Pisiform excision for pisotriquetral instability and arthritis

Isolated Osseous Excision in the Adult Carpus: A Narrative Review

Various pathologies of the adult carpus result in clinical scenarios where excision can be considered and even recommended. In the appropriate patient population, isolated carpal excision can alleviate pain and improve mobility. Excisions of the pisiform, trapezium, and trapezoid have abundant literature evidence to support positive long-term functional outcomes. In contrast, isolated excision of the capitate, hamate, and triquetrum has limited support in the literature secondary to compromise of carpal mechanics and lead to recurrent pain. Additionally, isolated scaphoid and lunate excision are best avoided secondary to carpal collapse and should be paired with concomitant stabilizing procedures in the carpus. This article provides a comprehensive literature review of isolated excision of each osseous carpal bone, their indications, and previously assessed outcomes.

Carpal dislocations

Carpal dislocations result from sequential disruption of the complex relationship between the bones and ligaments of the wrist. Injuries to the carpus occur via predictable mechanisms, an understanding of which is critical to identify and treat these frequently missed patterns of injury and to avoid the sequela of chronic instability. Lunate dislocations are by far the most common, but isolated dislocation of other carpal bones can also occur. Open reduction and internal fixation still remains the gold standard for treatment regardless of the debate around the specific approaches. These high-energy injuries are associated with significant long-term morbidity even when identified promptly and appropriately treated. This review will focus on the evaluation and management of common forms of carpal dislocations.

Patient Satisfaction with Pisiform Excision for Pisotriquetral Instability or Arthritis: A Prospective Review

Background  Pisotriquetral pain and instability is an elusive cause of ulnar-sided wrist pain. Initial treatment of chronic pisotriquetral pathology should involve a trial of nonoperative therapy such as neutral wrist splint, anti-inflammatories, and intra-articular steroid injections. The mainstay of surgical management of pisotriquetral pain is pisiform excision. Purpose  This prospective study seeks to understand patient satisfaction after pisiform excision in patients with isolated pisotriquetral pathology. Patients and Methods  A consecutive series of nine cases of pisiform excision was performed by the senior surgeon. The primary outcome measure was determined a priori to be the Patient-Rated Wrist Evaluation (PRWE) score. Wrist range of motion, grip strength, and QuickDASH (shortened version of Disabilities of the Arm, Shoulder and Hand) scores were also collected preoperatively and at 3 and 12 months postoperatively as secondary outcome measures. Results  There was a very rapid improvement in the PRWE by 3 months, which was maintained at 12 months. The QuickDASH score was slower to improve, with a significant improvement by 12 months. There was no change in grip strength or wrist range of motion at any time point. Conclusion  Pisiform excision results in a very rapid improvement of symptoms and should be considered in cases of pisotriquetral instability or arthritis that fail conservative management. Level of Evidence  Level IV, case series.

Closed rupture of a flexor profundus tendon to the little finger caused by asymptomatic pisotriquetral osteoarthritis: A case required differentiation from the tendon rupture due to hamate bony irregularity by bone erosion

Carpal joint osteoarthritis and the formation of bony irregularities of the carpal bone cause closed flexor tendon ruptures. This report describes a case of a flexor profundus tendon closed rupture of the little finger due to asymptomatic pisotriquetral osteoarthritis in a 73-year-old woman, which required differentiation from tendon rupture due to hamate bony irregularity due to bone erosion. Computed tomography showed cortical bone irregularities of the hamate and the narrowing of the pisotriquetral joint space, and a bony spur on the radial side of the pisiform. Intraoperative findings revealed the capsule of the pisotriquetral joint was torn on the radial side. Pisiform-hamate ligament disruption and the bony spur on the pisiform were found on this side. However, the flexor tendon floor on the hamate was intact. Surgical resection of the pisiform and a free tendon interposition graft for tendon rupture restored the good function of the little finger. Particular attention should be paid in making the diagnosis in cases with multiple possible triggers for closed flexor tendon rupture.

Vascularized pisiform graft for the treatment of scaphoid nonunion: An anatomical study

Scaphoid fracture can evolve into scaphoid nonunion leading to wrist arthritis. Vascularized bone flaps used to treat scaphoid nonunion are supplied by delicate, small, or short arteries that are not always reliable. The pisiform bone has never been considered as a possible treatment of scaphoid nonunion since the traditionally harvested pedicle is too short. This study aimed to characterize the vascularization of the pisiform with the goal of developing a method of harvesting it with a longer pedicle that can be used as a graft to treat scaphoid nonunion. A cadaver study on 30 upper limbs was done in two parts: firstly, we dissected 20 cadaver specimens and documented the pisiform's vascularization (size, length, and articular surface) as well as anatomical characteristics of the dorsal ulnar artery; secondly, we used 10 cadaver specimens to study an experimental surgical procedure in which a vascularized pisiform graft is used to treat an artificially created nonunion and confirm its feasibility. The pisiform artery originated from the dorsal ulnar artery in all 20 dissections. Its average length of 4.036cm could be increased by 11% by ligating the upstream collateral branches from the dorsal ulnar artery. The pedicled vascularized pisiform flap was grafted to the scaphoid in 10 experimental procedures performed on fresh cadavers. The vascularized pisiform graft consists of a reliable vascular pedicle and well vascularized multi-cortical bone with a cartilaginous surface. However, more studies are needed to confirm the feasibility of this flap as an alternative for treating unstable scaphoid nonunion.

Long-Term Results of Pisiformectomy in a Cohort of 57 Patients

Background  Excision of the pisiform is an infrequently used option for pisotriquetral joint dysfunction when nonoperative treatment is ineffective. This study reviews the patient-reported outcomes of patients treated with pisiformectomy, and furthermore focuses on the complications and the need for and time to revision procedure. Materials and Methods  Medical records of 57 patients were manually reviewed and assessed for complications, rate of unplanned reoperations, and type of reoperations. Thirty-seven patients (65%) completed patient-rated outcomes surveys at a median of 10 years after their procedure. Results  The complication rate was 13% ( n  = 7). Ulnar nerve symptoms were noted in three patients. No reoperations were performed after the pisiform excision. Out of the 16 patients who had preoperative symptoms of ulnar nerve compression at the wrist, 10 patients reported that their symptoms had completely resolved after the surgery. The median Quick Disability of Arm, Shoulder and Hand (QuickDASH) score after surgery was 4.5 (2.3-16), median score for pain 0 (interquartile range [IQR]: 0-2), and median score for overall satisfaction 10 (IQR: 8-10). Conclusions  Pisiformectomy is a surgery used sparingly in cases with refractory pain associated with arthrosis of the pisotriquetral joint or enthesopathy of the flexor carpi ulnaris/pisiform interface. When utilized in this fashion, patients report limited disability on patient-rated outcome measures, low pain scores, and high satisfaction at mid- to late follow-up.

Acute ulnar nerve compression associated with pisiform fracture - a case report and literature review

We evaluated a case of pisiform fracture with ulnar nerve compression managed with pisiformectomy. At 11 months’ follow-up, the patient regained range of motion of the wrist and grip strength with no subjective loss of function and normal nerve conduction study. We compared other treatment modalities and reviewed their outcomes.

Pisotriquetral Pain Treated with Bilateral Pisiform Excision in a Collegiate Diver

Background  Pisiform excision and pisotriquetral arthrodesis are two surgical options for the treatment of pisotriquetral joint pain when conservative methods fail. However, it is unclear which option is best for patients who experience substantial, repetitive loading on their wrists and wish to preserve wrist flexibility and function. Case Description  We present a case of bilateral ulnar-sided wrist pain related to the pisotriquetral joint in a 19-year-old collegiate diver. The pain was exacerbated by activities specific to this sport that requires wrist hyperextension, namely full weight-bearing on the hands (handstands), and has an impact on the hands and wrists upon water entry during dives due to direct palmar pressure. There were no radiographic signs of arthritis; however, there were bone marrow changes on magnetic resonance imaging (MRI). Management with rest, splinting, and corticosteroid injection failed to relieve the pain and precluded his ability to return to full-time diving. Treatment consisted of bilateral pisiform excision. Postoperatively, the patient returned to full-time competitive diving with resolution of his painful symptoms. Literature Review  Pisiform excision has been shown to have successful outcomes in terms of return to play for lower impact athletes (such as badminton) but has not been reported in athletes who experience a high degree of force repetitively (such as gymnasts or divers). There is one report of pisotriquetral arthrodesis in a young gymnast with suboptimal results. Clinical Relevance  This case report demonstrates that pisiform excision is a successful treatment for elite athletes who experience repetitive, palmar force on hyperextended wrists and subsequently develop ulnar-sided wrist pain.

Treatment of Pisotriquetral Arthritis by Pyrocarbon Interposition Arthroplasty

Purpose  Pisiformectomy is the baseline treatment for pisotriquetral arthritis when medical treatment fails to address the problem. This operation may lead to loss of mobility and strength in the wrist. This study reports the short-term outcomes of a new technique for treating pisotriquetral arthritis using a pisotriquetral interposition arthroplasty with a pyrocarbon implant. Patients and Methods  We performed a clinical and radiographic study on a series of eight patients who received this treatment at a mean follow-up of 2.8 years. We also studied the mobility of the implant and did assessed articular instability using dynamic radiology and fluoroscopy. Results  We observed one proximal dislocation of the implant in one hand which was reoperated to reposition the implant and strengthen the capsule. All patients were satisfied or very satisfied with their operation and had an average functional recovery period of 1.6 months. At the last follow-up, the Mayo Wrist Score (MWS), Quick Disability of Arm Shoulder and Hand (QDASH), and Patient-Rated Wrist Evaluation (PRWE) scores were 89, 18, and 20, respectively. Postoperatively, there was a 22% improvement in the grip strength of the wrists as well as improved mobility, mainly as regards the radioulnar deviation (47% improvement) and the Visual Analogue Scale (VAS) pain scores decreased from 8 preoperatively to 2 at the latest follow-up. The functional radiologic and fluoroscopic study reported good adaptive mobility of the implant in all the patients, without any indication of pisotriquetral joint instability. Conclusion  The short-term results of pisotriquetral arthroplasty using the Pyrocardan implant are encouraging. This new surgical solution appears to be a valid alternative to pisiformectomy or pisotriquetral arthrodesis. Long-term studies are required to confirm these preliminary findings.

Suture Fixation Using Polyblend Polyethylene Sutures With Hydroxyapatite Block for an Intra-articular Depression Fracture of the Pisiform Bone

Few cases in which open reduction and internal fixation was performed for displaced pisiform fractures have been reported. We present a new surgical technique for the treatment of depressed intra-articular pisiform fractures. First, the depressed fragment was reduced by pushing the bone tamp. Then, the fracture void resulting from the reduction of the depressed fragment was filled with a shaped hydroxyapatite block. Finally, the fragments were sutured using braided polyblend polyethylene sutures. The postoperative radiography could achieve a well-reduced articular facet, and this procedure had a good clinical outcome.

Management of Pisotriquetral Instability

Pisotriquetral instability is an often-overlooked condition that can lead to ulnar-sided wrist pain and dysfunction. Various case series and biomechanical studies have been published regarding the diagnosis and treatment of this condition. We review current methods for examining, diagnosing, and treating pisotriquetral instability.

Uncommon carpal fractures

Fractures of the hand are frequently encountered with injuries to the phalanges and metacarpals comprising the vast majority. Fractures of the carpal bones excluding the scaphoid, however, are fairly uncommon. Despite the rarity of fractures of the remaining seven carpal bones, they can cause a disproportionate amount of morbidity from missed diagnosis due to their subtlety as well as their frequent association with significant ligamentous disruption or even other carpal bone fractures. Delayed diagnosis can result in inadequate fracture care, which places the wrist at risk of disabling sequelae. This review focuses on the current concepts of pathophysiology, diagnosis, and treatment of carpal fractures other than the scaphoid.