The arthritic wrist. II--the degenerative wrist: indications for different surgical treatments

For the patient (and the surgeon) the ideal wrist is one that has good mobility, however very often the optimal surgical treatment is one that provides effective pain relief. The patient must be informed of the potential complications and limitations of each procedure. The patient's psychological profile and functional requirements will determine how well he/she adapts to the changes. Also, each surgeon has beliefs and personal experiences that influence the treatment decision and final result. Proximal row carpectomy (PRC) and the Watson procedure are two reference operations for osteoarthritis secondary to scapholunate instability and scaphoid non-union (SLAC and SNAC). Beyond the early complications and drawbacks specific to each, they provide good results that are maintained over time. PRC, which can be performed up to Stage II, is mainly indicated in patients with moderate functional demands, while the Watson procedure is more often done on a patient who performs manual labour, as long as the radiolunate joint space is maintained. Complete denervation is effective in three out of four cases and preserves the remaining mobility. Because of its low morbidity, the procedure can be suggested in patients with a mobile wrist and low functional demands or in older patients, independent of their wrist mobility. Total wrist fusion is not only a rescue procedure. For a young patient who performs heavy manual labour with extensive osteoarthritis and progressive forms of Kienböck's disease, this procedure provides the greatest chance of returning to work and not being socially outcast. The role of osteochondral autografts, implants and wrist prostheses in the treatment arsenal need to be better defined.

Four-corner fusion and scaphoid excision using headless compression screws for SLAC and SNAC wrist deformities

Scapholunate advanced collapse and scaphoid nonunion advanced collapse wrist deformities are the most common causes of traumatic arthritis of the wrist. Four-corner fusion and scaphoid excision has proven to be an effective procedure for relieving pain and preserving range of motion in the wrist joint. Several methods for providing fixation of the midcarpal joint during fusion have been used, including K-wires, staples, and the Spider plate. K-wire fixation has proven effective, but requires a period of cast immobilization to protect the fusion mass. The Spider plate was promising, but has not been without complications. The development and improvements in cannulated headless compression screws has resulted in increased indications for their use, including fixation for 4-corner fusion. We review the technique and tips developed by the senior author over the last several years using headless compression screws for fixation of the midcarpal joint. Acutrak 2 Standard implants were used. This technique has allowed for early range of motion with reliable fusion rates.

[Repair of complicated degloving injuries of opposite finger with akin united flaps pedicled with dorsal carpal branch of ulnar artery]

OBJECTIVE

To evaluate the clinical efficacy of akin united flaps pedicled with dorsal carpal branch of ulnar artery in repairing complicated degloving injuries of the opposite fingers.

METHODS

Between August 2005 and August 2009, 11 cases of complicated degloving injuries of single finger were treated, including 8 males and 3 females with an average age of 26 years (range, 19-55 years). The defect locations were thumb in 1 case, index finger in 7 cases, and middle finger in 3 cases, including 9 cases of mechanical injury and 2 cases of traffic accident injury. The extent of skin avulsion was the proximal segments or beyond the middle segment of finger with a defect range from 5.0 cm x 4.5 cm to 8.0 cm x 5.5 cm. Complicated injuries included phalangeal fracture in 2 cases, extensor tendon injury in 3 cases, flexor and extensor tendon injuries in 1 case, digital vascular injury in 9 cases, and digital nerve injury in 6 cases. The time from injury to operation was 2-18 hours (mean, 4.8 hours). The akin united flaps were designed on the basis of anatomical distribution of the dorsal carpal branch of ulnar artery. The proximally pedicled flaps enclosed palmar finger, and the distally pedicled flaps enclosed dorsal finger. The size of flaps ranged from 10 cm x 3 cm to 16 cm x 3 cm. The donor sites were sutured directly. After 3 weeks, the pedicle was cut.

RESULTS

Light yellow secretion and eczema on the flap were observed in 1 case at 3 days, were cured after 2 weeks of dressing change; other flaps survived and healing of incisions by first intention was achieved. The incisions at donor sites healed by first intention. The secondary plastic operation was performed in 2 cases because of bulky flaps at 3 months after operation. Eleven patients were followed up postoperatively 6-12 months (8 months on average). The texture and appearance of all the flaps were satisfactory. The two-point discrimination was 12-20 mm with satisfactory recovery of finger function at 6 months after operation. According to Jebsen standard, the results were excellent in 8 cases, good in 2 cases, and poor in 1 case.

CONCLUSION

With reliable blood supply, easy dissection, less injury at donor site, and good repair results, the akin united flaps pedicled with dorsal carpal branch of ulnar artery is a good method to repair complicated degloving injuries of the opposite fingers.

[Treatment of carpal fractures. Recommendations of the Hand Surgery Group of the German Trauma Society]

The primary goal in the treatment of carpal fractures is the preservation of a painless wrist function. Scaphoid fractures are the most common carpal fractures and when such a fracture is clinically suspected CT or MRI scans are usually advisable. Only stable and non-displaced scaphoid fractures can be treated conservatively, all other fractures require internal fixation with restoration of normal anatomy. Second most common are fractures of the triquetrum which can occur as chip avulsions of the dorsal rim and are usually treated symptomatically. Fractures of the body of the triquetrum should be treated according to the degree of instability and displacement. This is virtually true for all carpal bones. Perilunate fracture dislocations of the carpus deserve special attention. In these severe injuries a fracture line can run through all carpal bones but the scaphoid is mostly affected. Accurate reduction and internal fixation by screws and K-wires are indicated not only in these cases, but also in carpometacarpal fracture dislocations.

[Fractures of the hamate bone and metacarpal bone: a rare combination]

BACKGROUND

Fractures of the hamate bone are rare, but are being seen more frequently due to the increasing popularity of racket sports and golf.

CASE DESCRIPTION

A 43-year-old man presented at our emergency department with a swollen, painful left hand after hitting a concrete wall with his fist. X-rays and CT scans revealed comminuted fracture of the hamate bone and the base of the fourth metacarpal bone. Open reduction and internal fixation, using screws and Kirschner wires, were performed. The postoperative course was uneventful. At one-year follow-up the patient had regained full use of his hand.

CONCLUSION

On conventional X-rays, 60% of wrist fractures are missed. If the clinical picture indicates a fracture of the hamate bone but conventional X-rays reveal no abnormalities then a supplementary CT-scan is advisable. Non-displaced fractures, or fractures with little displacement, can be treated conservatively, but surgical treatment is preferred in the case of displacement or non-union.

Comparison between proximal row carpectomy and four-corner fusion for treating osteoarthrosis following carpal trauma: a prospective randomized study

OBJECTIVE

To compare the functional results of carpectomy and four-corner fusion surgical procedures for treating osteoarthrosis following carpal trauma.

METHODS

In this prospective randomized study, 20 patients underwent proximal row carpectomy or four-corner fusion to treat wrist arthritis and their functional results were compared. The midcarpal joint was free of lesions in all patients.

RESULTS

Both proximal row carpectomy and four-corner fusion reduced the pain. All patients had a decreased range of motion after surgery. The differences between groups were not statistically significant.

CONCLUSIONS

Functional results of the two procedures were similar as both reduced pain in patients with scapholunate advanced collapse/scaphoid non-union advanced collapse (SLAC/SNAC) wrist without degenerative changes in the midcarpal joint.

Ulnocarpal epiphyseal arthrodesis for recurrent deformity after centralization for radial longitudinal deficiency

PURPOSE

To report our results for ulnocarpal epiphyseal arthrodesis for recurrent or late-presenting wrist deformity in patients with radial longitudinal deficiency, using both objective data and long-term subjective follow-up evaluation.

METHODS

A retrospective review of our surgical logs between 1970 and 2007 identified 12 postcentralization patients treated with ulnocarpal epiphyseal arthrodesis, and 1 patient (who had reached skeletal maturity) treated with traditional ulnocarpal arthrodesis. Indications for the arthrodesis included postcentralization recurrence of radial angulation to greater than 45°, an inability to actively extend the wrist to within 25° of neutral (ie, 25° of flexion), or both. We collected objective and radiographic data on all 12 patients by chart review at a mean of 89 months (range, 2-472 mo) after arthrodesis. We collected subjective data from 9 patients at a mean of 160 months (range, 14-602 mo) after arthrodesis.

RESULTS

Ulnocarpal union was obtained in 11 wrists at an average of 4 months (range, 2-6 mo); the 1 case of nonunion was treated successfully with revision arthrodesis. The mean radial angulation position was 20° after arthrodesis (range, 0° to 35°), an average improvement of 42°. The mean position of wrist fusion was 11° of flexion (range, 0° to 35° of flexion), an average improvement of 7°. The mean postoperative Disabilities of the Arm, Shoulder, and Hand score was 24.5 (SD, 12.3; range, 6.8-36.4). Final postoperative Visual Analog Score rating for function averaged 8 (range, 4-10); for appearance, it averaged 7 (range, 5-10), and for pain, it averaged 1 (range, 0-5).

CONCLUSIONS

Ulnocarpal and epiphyseal arthrodesis are appropriate surgical procedures to stabilize the carpus in postcentralization patients with recurrent or late-presenting wrist deformity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Proximal row carpectomy with a dorsal capsule interposition flap

Arthritis of the wrist can be a debilitating condition that presents with progressive pain and loss of motion. A proximal row carpectomy (PRC) is indicated for the management of wrist arthritis and is designed to improve pain while maintaining motion. It involves excision of the scaphoid, lunate, and triquetrum with the formation of a new articulation between the base of the capitate and the lunate fossa of the distal radius. The PRC is a technically straightforward procedure that can produce reliable results. It is contraindicated in cases with midcarpal arthritis and degeneration of the base of the capitate. In addition, there is a question of durability of the new articulation between the capitate and the lunate fossa of the distal radius. The use of interposition tissue can potentially decrease joint contact pressures and improve long-term durability. A PRC technique with the use of an interposition flap based on the dorsal capsule of the distal radius is presented.

Ulnar artery thrombosis and nerve entrapment at Guyon's canal: our diagnostic and therapeutic algorithm

Hypothenar hammer syndrome is a rare condition of ulnar artery aneurysm or thrombosis, which can be associated with a neuropathy of the ulnar nerve. There is no agreement regarding an optimal diagnosis and treatment for this syndrome. Most authors suggest angiography as the gold standard for diagnosis and recommend observation for the thrombotic type, and reconstructive surgery for the aneurysmal type. We report here our diagnostic and therapeutic algorithm, reviewing 9 patients with ulnar artery thrombosis and nerve entrapment at Guyon's canal; and an evaluation of the type of management including: anamnesis, diagnostic tests, and reconstructive surgery. We consider resection of the arterial thrombotic segment as the treatment of choice, due to the fact that ulnar arterial thrombosis can induce severe chronic inflammation into Guyon's canal and ulnar nerve sufferance. Therefore, we propose a planned approach, including 3 steps: clinical evaluation with Tinel and Allen's tests; magnetic resonance and ultrasound images; ulnar nerve decompression and arterial reconstruction. We believe that this practice is important for the early therapy of ulnar arterio-neuropathy in affected patients.

Distal radius hemiarthroplasty combined with proximal row carpectomy: case report

Severe wrist arthritis is most commonly treated by complete wrist arthrodesis, which provides predictable pain relief but the loss of motion may reduce ease of function. In selected patients, motion preserving surgical options, including limited intercarpal fusion, proximal row carpectomy (PRC), and total wrist arthroplasty (TWA) are considered. However, limited fusion and PRC are typically possible only in less severe cases in which there are some articular surfaces showing minimal degeneration that can be retained. TWA is an option for patients who have lower activity demands and specific needs or desires to maintain some wrist motion. Recent utility and decision analysis studies demonstrate that arthroplasty is associated with higher qualify adjusted life year (QALY) than arthrodesis in patients with rheumatoid arthritis. Despite these positive aspects of TWA, the procedure is not as widely accepted as hip, knee, or shoulder arthroplasty. Early implants had problems related to both materials and design, with breakage, loosening and joint imbalance being common complications. Newer generation implants are improved with more predictable early function, less joint imbalance, and rare breakage, but distal component loosening remains a substantial problem. Thus, patients with poor bone stock and those with high activity demands are typically not candidates for TWA, and all patients are advised to restrict activities to reduce the risk of implant loosening. A new motion preserving procedure has recently been used at our institution in selected patients with severe arthritis who do not qualify for TWA but request an alternative to complete wrist fusion. In this procedure, a distal radius implant arthroplasty is combined with a PRC. The distal radius component of a Universal 2 (UNI 2) total wrist arthroplasty system (Integra life Sciences, Plainsboro, NJ) is used. To our knowledge, there have been no previous publications on this technique. We report our first two cases which have shown a satisfactory early outcome for pain relief and functional wrist motion.

Scaphoid dislocation associated with axial carpal dissociation during volar flexion of the wrist: a case report

We present the first report of a patient with an isolated scaphoid dislocation with axial carpal dissociation sustained during volar flexion of the wrist. The scaphoid was dislocated to the radial side of the radial styloid process and was slightly shifted to the dorsal side. It was shown that the position of the wrist played an irrelevant role for occurring scaphoid dislocation.

Pathology and therapeutic results in patients with intraosseous ganglia of the carpal bone

This study evaluated the pathology and therapeutic results of seven patients with intraosseous ganglia of the carpal bone. The mean age at the time of surgery was 27.6 years. The lesions were localized in the proximal carpal row in six patients and in the distal carpal row in only one. Surgical treatment was performed in all patients with good bone union. None had pain during activity or at rest and no recurrence had occurred. The intraosseous ganglia in four patients was of the idiopathic type, and in the other three patients was of the penetrating type. Although intraosseous ganglia of the carpal bone is reported as a rare disease, there were 159 cases in the literature. The pathology was intra- or extraosseous development, showing variation, but most cases were localized in the proximal carpal row.

Donor sites for pedicled skeletal grafts of the hand, wrist, and forearm

Pedicled bone and periosteal grafts provide successful reconstruction of skeletal problems of the distal radius, wrist, and hand. The purpose of this study was to evaluate the available alternatives and to propose the most suitable skeletal grafts for the reconstruction of the distal radius, and the carpal and hand bones. The alternative donor sites (dorsal and palmar distal radius, and metacarpals), their pedicles, and the potential coverage area in relation to specific wrist and hand pathology were determined in the cadaveric dissections. In the clinical setting, 75 pedicled grafts were used for the treatment of scaphoid nonunions (62 cases), lunate necrosis (8 cases), reconstruction of the metacarpal defects (2 cases), and wrist fusions (3 cases). All alternatives have the advantage of a single approach that may be performed under tourniquet control, from the same team. Among the available alternatives, surgeon's familiarity plays the most important role for the final selection of the graft.

Effect of coexistent scaphotrapezoidal osteoarthrosis on outcome after trapeziectomy

Scaphotrapezoidal osteoarthrosis can cause persistent pain after trapeziectomy. It has previously been recommended that the scaphotrapezoidal joint should be resected at the time of trapeziectomy to avoid this complication if radiographs show evidence of joint degeneration. We have reviewed the records of 77 patients who had 87 trapeziectomies and assessed their radiographs for the presence and degree of osteoarthrosis. There was evidence of scaphotrapezoidal osteoarthrosis in almost half of the hands. Its presence, however, had no influence on subjective or objective measures of pain, function or power before or after operation, or on outcome. Only one patient required resection of the scaphotrapezoidal joint because of persistent pain. Resection of the joint cannot be recommended as a routine adjunct to trapeziectomy on radiological evidence alone.

Treatment of Kienböck disease in an 11-year-old girl with temporary fixation of the scaphotrapeziotrapezoidal joint

An 11-year-old girl with Kienböck disease (stage IIIA) was treated by temporary scaphotrapeziotrapezoidal fixation. It was fixed in a cast for four weeks and wires removed after eight weeks. Follow up examinations showed that movement of the wrist and grip strength were improved, and she had no pain while revascularisation of the lunate could be seen on magnetic resonance imaging.

Outcome of proximal row carpectomy

Fifty-one patients who had had proximal row carpectomy between 1992 and 2002 with a minimum follow-up of one year were followed up clinically and radiologically retrospectively. Their diagnoses included Kienböck disease (n=21), avascular necrosis of the scaphoid (n=4), nonunion of the scaphoid with osteoarthritis (n=9), and scapholunate advanced collapse (n=17). The mean follow-up was 5 years, 8 months. The mean "disabilities of the arm, shoulder and hand" (DASH) score was 18. The mean patient-rated wrist evaluation (PRWE) score list was 25% of maximum disability for the function and pain score. Thirty-four patients (87%) were able to return to work a mean of six months after operation (range 3 weeks - 35 months). Nine patients (11%) required arthrodesis of the wrist and are considered as failures. Mean flexion of the wrist was 66%, extension 73%, radial deviation 74%, ulnar deviation 76%, and grip force 70% of the opposite side. Excision of the proximal row provided predictable and durable pain relief, restored functional movement and grip strength, and allowed returned to gainful employment in most of the patients.

Pancarpal and partial carpal arthrodesis

Arthrodesis can be an effective procedure to restore acceptable function and alleviate pain when other medical or surgical treatments are not possible. A thorough knowledge of carpal anatomy and strict adherence to the principles of arthrodesis are essential to success. The most important factor in determining whether a partial carpal arthrodesis can be performed is the stability of the antebrachiocarpal joint. Multiple techniques, including plating, pinning, and external skeletal fixation, have proven successful, and this article discusses these techniques and the complications of each.

Comparison of the "contact biomechanics" of the intact and proximal row carpectomy wrist

PURPOSE

The proximal row carpectomy (PRC) is a clinically useful motion-preserving procedure for various arthritides of the wrist. However, there are few studies on the "contact biomechanics" after PRC. The purpose of this study is to evaluate the contact biomechanics in terms of pressure, area, and contact location of the intact and PRC wrist.

METHODS

Six fresh-frozen cadaver forearms were tested in neutral, 45 degrees of flexion, and 45 degrees of extension. In the intact wrist, Fuji UltraSuperLow pressure contact film was placed in the radioulnocarpal joint. The specimen was loaded to a total force of 200 N. We then performed a PRC, and the experiment was repeated using Fuji Low film. The film was scanned and analyzed with a customized MATLAB program. Multivariable analysis of variance with multiple contrast testing and Student's t-test were performed for statistics.

RESULTS

In the intact wrist, scaphoid contact pressure averaged 1.4 megapascals (MPa), and lunate contact pressure averaged 1.3 MPa. In terms of contact location, scaphoid contact in the intact wrist significantly moved dorsal and ulnar in flexion and significantly moved volar and radial in extension. Lunate contact significantly moved dorsal in flexion. PRC wrist contact pressure was 3.8 times that of the intact wrist, and the contact area was approximately 26% that of the intact wrist. Lastly, in terms of the amount of contact translation after PRC, the capitate contact translated (7.5 mm) more than did the scaphoid contact (5.6 mm) and had about equal translation to that of the lunate (7.3 mm).

CONCLUSIONS

Contact pressure increased significantly and contact area decreased significantly after PRC. There is significant contact translation after PRC (more than scaphoid translation but equal to lunate translation), which provides quantitative support of the theory that translational motion of the PRC may explain its good clinical outcomes.

[Proximal row carpectomy in the treatment of degenerative arthritis of the wrist]

PURPOSE OF THE STUDY

To evaluate the outcome in patients treated by proximal row carpectomy at a follow-up of at least 12 months.

MATERIAL

A total of 28 patients were treated by proximal row carpectomy for degenerative arthritis of the wrist due to previous trauma to the wrist or avascular necrosis of the lunate. Of them, 24 underwent a follow-up examination at least 12 months post-operatively. Proximal row carpectomy was indicated in 11 patients for scaphoid non-union advance collapse (SNACwrist), in five patients for scapholunate advanced collapse (SLAC-wrist), in four patients for inveterate dislocation of the wrist, and in four patients for avascular necrosis of the lunate. Ten patients with proximal row carpectomy were simultaneously treated by partial resection of the posterior interosseous nerve and two patients by limited radial styloidectomy. In one patient we performed distraction resection arthroplasty of the wrist using the Fitzgerald method.

METHODS

The follow-up clinical and radiological examinations were performed after a minimum of 12 months post-operatively.We evaluated the range of wrist motion, grip strength, the presence of resting pain and pain dusing physical activities and the patient's satisfaction with the treatment outcome. By radiological examination we assessed radiocapitate joint degeneration and translation of the capitate bone in relation to the lunate facet of the radius. The differences between the results of pre- and post-operative clinical examinations were statistically evaluated using the Student's t-test, Sign test, Mann-Whitney test, and Wilcoxon signed rank test. The results were considered to be significant if p < 0.05.

RESULTS

Improvements in the range of motion in the flexion-extension arch, dorsal flexion, radial deviation and grip strength, expressed as percentages of these values for the opposite, unaffected wrist, were statistically significant. The differences in palmar flexion and ulnar deviation were statistically insignificant. Pain relief at rest and during physical activities was statistically significant. At the follow-up examination most patients (87.5%) reported an overall improvement. The difference in overall improvements between the patients with and without partial resection of the posterior interosseous nerve was not statistically significant.

DISCUSSION

The advantages of this procedure involve its technical simplicity, maintenance of wrist motion, satisfactory grip strength and pain relief, and a relatively low occurrence of post-operative degenerative wrist changes. These changes are not in correlation with functional complaints.

CONCLUSIONS

As shown by our results as well as published data, proximal row carpectomy is an effective surgical procedure for the treatment of degenerative arthritis of the wrist for its technical simplicity and favourable functional outcomes. Key words: proximal row carpectomy, SNAC-wrist, SLAC-wrist, avascular necrosis of the lunate, dislocation of the wrist, posterior interosseous nerve resection.

New method of fixation in above-wrist replantation in patient with traumatic total carpal loss--a case report

The incidence of above-wrist replantations is decreasing, mainly due to better working conditions and increased safety precautions. Osteosynthesis with a plate or external fixator is usually regarded as the gold standard of fixation. We present an unusual case of intramedulary fixation of both forearm bones to the 2nd and the 5th metacarpal bone in the case of a patient with total carpal loss. This kind of fixation gives a satisfactory result with virtually no limitation of pronation and supination movements of the wrist.

Wide excision and ulno-carpal arthrodesis for primary aggressive and recurrent giant cell tumours

Twenty-five patients underwent wide resection of the distal radial giant cell tumours (GCTs) followed by ulno-carpal arthrodesis. There were 15 male and ten female patients, with an average age of 21.5 years. Tumours included ten primary aggressive and 15 recurrent GCTs. Mean follow up was 2.4 years. Pain, swelling and reduced range of movement (ROM) were noted. Average time to fusion was 7.6 months. Five patients had persistent pain in the proximal forearm. Grip strength was 65% compared to the uninvolved side. Two patients had superficial wound infection, two underwent additional bone grafting and three implant removals due to hardware prominence were carried out. There was no evidence of carpal instability or arthritis on clinical or radiological examination at the time of final follow up. Fusion of the carpus to the ulna is a simple method of producing a painless stable wrist, though at the expense of mobility. The procedure allows wide resection with a lower rate of recurrence. Pain in the proximal forearm seems to persist for 3 to 4 months only to improve at subsequent follow up. The procedure provides a valid option for the management of primary aggressive and recurrent GCTs of distal radius.

Treatment for scaphoid fracture and nonunion--the application of 3.0 mm cannulated screws and pedicle vascularised bone grafts

SUMMARY BACKGROUND

Scaphoid fractures are very common in wrist trauma, and scaphoid nonunions with avascular necrosis are frequent complications of a fractured scaphoid. The purpose of these two retrospective studies was to examine the clinical and x-ray results of treatments for acute scaphoid fracture and scaphoid nonunion. The surgical techniques of cannulated screw fixation and pedicled vascularised bone graft are described.

METHODS

From 2001-2004, 80 patients with scaphoid fractures were treated with 3.0 mm cannulated screws and 5.5 mm threaded washers in our hospitals. The average age was 35 years, and the average time from injury to surgery was 16.5 hours. Outcomes were assessed by x-ray and the modified Mayo wrist score system. During the 6-year period of 1998-2004, 72 patients with scaphoid nonunions were treated using pedicled vascularised bone graft (VBG)in our hospitals. The average age was 38.5 years, and the average time from injury to surgery was 9.5 months.

RESULTS

The union rate was 96.25% and satisfactory function rate was 93.75% in acute scaphoid fractures with an average follow-up of 3.5 years. The union rate (90.28%) and satisfactory function rate (81.94%) achieved in scaphoid nonunions were acceptable, with an average follow-up of 5 years.

CONCLUSIONS

Our studies suggested that appropriate application of a cannulated screw and threaded washer was able to produce satisfactory results in scaphoid fracture, and that pedicled vascularised bone graft was effective for treating scaphoid nonunion.