Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of "0," "5," and "10" reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of "8" or higher for 80% or more of the panelists. RESULTS: Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds. CONCLUSIONS: Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC. CLINICAL RELEVANCE STATEMENT: MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries. KEY POINTS: • Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.

Interdisciplinary consensus statements on imaging of scapholunate joint instability.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of '0', '5' and '10' reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of '8' or higher for 80% or more of the panellists. RESULTS: Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available. CONCLUSIONS: Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability. KEY POINTS: • Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability. • Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability. • Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

Extrinsic and Intrinsic Ligaments of the Wrist.

Carpal stability depends on the integrity of both intra-articular and intracapsular carpal ligaments. In this review, the role of the radial-sided and ulnar-sided extrinsic and intrinsic ligaments is described, as well as their advanced imaging using magnetic resonance arthrography (MRA) and contrast-enhanced magnetic resonance imaging (MRI) with three-dimensional (3D) scapholunate complex sequences and thin slices. In the last decade, the new concept of a so-called "scapholunate complex" has emerged among hand surgeons, just as the triangular ligament became known as the triangular fibrocartilage complex (TFCC).The scapholunate ligament complex comprises the intrinsic scapholunate (SL), the extrinsic palmar radiocarpal: radioscaphocapitate (RSC), long radiolunate (LRL), short radiolunate (SRL) ligaments, the extrinsic dorsal radiocarpal (DRC) ligament, the dorsal intercarpal (DIC) ligament, as well as the dorsal capsular scapholunate septum (DCSS), a more recently described anatomical structure, and the intrinsic palmar midcarpal scaphotrapeziotrapezoid (STT) ligament complex. The scapholunate (SL) ligament complex is one of the most involved in wrist injuries. Its stability depends on primary (SL ligament) and secondary (RSC, DRC, DIC, STT ligaments) stabilizers.The gold standard for carpal ligament assessment is still diagnostic arthroscopy for many hand surgeons. To avoid surgery as a diagnostic procedure, advanced MRI is needed to detect associated lesions (sprains, midsubstance tears, avulsions and chronic fibrous infiltrations) of the extrinsic, midcarpal and intrinsic wrist ligaments, which are demonstrated in this article using 3D and two-dimensional sequences with thin slices (0.4 and 2 mm thick, respectively).

Treatment of the distal radius fractures with percutaneous pinning: evolution to the HK2 system.

Displaced fractures of the distal radius often require reduction and fixation to improve outcome in active patients. The volar locking plate gained ground over pinning, which was the first surgical solution described. But pinning methods have since evolved with fewer complications. The authors present a clinical study of distal radius fracture fixation using the HK2 technique, where subchondral pins are connected to intra-focal pins. The results are satisfactory with a lower complication rate compared to other pinning methods. This technical improvement relaunches the pinning technique, with its two advantages, being faster and significantly cheaper than locking plates, with similar long-term functional results.

Advanced imaging of the scapholunate ligamentous complex.

The scapholunate joint is one of the most involved in wrist injuries. Its stability depends on primary and secondary stabilisers forming together the scapholunate complex. This ligamentous complex is often evaluated by wrist arthroscopy. To avoid surgery as diagnostic procedure, optimization of MR imaging parameters as use of three-dimensional (3D) sequences with very thin slices and high spatial resolution, is needed to detect lesions of the intrinsic and extrinsic ligaments of the scapholunate complex. The paper reviews the literature on imaging of radial-sided carpal ligaments with advanced computed tomographic arthrography (CTA) and magnetic resonance arthrography (MRA) to evaluate the scapholunate complex. Anatomy and pathology of the ligamentous complex are described and illustrated with CTA, MRA and corresponding arthroscopy. Sprains, mid-substance tears, avulsions and fibrous infiltrations of carpal ligaments could be identified on CTA and MRA images using 3D fat-saturated PD and 3D DESS (dual echo with steady-state precession) sequences with 0.5-mm-thick slices. Imaging signs of scapholunate complex pathology include: discontinuity, nonvisualization, changes in signal intensity, contrast extravasation (MRA), contour irregularity and waviness and periligamentous infiltration by edema, granulation tissue or fibrosis. Based on this preliminary experience, we believe that 3 T MRA using 3D sequences with 0.5-mm-thick slices and multiplanar reconstructions is capable to evaluate the scapholunate complex and could help to reduce the number of diagnostic arthroscopies.

Pathology of extrinsic ligaments: a pictorial essay.

The role of the extrinsic ligaments, together with the intrinsic ligaments, appears to be much more important than previously thought in the setting of carpal stability. The anatomy and pathology of the extrinsic wrist ligaments is complex. Magnetic resonance imaging (MRI) with thin slices is essential for visualization. This article describes the pathological appearance of the extrinsic palmar and dorsal radiocarpal and ulnocarpal ligaments on MRI, correlated with arthroscopy (performed by two skilled hand surgeons), clinical findings, and follow-up. High-resolution MRI, especially using isotropic three-dimensional sequences with orthogonal multiplanar reconstructions on 3T MR systems, allows detailed depiction of many of the extrinsic ligaments affected in carpal injuries. Recognition of ligament abnormalities is improved by intra-articular or intravenous injection of contrast before the examination. Both techniques may help to determine the precise localization, size, and extent of dorsal and palmar radiocarpal and ulnocarpal ligament lesions. Further experience with these techniques is needed to define the place of MRI in the management of traumatic wrist injuries.

Kienböck's disease in 2021.

The cause of Kienböck's disease is still unclear. It was initially considered as osteomalacia, before being recognized as avascular necrosis of the lunate. Its functional prognosis is doubtful, given that the progression often leads to wrist degeneration. Conservative treatment does not provide good results in adults; thus surgery is often needed. Certain anatomical factors such as the ulnar variance, configuration of the lunate or orientation of the radial glenoid have turned out not to contribute to necrosis but may contribute to lunate fracture. The lunate's vascularization can be precarious and mostly depends on the capsular arterioles. The lunate is a very mobile bone that participates in wrist movements, both in the radiocarpal joint and especially in the mid-carpal joints during activities of daily living. Radiographs are not the only diagnostic tools. The lunate makes contact with the radius and triangular fibrocartilage complex and is often subjected to high shear loads at the edge of the radius that can cause it to fracture. MRI and arthroscopy can contribute to the assessment. Kienböck's disease is likely an inflammatory, biological venous thrombosis disorder that leads to local damage due to intraosseous compartment syndrome. The basis of surgical treatment is to decompress the lunate to shield it from shear and compression loads. Existing osteotomy procedures will be described and compared to better understand their biomechanical effects. Some osteotomies do not reduce the loads transmitted to the lunate but can reduce the risk of intra-osseous shear. Some osteotomies may place excessive pressure on the lunate on its ulnar side. Some techniques are extra-articular and preserve the capsule's vascularization along with the anatomy of the mid-carpal joint. When the lunate damage is so severe that the bone's viability is compromised, bone grafting or replacement have been proposed. The palliative techniques typically used for wrist degeneration are indicated in the terminal stages. There are currently no effective biological treatments. While the origin of Kienböck's disease is still unknown, we now know that decompression osteotomies, while they do not heal the necrosis, protect the lunate from collapse, which hopefully provides enough time for biological healing to occur.

Volar Ganglion Cyst and Echo-Guided Assistance for the Arthroscopic Removal.

The ganglion of the wrist is very common but with uncertain prognosis. The arthroscopic resection seems to improve the result compared with open procedure, in decreasing recurrence and morbidity. Volar ganglions are close to the radial artery, the flexor pollicis longus tendon, and even the median nerve. Ultrasonography combined with arthroscopy offers incomparable safety for the resection of volar ganglions. The technical steps of this combined procedure are described, and the first published series are discussed.

Wrist Trauma: More Than Bones.

Acute and subacute wrist trauma predominantly consist of fractures of the distal radius in elderly patients and most frequently carpal fractures (scaphoid, followed by triquetrum and hamatum) and avulsion fractures of the ulnar styloid in younger patients, especially in sports-related injuries but also in work activities. The initial radiographs may miss the fractures and result when untreated in complications as nonunion, osteonecrosis, and degenerative osteoarthritis. Fractures of the distal radius and of the scaphoid may be associated with ligament injuries, most frequently the scapholunate complex, which are often overlooked at the emergency department. Patients without osseous injuries may present intrinsic and extrinsic ligament tears that may lead to carpal instability when they are clinically and/or radiologically missed. Therefore, in acute and subacute setting, computed tomography may be helpful for the detection of subtle fractures, and magnetic resonance imaging, for the early diagnosis of occult fractures and ligament injuries.

Arthroscopically Assisted Eaton-Littler Trapeziometacarpal Ligamentoplasty.

Background Eaton-Littler ligamentoplasty has proven its efficacy in the treatment of trapeziometacarpal (TMC) instability. Description of Technique In this article, we describe the arthroscopically assisted Eaton-Littler ligamentoplasty through two clinical cases. Patients and Methods Arthroscopy is used to accurately place the metacarpal bone tunnel and pass the slip of flexor carpi radialis tendon in the latter. This procedure avoids soft-tissue dissection and could improve the outcome of this well-known surgery. Results The two clinical cases showed good short-term outcome with a decrease of pain and good function. Conclusions Arthroscopy to assist Eaton-Littler TMC ligamentoplasty is technically feasible, allowing a less invasive surgery. A larger prospective controlled study with a longer term outcome is mandatory to assess the real advantages of this modified procedure.

Lunate loads following different osteotomies used to treat Kienböck's disease: A 3D finite element analysis.

BACKGROUND: One of most accepted principles for treating Kienböck's disease before wrist degeneration settles in is to decompress the lunate by an osteotomy. Several osteotomies have been proposed since 1935. However, they are based on biomechanical hypotheses that are sometimes conflicting: This study compares the decompression effect of radius transverse shortening, radius lateral closing and medial closing wedge osteotomies, capitate shortening - with and without hamate shortening - and a Camembert-type radius wedge osteotomy with and without ulnar head shortening according to Sennwald. METHODS: We built a 3D wrist model using finite elements that included the metacarpal, carpal and forearm bones. All wrist ligaments and Triangular Fibrocartilage Complex were incorporated in the simulation. Load was applied on the metacarpals with the forearm bones fixed. We then applied the different osteotomies to the model. FINDINGS: When load was applied to the wrist, the osteotomies that best unloaded the lunate were the capitate shortening osteotomy combined with hamate shortening and the Camembert osteotomy combined with ulna shortening; the latter was the only osteotomy that completely unloaded the lunate. INTERPRETATION: We think the association of the radius Camembert osteotomy and ulna Sennwald's shortening osteotomy is the most effective procedure to propose in Kienböck's disease.

Evaluation of Kienböck's Disease Treated by Camembert Osteotomy at Seven Years.

In Kienböck's disease, radius shortening osteotomy is the most common treatment. The Camembert procedure is a wedge osteotomy that shortens only the radius facing the lunate. Its aim is to offload the lunate by redirecting the compression stress of the grip forces toward the scaphoid. The purpose of this study was to determine if the Camembert osteotomy is effective in improving clinical symptoms and limits lunate collapse. The series include 10 patients who underwent a Camembert osteotomy for Kienböck's disease between 2002 and 2012 (one bilaterally). They are six men and four women, aged 40.6 years. Five patients had an additional ulnar shortening osteotomy if ulnar variance was neutral or positive. The mean follow-up is 7 years. Preoperatively, range of motion, grip strength, pain, and functional scores were poor. All osteotomies healed within 3 months. Extension, ulnar deviation, grip, functional scores improved significantly. In 10 cases, there were improvement in the T1 and T2 signals on the magnetic resonance imaging (MRI). There was no lunate collapse. This series shows good results with no worsening of the lunate shape. There was no ulnocarpal impingement. The Camembert osteotomy proposes to offload the lunate and redirect strains toward the scaphoid. The supposed interest is to protect the lunate from collapse. In this small series, the Camembert osteotomy improved function in patients with early stage Kienböck's disease. MRI aspects improve in most cases and no patients collapsed. Camembert can be used in combination with a Sennwald's ulnar shortening when ulnar variance is neutral or positive. Authors propose this procedure for Lichtman's stages 1-2-3A if there are no cartilage or ligament lesions. This is a Level IV, case series study.

Arthroscopic Classification of the Lesions of the Dorsal Capsulo-Scapholunate Septum (DCSS) of the Wrist.

The dorsal capsulo-scapholunate septum (DCSS) is an anatomic structure linking the scapholunate ligament and the dorsal capsule of the wrist. It should be a predynamic scapholunate stabilizer. The authors, using their experience for the extrinsic ligaments testing, suggest an arthroscopic testing of the DCSS. The status could be graded in 4 stages according to the trampoline aspect and to the fiber attachment. They report a preliminary study on a series of 53 arthroscopies made between January 2014 and December 2015 with evaluation of scapholunate ligament instability and DCSS laxity. There is a significant correlation between the lesional stage of the DCSS and the arthroscopic predynamic scapholunate instability stage (P<0.01).

The role of extrinsic ligaments in maintaining carpal stability - A prospective statistical analysis of 85 arthroscopic cases.

Several biomechanical studies have shown that the scapholunate (SL) and lunotriquetral (LT) ligaments are not the only stabilizers of the proximal carpal row. However, no study has yet analyzed the range of ligament lesions leading to instability in vivo. Arthroscopy has been used to assess the condition of the wrist's extrinsic ligaments by palpating and tensioning the various ligament and capsule structures. In this prospective study, this arthroscopic method was used in 85 cases of wrist sprain without static instability to evaluate the correlation between lesions of the intrinsic and extrinsic carpal ligaments and carpal instability. In SL instability, a scapholunate interosseous ligament (SLIL) lesion was statistically correlated with lesions of the long radiolunate ligament (P<0.05). There also was a statistically significant correlation between lesions of the SLIL and the radioscaphocapitate, scaphotrapezial and dorsal intercarpal ligaments. There was a correlation between the stage of SL instability and the number of lax extrinsic ligaments (P<0.05) but not with the severity of the extrinsic ligament lesions. In LT instability, a LT interosseous ligament lesion was statistically correlated with lesions of the dorsal intercarpal ligament (P<0.05). There also was a correlation between the stage of LT instability and the number (P<0.005) and severity (P<0.001) of the extrinsic ligament lesions. Arthroscopy can reveal hidden radiographic instability and can also be used to define the number and severity of injured ligaments. In carpal instability, a lesion of one intrinsic carpal ligament was associated with a lesion of one or more extrinsic ligaments.

A systematic method of arthroscopic testing of extrinsic carpal ligaments: implication in carpal stability.

Several biomechanical studies have shown that the scapholunate and lunotriquetral ligaments are not the only stabilizers of the proximal carpal row. However, no study has yet analyzed the spectrum of ligamentous lesions in vivo, leading to instability. We describe an arthroscopic technique for evaluating the extrinsic carpal ligaments. The testing relies on visualization and palpation of different ligaments. Their integrity is assessed with a 4-stage scale. Radiocarpal arthroscopy enables assessment of the following ligaments: the radiocarpal part of the radio-scapho-capitate, the long radiolunate, the short radiolunate, the ulnolunate, the ulnotriquetral, and the dorsal radiocarpal. Midcarpal arthroscopy enables assessment of the mid part of the radio-scapho-capitate, the triquetrocapitate, the scaphotrapezial, and the dorsal intercarpal. Above assessment is proposed in addition to assessing the articular cartilage, scapholunate, and lunotriquetral ligaments. This method allows a precise arthroscopic assessment of the extrinsic ligaments of the wrist. It could give an important help in the understanding of carpal instability.

The EWAS Classification of Scapholunate Tears: An Anatomical Arthroscopic Study.

Treatment of scapho-lunate (SL) injuries is still a challenge for the surgeon, especially in chronic cases. The aim of the study isto experimentally cut, specific portions of scapholunate ligament and extrinsic ligaments and check their corresponding arthroscopic finding in order to understand the pathogenesis and develop a new classification system which is an evolution of the present arthroscopic classifications. Materials and Methods Thirteen cadaver wrists were studied under arthroscopy. Different portions of the scapho-lunate ligament were subsequently sectioned. In group A the sectioning sequence was: anterior SLIOL, RSC, LRL, SLIOL's proximal and posterior, DIC, DRC ligament and ST ligaments (8 cases). In group B it was: SLIOL's posterior and proximal, DIC, SLIOL's anterior, LRL, RSCL, DRC, ST ligaments (5 cases). The anatomo-pathological findings after each sectioning were correlated to the classification system proposed (Table 1). Results In group A, stage 3A was obtained when SL ligament's volar and intermediate portion and/ or SC/LRL ligaments were sectioned. A stage 3C was obtained when section of posterior SLIOL was sectioned as well. A stage IV when the DIC was also sectioned. In group B a stage 3B was obtained by cutting intermediate, posterior portion of the SLIOL ligament and DIC. A stage 3C was obtained when the anterior part of the SLIOL was also sectioned. In all cases, sectioning of the SLIOL lead to a stage 3C only if associated with sectioning of at least one of the extrinsic stabilizers (DIC or SC/LRL). Sectioning of DIC and SC ligament, in addition to SLIOL led to an arthroscopic stage IV. When ST, DRC and TH ligaments were also sectioned significant radiological signs appeared (stage V). Conclusions This study helps us to understand the anatomo-pathological scapho-lunate lesions in their different stages of partial lesions. Commonly called scapho-lunate lesions are complex, involving also extrinsic ligaments.

Surgical technique of a radial wedge "camembert" osteotomy in Kienböck disease.

The main accepted principle to treat Kienböck disease is to decompress the lunate. Radius shortening is the most used technique. Three transverse osteotomies of the radius are described: neutral shortening osteotomy, lateral closing wedge osteotomy, and medial closing wedge osteotomy. Shortening the radius decompress the lunate and more or less the scaphoid. This deviates axial constraints toward ulna and triangular fibrocartilage complex. But the ulnar wrist is not able to support important axial constraints. The authors propose a solution to decompress only the lunate and not the scaphoid. This solution deviates axial constraints toward the scaphoid, which is naturally the most capable bone to support it. The authors describe a new radial nontransverse decompression wedge osteotomy. It allows to shorten the radius in front of the lunate. The fixation is done with a dorsal staple. To complete lunate decompression, authors propose to associate a metaphysal ulnar oblique shortening, essentially if ulnar variance is neutral or positive. The preliminar results on 10 cases are presented.