. However, SHUEE, range of motions and PODCI were comparable between the CIMT and operative groups.

Evaluation of the validity and reliability of the KFORCE Sens® electrogoniometer in evaluation of wrist proprioception.

The aim of this study was to determine the validity and reliability of the KFORCE Sens® electrogoniometer in the evaluation of wrist proprioception. Wrist position sense was assessed on a Baseline® 360° universal goniometer and a KFORCE Sens® device. The validity and reliability of the KFORCE Sens® device for wrist position sense evaluation were investigated by comparing the two data sets. Fifty-three healthy volunteers (39 female, 14 male) with a mean age of 22.83 ± 1.28 years (range, 21-27 years) were included. Joint position sense test-retest reliability (intra-class correlation coefficient) on KFORCE Sens® was "very good" for all wrist movements. There was a very strong correlation between flexion-extension movements on the dominant side (r = 0.955), and a strong correlation between ulnar-radial deviation movements (r = 0.745). There was also a very strong (r = 0.863) correlation between flexion-extension movements on the non-dominant side and a strong correlation (r = 0.690) between ulnar-radial deviation movements (p < 0.05). Our results showed that the KFORCE Sens® device was a valid and reliable evaluation means of assessing wrist position sense.

Wrist shortening arthrodesis with volar plate in a dorsal position for spastic wrist contracture.

Total wrist arthrodesis in severe wrist flexion deformities (greater than 60°) due to spasticity represents a valid therapeutic option. It aims to improve the hand's appearance, hygiene, function and to prevent the deformity from getting worse. The objective of this study is to evaluate the clinical and anatomical results of wrist shortening arthrodesis using a classic volar plate in the dorsal position in functional surgery for central spastic hands. We conducted a single-center analysis of a series of patients who underwent this shortening arthrodesis. The review at a minimum 1-year follow-up included a clinical evaluation (House score, INOM score, patient satisfaction and complications), and anatomical evaluation (arthrodesis position, bone healing and carpometacarpal arthropathy). Twenty-eight patients with a mean age of 40.6 years (18-74) were included at a mean follow-up of 30.6 months (12-75). The fusion rate was 100%. No carpometacarpal arthropathy was noted. The mean position of the fused wrist was 11° extension and 15° ulnar tilt. There were two complications (7%): one postoperative hematoma and one case of discomfort due to impingement that required plate removal. The House score was significantly improved postoperatively (2.4 (0-5) versus 1.8 (0-4), p < 0.001), as was the INOM score (45 (12-64) versus 63 (36-84), p < 0.001). The patient satisfaction rate was 93%. The use of a simple and common material (volar plate in dorsal position) during this challenging surgery (spastic wrist contracture), provides good anatomical results and high patient satisfaction. LEVEL OF EVIDENCE: Level 4, case series, therapeutic study.