Joint-sparing arthroscopic management of avascular necrosis of the capitate.

Avascular necrosis of the proximal pole of the capitate is an exceedingly rare pathology with few therapeutic solutions. The largest published series concerned a cohort of 6 cases over 10 years. The present case concerns our experience with avascular necrosis of the capitate in a 20-year-old woman. Due to her age and high functional demand, we opted for a minimally invasive solution using arthroscopy. We performed an X-shaped palmaris longus tendon interposition arthroplasty at the midcarpal joint between the capitate and the lunate. We here report 2 years' follow-up.

Effectiveness of early versus delayed motion in patients with distal radius fracture treated with volar locking plate: A systematic review and meta-analysis.

The aim of this study was to determine the effectiveness of early versus delayed motion on the functional outcomes in patients with distal radius fracture (DRF) treated with a volar locking plate. A systematic review and meta-analysis of randomized clinical trials was performed. An electronic search was performed in the Medline, Central, Embase, PEDro, Lilacs, Cinahl, SPORTDiscus, and Web of Science databases. The eligibility criteria included randomized clinical trials that compared the effect of early versus delayed motion on wrist and/or upper limb function, pain, grip strength, and wrist range of motion in subjects older than 18 years with DRF treated with a volar locking plate. Five clinical trials were included that met the eligibility criteria for the quantitative synthesis. At 6 weeks, the PRWE questionnaire showed a mean difference (MD) of -10.6 points (p < 0.001), the MD was -11.1 points for the DASH questionnaire (p < 0.001), -0.56 cm for pain on VAS (p = 0.01), 5.0 kg for grip strength (p = 0.01), 12.5 degrees for wrist flexion (p = 0.07), and 12.8 degrees for wrist extension (p = 0.05). All differences favored the early motion treatment. At 3 months of follow-up, only the DASH, pain on VAS, and grip strength showed significant differences in favor of early motion. At 1 year of follow-up, none of the variables studied were different between groups. In the short term, there was moderate to high evidence of clinically and statistically significant differences in the functional outcomes in favor of early versus delayed motion in patients with DRF treated with a volar locking plate. But these differences were not observed at 1 year of follow-up. PROSPERO registration no.: CRD42020158706.

COVID-19: Initial experience of an international group of hand surgeons.

The emergence of the COVID-19 pandemic has severely affected medical treatment protocols throughout the world. While the pandemic does not affect hand surgeons at first glance, they have a role to play. The purpose of this study was to describe the different measures that have been put in place in response to the COVID-19 pandemic by hand surgeons throughout the world. The survey comprised 47 surgeons working in 34 countries who responded to an online questionnaire. We found that the protocols varied in terms of visitors, health professionals in the operating room, patient waiting areas, wards and emergency rooms. Based on these preliminary findings, an international consensus on hand surgery practices for the current viral pandemic, and future ones, needs to be built rapidly.

Indications, techniques, and outcomes of arthroscopic repair of scapholunate ligament and triangular fibrocartilage complex.

This review includes updated understanding of the roles of intrinsic and extrinsic carpal ligaments in scapholunate instability and details the author's experience of indications, arthroscopic repair methods, and outcomes of treating the instability. A classification on triangular fibrocartilage complex injuries is reviewed, followed by author's indications, methods, and outcomes of arthroscopic repair of triangular fibrocartilage complex injuries.

Treatment of dynamic scapholunate instability dissociation: Contribution of arthroscopy.

Scapholunate (SL) ligament injuries generally result from trauma to an extended, supinated wrist, leading to chronic instability that progresses toward osteoarthritis. They can occur together with distal radius fracture. These injuries can be difficult to diagnose, especially early on. Treating chronic SL ligament injuries before the onset of osteoarthritis is still a challenge for surgeons. Until recently, the recommended treatments consisted of open SL ligament reconstruction or repair procedures that reduce pain and improve pinch strength but also lead to wrist stiffness. The introduction of arthroscopy has completely changed our understanding of these injuries and how to treat them. We review here the treatment approach through the eyes of three specific groups of surgeons: the "pioneers" who first analyzed these injuries; the "specialists" who explored various stabilization techniques to compensate for the torn SL ligament; and the most recent group, the "anatomists" who, based on recent arthroscopy findings, sought to reconstruct the anatomical structures as accurately as possible and who developed the concept of the SL complex.

Assessment of the structures at risk during wrist arthroscopy: a cadaveric study and systematic review.

UNLABELLED: We assessed the proximity of neurological structures to arthroscopic portals in a cadaveric study and through a systematic review. Arthroscopy was performed on ten cadaveric wrists. Subsequently the specimens were dissected to isolate the superficial branch of the radial nerve, the dorsal branch of the ulnar nerve, the posterior interosseous nerve and the extensor tendons. We measured the distances from the nerves to common portals. For the systematic review Pubmed and EMBASE were searched on the 31 May 2014 for cadaveric studies reporting the proximity of neurological structures to any arthroscopic wrist portal. In the cadaveric study, partial injuries were seen to six extensor tendons and one posterior interosseous nerve; it was assumed this was due to creation of the portals. Seven published studies were included in the systematic review. The dorsal sensory branch of the ulnar nerve was found to be at risk by performing the 6 Ulnar, 6 Radial and ulnar midcarpal portals, the sensory branch of the radial nerve by the 1-2 and 3-4 portals and the posterior interosseous nerve by the 3-4 and 4-5 portals. LEVEL OF EVIDENCE: V.

Education in wrist arthroscopy: past, present and future.

PURPOSE: Arthroscopy has assumed an important place in wrist surgery. It requires specific operative skills that are now mainly acquired in the operating room. In other fields of endoscopic surgery, e-learning and virtual reality (VR) have introduced new perspectives in teaching skills. This leads to the following research question: Could the current way of teaching wrist arthroscopy skills be supported using new educational media, such as e-learning and simulator training? METHOD: The literature was searched for available methods of teaching endoscopic skills. Articles were assessed on the evidence of validity. In addition, a survey was sent to all members of the European Wrist Arthroscopy Society (EWAS) to find out whether hand surgeons express a need to embrace modern educational tools such as e-learning or simulators for training of wrist arthroscopy skills. RESULTS: This study shows that the current way of teaching wrist arthroscopy skills can be supported using new educational media, such as e-learning and simulator training. Literature indicates that e-learning can be a valuable tool for teaching basic knowledge of arthroscopy and supports the hypothesis that the use of virtual reality and simulators in training enhances operative skills in surgical trainees. This survey indicates that 55 out of 65 respondents feel that an e-learning program would be a valuable asset and 62 out of the 65 respondents are positive on the additional value of wrist arthroscopy simulator in training. CONCLUSION: Study results support the need and relevance to strengthen current training of wrist arthroscopy using e-learning and simulator training. LEVEL OF EVIDENCE: V.

Development and validation of a computer-based learning module for wrist arthroscopy.

The objective of this study was to develop and validate a computer-based module for wrist arthroscopy to which a group of experts could consent. The need for such a module was assessed with members of the European Wrist Arthroscopy Society (EWAS). The computer-based module was developed through several rounds of consulting experts on the content. The module's learning enhancement was tested in a randomized controlled trial with 28 medical students who were assigned to the computer-based module group or lecture group. The design process led to a useful tool, which is supported by a panel of experts. Although the computer based module did not enhance learning, the participants did find the module more pleasant to use. Developing learning tools such as this computer-based module can improve the teaching of wrist arthroscopy skills.

Vascularized bone graft pedicled on the volar carpal artery from the volar distal radius as primary procedure for scaphoid non-union.

INTRODUCTION: The treatment of scaphoid non-union with non-vascularized bone graft leads to non-union in 10 to 20% of cases and up to 50% in case of proximal pole necrosis. Vascularized bone graft improves consolidation rates, but is generally restricted to secondary scaphoid non-union. HYPOTHESIS: This study assessed the value of a primary vascularized bone graft pedicled on the transverse volar carpal artery from the volar aspect of the distal radius as donor site. PATIENTS AND METHODS: This retrospective study included 111 cases of vascularized bone graft for scaphoid non-union as primary procedure in 73 cases and secondarily in 38. The procedures were performed through a single incision. RESULTS: Mean delay before surgery was 25.5 and 33 months respectively, with union rates of 96% and 89.5%. Results showed improvement in both groups, but were better in primary surgery in terms of range of motion, strength, pain, function, satisfaction and return to work. There were more complications with secondary surgery. DISCUSSION: All reports agree that union is better with vascularized bone graft. This technique performed as a day of admission surgery through a single incision under locoregional anesthesia seems feasible as a primary intervention.

Arthroscopic treatment of scaphotrapeziotrapezoid osteoarthritis.

Scaphotrapeziotrapezoid (STT) joint osteoarthritis accounts for 13% of all wrist arthritis cases. The arthroscopic treatment combines radial midcarpal portal and STT portal called 1-2 midcarpal portal. We performed 13 isolated resections from the scaphoid distal pole. Patients were only women (average age, 58 years). Pain, mobility, and muscular strength improved significantly. At the same time, we fitted an interposition pyrocarbon implant after resection in 13 patients (average age, 67 years). We had 2 implant dislocations due to technical errors. Outcome quality optimized by the initial mini-invasive approach and arthroscopy should make selection of some treatment indications possible.

Arthroscopic interposition arthroplasty of the trapeziometacarpal joint.

PURPOSE: In carpometacarpal (CMC) arthritis of the thumb, the use of interposition techniques (polylactic acid, pyrocarbon, dacron) has been increasing recently. These techniques are most often combined with open or arthroscopic complete or partial trapeziectomy. This article reports the results at one year of the arthroscopic interposition of an absorbable implant performed without trapeziectomy. METHODS: Our series included 25 patients aged 60.5 years on average, presenting with osteoarthritis of the trapeziometacarpal joint that had been medically treated for 18.5 months on average. All patients were operated using 1-ulnar (U) and 1-radial (R) portals. After joint debridement, a polylactic acid implant was inserted under arthroscopic control. Outcome evaluation consisted of the assessment of pain intensity, grip strength, pinch strength, opposition, thumb abduction and Dell radiological staging. RESULTS: The average follow-up was 14 months. Postoperative radiological data showed significant differences from baseline clinical data regarding all evaluated variables: 0.68 vs. 3.5 for pain, 24.76 Kg vs. 16.64 Kg for grip strength, 6.44 Kg vs. 3.64 Kg for pinch strength, 8.6 vs. 7.28 for opposition, 81.2° vs. 69.6° for thumb abduction, and 1.08 vs. 2.88 on the Dell stage. Eleven complications occurred, including a type 1 complex regional pain syndrome, one sepsis, and nine inflammatory reactions that resolved after an average of 3 weeks. CONCLUSIONS: Our technique is simple, rapid, cost-effective, and does not necessitate trapeziectomy, even partial. It has the same indications as other non-radical interventions. The follow-up duration of our study was too short for long-term evaluation but short-term outcome appeared superior to that in other published series. The regional inflammatory reactions that occurred in our series were transient and probably related to implant resorption. Our promising results suggest extending the indication of arthroscopic interposition to more advanced stages of proximal joint osteoarthritis.

Arthroscopic dorsal capsuloplasty in chronic scapholunate ligament tears: a new procedure; preliminary report.

We report our preliminary results of arthroscopic dorsal capsuloplasty for chronic scapholunate lesions to obviate the need for an open exposure of the wrist capsule. Twenty-two consecutive patients with scapholunate ligament tears underwent an arthroscopically-assisted dorsal capsuloplasty with or without percutaneous pinning. The mean age of subjects was 36 years (range, 27 to 55 years). The mean preoperative delay was 9 months (range 3 to 24 months). Criteria for surgery were persistent pain over the dorsal radial wrist in the scapholunate region and a positive finding on performing Watson's test. All patients were reviewed at a mean follow-up of 13 months (range, 7 to 19 months). The range of motion was recovered with a slight limitation in flexion in only four cases. The average grip strength attained was 96% of the contralateral side. The results in terms of pain were excellent. The seven high level athletes resumed practice at the same level as prior to the injury. A longer follow-up is necessary to confirm these encouraging preliminary results.

[Vascularized bone grafting from the volar distal radius for carpal bones reconstruction]. / Le transfert osseux vascularisé prélevé sur la face antérieure du radius dans la reconstruction des os du carpe.

We report the use of vascularized bone graft harvested from the volar aspect of distal radius for carpal bone reconstruction. This transplant is known and used since 1965, but the technical description of reliable harvesting more recent is presented. The anatomical dissection of 30 corpses found in a constant way the presence of the transverse carpal artery which born from radial artery. This vascularized bone graft was used for the treatment of 112 scaphoid nonunion with an average follow-up of 27.82 months (10-107). Union was obtained in 95.54% of the cases with an average of 6.7 weeks (6-9). We report also the result of this vascularized bone graft for the revascularization of the lunatum in 22 patients with Kienböck's disease with an average follow-up of 74 months (60-124). The postoperative MRI control with a minimum of 8 months showed 17 healing, three stabilizations of lesions and two failures requiring a secondary palliative surgery. The use of a vascularized transplant harvested from the volar aspect of distal radius is now a well codified, meticulous but reliable and sure technique, which requires a single approach for the reconstruction of some carpal bones (scaphoid, lunatum) allowing a locoregional anesthesia and an outpatient basis.

Extensor carpi radialis brevis ligamentoplasty and dorsal capsulodesis for the treatment of chronic post-traumatic scapholunate instability.

OBJECTIVES: To present a novel surgical technique that includes both extensor carpi radialis brevis (ECRB) ligamentoplasty and dorsal capsulodesis for the treatment of chronic post-traumatic scapholunate instability. METHODS: We performed a retrospective review of 32 patients with chronic post-traumatic scapholunate instability (stage 4 or 5 according the Garcia-Elias' classification) who were treated with this technique. Pre- or intraoperative arthroscopic evaluation was carried out in all cases. RESULTS: The postoperative wrist range of motion was generally improved except for wrist flexion. In 20 patients out of 29, the DISI deformity was corrected. Grip strength and pain was also improved postoperatively. Based on the Mayo wrist scoring, 16 patients had excellent results, eight patients had good results, three patients had fair results, and five patients had poor results. CONCLUSION: Our technique which combines ECRB ligamentoplasty with dorsal capsulodesis is a reliable option for the surgical treatment of chronic postchronic post-traumatic scapholunate instability.

[Treatment of acute scapholunate ligament tears with simple wiring and arthroscopic assistance]. / Traitement des lésions aiguës du ligament scapholunaire par simple brochage avec assistance arthroscopique.

Scapholunate ligament tears give chronic instability leading in SLAC. The wrist arthroscopy allows to see the lesions, even in early stage, and to treat them, with a simple K-Wires fixation in acute cases. The patients were operated on in outpatient basis with tourniquet and local general anaesthesia. In acute cases, the scapholunate dissociation was reduced by external and internal manoeuvres. The fixation was done with two pins under arthroscopic and fluoroscopic controls. We report a series of 66 acute cases (less than 45 days after trauma). Forty-four patients were males and 22 females. The average age was 39 years old (range 19-46). Our average follow-up in acute cases was 36 months (range 14-61). According the "Mayo Wrist Score", we obtained 92 % of good or excellent results. The wrist arthroscopy is the best technique for early diagnosis, guarantee of best functional results.

Four corner arthrodesis limited to the centre using a scaphoid one piece graft and a dorsal circular plate.

We present 20 patients, who had a four corner arthrodesis, from July 2006 to March 2008, using a dorsal circular plate, to treat scaphoid nonunion and scapholunate dissociation with advanced collapse (SNAC, SLAC). The surgical technique was a fusion restricted to the central area filled with one piece of cancellous bone graft taken from the excised scaphoid. Wrist motion, grip strength, and Disabilities of Arm Shoulder and Hand (DASH) score improved after surgery at a mean follow-up of 20.2 months. Fusion occurred in 19/20 patients. Two patients (10%) had persistent pain. The rest had a good clinical result. We found that four-corner fusion using a dorsal circular plate using the specific technical modifications was successful.

[Comparison of two arthroscopic classifications for scapholunate instability]. / Comparaison de deux classifications arthroscopiques pour l'instabilité scapholunaire dissociative.

The W. Geissler's and G. Dautel's arthroscopic classifications for scapholunate instability have been compared in a prospective, multicentric study. Physical, radiographic and arthroscopic data from 50 patients were reported by eight operators working in eight different institutions. Two questions were asked for each study case: Which classification seemed to be the more easy to use? Which classification seemed to give the best treatment algorithm? The good and bad points of each classification are presented. Neither of these two classifications is ideal, so the authors propose a classification incorporating the important points gleaned from the study. The proposed classification is simple, reproducible and precise, especially in terms of scapholunate ligament status.

[Arthroscopic management of intra-articular fractures of the distal radius]. / Traitement des fractures articulaires du radius distal sous contrôle arthroscopique: technique opératoire et choix thérapeutiques.

The use of arthroscopy in the management of intra-articular fractures of the distal radius has become established over the last ten years, but the operative technique is not yet standardised. We report our experience with this technique and give a stage by stage description of the operative procedure. The arthroscopic part of the procedure consists firstly of an evaluation of the bony, cartilaginous and ligamentous injuries and secondly direct visual control of the reduction. The choice of bone fixation depends on the individual preferences of the surgeon but may be influenced by the configuration of the fracture. A literature review reiterates the advantages of arthroscopic assistance in managing these fractures without revealing any disadvantages. However, mastery of the arthroscopic techniques is vital before the full advantages of this type of management can be realised.

Abductor pollicis longus "hammock" ligamentoplasty for treatment of first carpometacarpal arthritis.

The association of trapeziectomy with ligamentoplasty is a simple treatment for osteoarthritis at the base of the thumb. Here we present the long-term results of a technique that creates a "hammock" under the first metacarpal bone using the Abductor Pollicis Longus tendon. This paper reports the results of treatment by this operation of 60 thumbs in 50 patients, including 13 men and 37 women of average age 60 (46-75) years. Thirty thumbs presented with severe pain and 30 with moderate pain. At final follow-up, 47 thumbs (78%) had experienced dramatic relief of pain following the procedure, 12 (20%) thumbs still had mild pain and one (2%) thumb had severe pain. No patients needed revision.

[Therapeutic interest of wrist arthroscopy: about 1000 cases]. / Intéret thérapeutique de l'arthroscopie du poignet: à propos de 1000 cas.

Wrist arthroscopy is a relatively recent procedure because it was described in the 70's. During the first period of 80's it became an indisputable technique of diagnosis. Since the 90's many therapeutic procedure were described by several authors all over the world. This technique increase a lot the understanding of wrist pathologies and ameliorate significantly the results for patients. We report our experience about 1000 wrist arthroscopy between 1998 and 2005. The patients were always operated on outpatient basis under local regional anaesthesiology. The arm was laid on the table and the hand on in-line traction (5-7 kg). We used a 2.4 mm arthroscope, 30 degree angled. The both joints, radiocarpal and midcarpal, were systematically explored. The small portals were not closed. In our experience, only 42 arthroscopies (4%) were without surgical procedure. We separated the indications in 7 chapters: (1) arthoscopic assistance for fractures treatment (distal radius and scaphoid: 7%; (2) TFCC tears (17%); (3) treatment of intrinsic ligaments tears (scapholunate and lunotriquetral: 21%); (4) ectomy (radial styloidectomy, wafer, carpal boss 13%); (5) resection of wrist ganglia (21%); (6) partial prosthesis (2.5%); (7) others techniques (arthrolysis, synovectomy 14.5%).