Dorsal radiocarpal ligament capsulodesis for chronic dynamic lunotriquetral instability

Outcomes Following Surgical Interventions for Isolated Lunotriquetral Interosseous Ligament Injuries: A Systematic Review

Ulnar-sided wrist pain can be attributed to various bony and ligamentous structures. The purpose of this review is to compare outcomes following surgical interventions for isolated lunotriquetral (LT) interosseous ligament injuries in adults. We assessed 202 procedures from 9 retrospective case series studies of low to moderate quality based on the Structured Effectiveness Quality Evaluation Scale. The comparative outcomes (ie, range of motion, pain, strength, quality of life, complications, return to work, and patient satisfaction) were aggregated and categorized under arthrodesis, capsulodesis, ligament repairs and reconstruction, and ulna shortening osteotomy procedures. Although the comparison of outcomes was largely inconclusive due to the heterogeneity and the omission of preoperative characteristic data, we did observe higher complications and reoperation rates post LT arthrodesis. It is recommended that all outcomes be standardized and presented uniformly with best practices developed to better characterize the injury's severity and integrity in future studies.

Revisiting Lunotriquetral Arthrodesis in Chronic Lunotriquetral Ligamentous Injuries

Background  Chronic lunotriquetral (LT) ligament tears are a source of ulnar-sided wrist pain. Left untreated, complete tears of the LT ligament may progress to a volar intercalated segment instability deformity and eventual carpal arthritis. Various treatments have been proposed, one of which is LT arthrodesis. LT arthrodesis has been criticized for high rates of nonunion frequently requiring reoperation, and therefore has largely fallen out of favor. However, our experience has been quite different from the literature. This study examines a single surgeon's experience with LT arthrodesis over a 15-year period. Methods  A retrospective review of the senior author's practice over a 15-year period was performed. All adult cases of LT arthrodesis for chronic LT injuries were included. Headless compression screw and cancellous bone graft from the distal radius were used for primary arthrodesis in all cases. The primary outcome was rate of union, and secondary outcomes were time to union, secondary or salvage procedures, and range of motion. Nonparametric statistical analysis was used to calculate differences in outcomes. Results  Twenty-eight patients met inclusion criteria. The median age was 45.5 (interquartile range [IQR] 35-50) years and 75% were male. The dominant hand was most commonly affected. Eighty-six percent of patients achieved union, one patient required redo arthrodesis, and one patient went on to wrist salvage. Three patients developed a pain-free pseudoarthrosis. Median time to radiographic union was 8.8 (IQR 5.9-11.9) weeks. Conclusion  Despite multiple previous reports, this study demonstrates that LT arthrodesis for chronic LT injuries is a safe technique with high rates of successful union. Further comparative studies are warranted to determine the optimal treatment for chronic LT injuries.

Technique for Reconstruction of Midcarpal Instability Associated with Lunotriquetral Coalition

Carpal coalition is a rare congenital presentation of 2 or more fused carpal bones due to a failure of apoptotic segmentation during development. The most common subtype is lunotriquetral coalition (LTC). Most cases are asymptomatic and found incidentally on imaging; however, a few symptomatic cases requiring treatment have been reported. Surgical intervention of arthrodesis and proximal row carpectomy in adults have been reported where conservative management of splinting, physiotherapy, anti-inflammatory medication, or steroid injections have failed. We report a unique case of Minnaar type 2 LTC in a 20-year-old man with a 6-year history of daily right wrist pain and symptomatic wrist instability whose previous conservative therapies failed. Midcarpal instability and volar intercalated segment instability—volar flexion of the lunate—were present. A novel technique using the palmaris longus tendon to reconstruct the triquetrohamate, triquetrocapitate, and dorsal radiolunate ligaments was performed. The graft was secured dorsally to the hamate, triquetrum, and capitate. An additional graft from the lunate to distal radius acted as a biomechanical checkrein. There were no complications. Temporary Kirschner wires were removed 2 months postoperatively, followed by occupational hand therapy. At 1-year follow-up, the patient no longer reported pain or lunotriquetral tenderness. Midcarpal instability and volar intercalated segment instability resolved. Postoperative right wrist flexion and extension were 40 and 75 degrees, respectively. We discuss the successful outcome of this novel technique as an alternative to arthrodesis in the surgical management of LTC.

Arthroscopic Dorsal Ligamentocapsulodesis in the Treatment of Isolated Lunotriquetral Interosseous Ligamentous Injury: A Retrospective Case Series of 22 Patients

Background: The literature is scarce regarding isolated tears of lunotriquetral interosseous ligament (LTIL). The purpose of this study was to present mid-term clinical and functional results of arthroscopic dorsal ligamentocapsulodesis in the treatment of isolated LTIL tears. Methods: Twenty-two patients (8 females, 14 males; mean age: 31 years; age range: 18-42) with isolated LTIL tears verified by wrist arthroscopy were retrospectively reviewed and included in the study. The mean follow-up was 55 months (range: 24-84). The modified Mayo wrist score, visual analog scale (VAS), flexion and extension deficits of passive wrist range of motion (ROM), pain-free ROM with forced wrist extension and grip strength were measured in all patients preoperatively and at final follow-up. Results: The mean modified Mayo wrist score significantly improved from 50 ± 10.29 preoperatively (range: 30-65) to 86 ± 11.61 (range: 60-100) at the final follow-up (p < 0.001). The mean VAS score significantly improved from 7.1 ± 0.83 (range: 6-8) preoperatively to 2.2 ± 1.35 (range: 0-6; p < 0.001) at the final follow-up. At the final follow-up examination, the forced wrist extension was painless in all but three patients who developed pain at 70º, 75º and 80º of extension, respectively. The mean strength of hand grip significantly increased from 38.6 ± 9.68 (range: 24-54) kg to 49.5 ± 12.36 (range: 33-66) kg at the final assessment (p < 0.001). No major complications were observed during or after the procedure. Conclusions: With the encouraging mid-term outcomes and a lower complication rate, arthroscopic LTIL dorsal ligamentocapsulodesis seems to be a safe and effective surgical technique in improving functional outcomes and reducing pain in patients with isolated LTIL tears. Level of Evidence: Level IV (Therapeutic).

LT Ligament Tears

Lunotriquetral (LT) ligament injuries are uncommon, however, should be considered in patients with ulnar-sided wrist pain. LT injuries are often associated with other injuries but can occur in isolation. Understanding the anatomy and pathomechanics will aid in making the diagnosis. Similar to other injuries, a thorough history and focused physical examination is critical. Radiographs may show normal findings; however, advanced imaging can support the diagnosis. Arthroscopy remains the gold standard for diagnosis. Most patients do well with conservative management; however, injury acuity and severity will direct surgical management. Anatomy, pathophysiology, and treatment options are discussed.

Arthroscopic dorsal capsulodesis for isolated lunotriquetral interosseous ligament injuries

We assessed the outcomes of isolated lunotriquetral ligament injuries in ten patients who underwent arthroscopic dorsal capsulodesis. Data from patient records, radiologic images and arthroscopic video records were evaluated. The patients were evaluated for ulnar-sided wrist pain with history and physical examination. Preoperative radiographs and MRIs for pain aetiology were assessed. The patients underwent arthroscopic dorsal capsulodesis and were evaluated 29 months (range 19-45) after surgery. Nine patients returned to their original jobs. In one patient pain was aggravated with heavy activities. Mean scapholunate angle was 44°. There were significant improvements postoperatively in pinch and grip strength and MAYO wrist, patient-reported wrist evaluation and pain scores. The wrist flexion-extension and the radial ulnar deviation were significantly improved compared with the contralateral hand. We conclude that arthroscopic dorsal capsulodesis offers effective management for isolated lunotriquetral interosseous ligament injuries.Level of evidence: IV.

Ulnar-Side Wrist Pain Management Guidelines: All That Hurts is Not the TFCC!

BACKGROUND

Ulnar-sided wrist pain is a common clinical problem, most often misdiagnosed as triangular fibrocartilage complex (TFCC) injury. It may be frustrating to the patient, as one may end up wearing a wrist splint for an unusually long period, disrupting their routine.

PURPOSE

Because of the dilemmas in the diagnosing the cause of ulnar-sided wrist pain, various algorithms have been suggested but it is an individual's choice to do a systematic assessment and follow in their routine clinical practice. We propose the 'storey concept' for examining the ulnar side of the wrist, with ulnar styloid as the reference point. The lower storey identifies the pathologies of the DRUJ, the intermediate storey identifies the pathologies of the radiocarpal joint and the upper storey identifies the pathologies of midcarpal and carpometacarpal joint.

CONCLUSION

Also, it is important to ramify the cause of pain into stable or unstable wrist, with or without arthritis, as this will guide us in managing the pain arising from distal radioulnar joint. In addition to methodical clinical examination, ideal radiographs and high-resolution MRI are critical to diagnose wrist pathologies. The role of wrist arthroscopy has consistently increased, and complements in both diagnosis and treatment of wrist pain especially in ambiguous situations.

Dorsal Bone–Ligament–Bone Reconstruction of Chronic Lunotriquetral Instability: Biomechanical Testing

Purpose

Lunotriquetral (LT) instability is uncommon and few biomechanical analyses of the condition exist. For chronic LT instabilities, arthrodesis has long been the treatment of choice but has a high risk for nonunion. The aim of this study was to evaluate an alternative treatment option using a bone–ligament–bone graft in a cadaver model and compare it with a conventional arthrodesis.

Methods

We used 10 cadaveric forearms with different loading positions. We employed computed tomography scans to evaluate the LT joint. Scans were performed with the joint intact after we sectioned the dorsal LT ligament and the palmar LT ligament. The joints were then reconstructed using a bone–ligament–bone graft from the capitate–hamate joint as well as with a compression screw simulating arthrodesis. The joints were then rescanned and 3-dimensional analysis was performed using specialized 3-dimensional software.

Results

Sectioning the dorsal part of LT ligament had little effect on kinematics; however, additional division of the palmar LT ligament resulted in increased mobility. Restoration of physiological kinematics could be partially achieved after bone–ligament–bone reconstruction. Arthrodesis showed increased intercarpal motion in the adjacent scapholunate and lunocapitate joints compared with the bone–ligament–bone reconstruction.

Conclusions

The bone–ligament–bone reconstruction displayed physiologic carpal kinematics in the adjacent joints compared with arthrodesis. It provided enough stability but still some mobility in the LT joint to be able to use it as a treatment modality for chronic LT instability without the risk for nonunion. Decreased intercarpal motion was not statistically significant although there appeared to be a trend toward it.

Type of study/level of evidence

Therapeutic IV.

Surgical Techniques for the Treatment of Acute Carpal Ligament Injuries in the Athlete

The treatment of athletes with carpal ligament injuries provides many challenges. Our initial goals remain to make a timely and accurate diagnosis, provide treatment options, and create an environment for shared decision making. To optimize outcomes and facilitate return to play, early surgical intervention may be warranted. This article reviews common carpal ligament injury patterns in the athlete with a focus on both classic and newer surgical techniques.

Lunotriquetral Ligament Reconstruction Utilizing a Palmaris Longus Autograft

Injury to the lunotriquetral ligament can result in midcarpal instability, with resultant alterations in normal wrist kinematics and subsequent arthrosis. We performed a previously undescribed technique of lunotriquetral ligament reconstruction in two patients utilizing a palmaris longus tendon autograft. Average age at presentation was 24 years old with a mean follow up of 10 months. Average range of motion was 62.5° of flexion and 57.5° of extension. Total arc of motion was 83% of the contralateral uninvolved extremity. Average grip strength was 31 kg which was 91% of the contralateral extremity. Average Quick Disability of Arm, Shoulder and Hand score was 12.5 and Modern Activity Subjective Survey of 2007 was 1.5. No complications were noted.

Inestabilidad lunopiramidal

Históricamente, la inestabilidad en el lado radial de la muñeca ha recibido mucha más atención que la inestabilidad en el lado ulnar, a pesar de ser una patología relativamente frecuente. Como consecuencia de ello, suele darse un retraso en el diagnóstico correcto y el tratamiento apropiado. Las lesiones del ligamento lunopiramidal pueden ser parciales o completas, y estas últimas pueden estar asociadas a lesión de los estabilizadores secundarios. Cuando se lesionan estos estabilizadores es cuando se produce una inestabilidad estática del carpo conocida como Volar Intercalated Segmentary Instability (VISI). Entre los test clínicos más utilizados para detectar una inestabilidad del ligamento lunopiramidal están el Ballottement test, descrito por Reagan, y el Shear test, descrito por Kleinman, aunque ambos poseen una sensibilidad y una especificidad bajas. Para el diagnóstico de estas lesiones se emplean técnicas como la radiografía simple (que suele ser normal si no hay una inestabilidad estática del carpo), la artrografía y la RMN, entre otras, aunque el gold standard lo constituye la artroscopia de muñeca. No existe un consenso en cuanto al tipo de tratamiento óptimo, ya que la mayoría de los estudios publicados son retrospectivos de nivel iv sin medidas objetivas estandarizadas mediante instrumentos validados. Además, en su mayoría describen los resultados del tratamiento tardío, ya que no se suelen diagnosticar en la fase aguda. Dentro de los tratamientos descritos se encuentran el tratamiento artroscópico (desbridamiento/termocoagulación asociados o no a estabilización con agujas de Kirscher), la reparación abierta, la reconstrucción del ligamento y la artrodesis del ligamento lunopiramidal.

Management of lunotriquetral instability: a review of the literature

Lunotriquetral ligament injury is a relatively common cause of ulnar-sided wrist pain. Injury ranges from partial stable ligament tears to extensive perilunate instability. Clinical decision-making largely depends on the chronicity, instability and cause of the ligament injury. Conservative treatment is generally regarded as first choice of treatment of mild lunotriquetral instability; however, outcome studies on conservative treatment are lacking. Temporary arthroscopic pinning and/or debridement are minimally invasive procedures of preference. In the case of more dissociative injury, surgical interventions may be performed. The literature suggests that soft tissue reconstruction is an effective procedure in this group. Arthrodesis of the lunotriquetral joint is associated with high rates of non-union (up to 57%) and the indications for surgery should therefore be very clear. Methodological issues make it hard to draw firm conclusions from the data. Studies on the effectiveness of conservative management and prospective comparative studies will further improve clinical decision-making in lunotriquetral instability.

LEVEL OF EVIDENCE

N/A.

Diagnosis and Treatment of Chronic Lunotriquetral Ligament Injuries

Chronic lunotriquetral (LT) injuries are less common than scapholunate ligament injuries and difficult to diagnose. They may be associated with positive ulnar variance. Clinical diagnostic tests elicit pain at the LT interval. Although radiographs are typically normal, MRI and wrist arthroscopy can help confirm the diagnosis. When conservative treatments fail, surgical options include LT ligament reconstruction, LT arthrodesis, and ulnar-shortening osteotomy (in patients with positive ulnar variance).

Ulnar impaction syndrome: incidence of lunotriquetral ligament degeneration and outcome of ulnar-shortening osteotomy

PURPOSE

We hypothesized that most patients with ulnar impaction syndrome have degenerative changes of the proximal lunotriquetral (LT) membrane and that ulnar-shortening osteotomy is an effective procedure in these patients.

METHODS

We retrospectively reviewed 50 wrists of 49 patients with idiopathic ulnar impaction syndrome who underwent an arthroscopic evaluation at the time of ulnar-shortening osteotomy, and subsequently at plate removal. Based on the Geissler classification, patients were divided into group A, normal, and group B, grades I to IV. The degree of degeneration of the proximal LT membrane at first-look arthroscopy was compared with that at second-look arthroscopy.

RESULTS

After ulnar-shortening osteotomy, both groups improved significantly in wrist range of motion and grip strength. According to the Mayo wrist score, 29, 18, and 3 patients showed excellent, good, and fair results, respectively. Of the 50 wrists, 25 had degenerative changes (group B) in the proximal LT membrane at the time of first-look arthroscopy. Of the 25 wrists in group B, 11 wrists improved based on the Geissler grade, 9 wrists showed no changes, and 2 wrists became worse. Clinically, patients demonstrated improvement after ulnar-shortening osteotomy regardless of the degree of degenerative LT ligament changes.

CONCLUSIONS

Degenerative LT membrane changes that were seen in about half of our patients were mostly of a mild nature, and the clinical outcomes of ulnar-shortening osteotomy were acceptable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Isolated lunotriquetral ligament tears treated with ulnar shortening osteotomy

PURPOSE

To evaluate outcomes in a single-surgeon series of ulnar shortening osteotomy for the treatment of traumatic isolated tears to the lunotriquetral interosseous ligament (LTIL).

METHODS

This study includes 53 consecutive cases of posttraumatic isolated LTIL tears treated with ulnar shortening osteotomy with minimum 1-year follow-up (range, 1.0-10.6 y). We confirmed all LTIL tears via arthroscopy before performing a precision 2.5-mm oblique osteotomy using a modified Rayhack technique. We assessed outcomes using grip strength measurements and Chun and Palmer's modified Gartland Werley wrist scoring system, which includes subjective and objective outcome measures.

RESULTS

Preoperatively, 45 cases were graded as fair (28%; n = 15) or poor (57%; n = 30) on the modified Gartland Werley score. There were insufficient data to calculate grades in 8 cases (15%). At final follow-up, most patients exhibited excellent (51%; n = 27) or good (32%; n = 17) scores, some scored fair (17%; n = 9), and none scored as poor. All subjective and objective variables significantly improved over a mean follow-up of 36 months (range, 12-127 mo). Mean grip strength increased from a value of 23 kg before surgery to 33 kg over the same period, a 41% increase. All patients achieved clinical and radiographic union by 10 months. Osteotomy plates were removed routinely in most cases (89%; n = 47) at a mean of 17 months.

CONCLUSIONS

Ulnar shortening osteotomy reduced symptoms of posttraumatic isolated LTIL tears in this single-surgeon series.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Immunohistochemical composition of the human lunotriquetral interosseous ligament

PURPOSE

The human lunotriquetral ligament (LTL) is a functionally important intrinsic hand ligament, which is assumedly subjected to insertion angle changes at the entheses during movement. To clarify whether the current model of the ligament's mechanical environment is reflected in its structural composition, we determined the regional distribution of extracellular matrix-related antigens.

METHODS

The extracellular matrix was immunohistochemically investigated in 12 LTLs from both wrists of 6 human donors (Mean age: 60 y).

RESULTS

The dorsal, proximal, and volar portions of the ligament immunolabeled for type I, III collagen and versican. Both entheses labeled strongly for type II collagen, aggrecan, and link protein and were distinctly cartilaginous. The ligament midsubstance was positive for collagen II in 30%, for aggrecan in 40%, and for keratocan and lumican in 100% of specimens. In contrast, keratocan and lumican were absent from the fibrocartilaginous entheses and the articular cartilage. Ligament insertion at a carpal bone occurs either directly through fibrocartilage or indirectly through a bilayered configuration of fibrocartilage and hyaline-like cartilage. The hyaline-like cartilage is continuous with the neighboring articular cartilage.

CONCLUSIONS

The LTL has an extracellular matrix comparable with that of ligaments experiencing a combination of tensile and shear/compressive load at the attachment sites. All regions of the LTL exhibit fibrocartilaginous entheses; purely fibrous attachment sites are rare. The ligament midsubstance shows a more fibrous phenotype than the entheses and expresses keratocan and lumican, which previously have not been recorded in any human hand ligament.

Ulnar-sided wrist pain: evaluation and treatment of triangular fibrocartilage complex tears, ulnocarpal impaction syndrome, and lunotriquetral ligament tears

Ulnar-sided wrist pain is a common cause of upper extremity disability. Presentation can vary from acute traumatic injuries to chronic degenerative conditions. Because of its overlapping anatomy, complex differential diagnosis, and varied treatment outcomes, the ulnar side of the wrist has been referred to as the "black box" of the wrist, and its pathology has been compared with low back pain. Common causes of ulnar-sided wrist pain include triangular fibrocartilaginous complex injuries, lunotriquetrial ligament injuries, and ulnar impaction syndrome.

Management of soft-tissue injuries in distal radius fractures

Distal radius fractures account for approximately 15% of all fractures in adults, and are the most common fractures seen in the emergency department. Soft-tissue injuries associated with distal radius fractures may influence strategies for the acute management of the fracture, but also may be a source of persisting pain and/or disability despite fracture healing. This article describes soft-tissue injuries and considerations for treatment associated with distal radius fractures, including injuries to the skin, tendon and muscle, ligaments, the triangular fibrocartilage complex, neurovascular structures, and related conditions such as compartment syndrome and complex regional pain syndrome.

[Chronic ulnar wrist pain in adults: diagnosis and treatment principles]

Adult patients with chronic ulnar wrist pain often seek medical advice. There are a number of diagnoses for chronic ulnar-sided wrist pain. A sound diagnostic strategy is therefore of paramount importance. Patient's history, clinical examination and high quality standard radiographs are the most important part of this strategy. Sophisticated investigations should only be performed to focus on solid clinical hypotheses. The palmar and dorsal aetiologies of ulnar wrist pain are considered as well as their treatment principles.