The effect of pisiform excision on wrist function

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.

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.

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.

Arthroscopic Pisiform Excision in Pisotriquetral Osteoarthritis Technique Using a Direct Pisotriquetral Portal

Pisotriquetral (PT) joint arthritis is a common cause of ulnar-sided wrist pain. Open pisiform excision is a well-established procedure and is indicated when the conservative treatment fails. Although arthroscopic visualization of the PT joint is part of the routine examination in a patient with ulnar-sided wrist pain, therapeutic arthroscopy of the PT joint is limited to one case in the literature through the standard dorsal portals. Arthroscopic pisiform excision is a novel technique described by the authors. The first aim of this procedure is pain relief maintaining wrist stability and strength. With this minimally invasive approach we believe that preserving the flexor carpi ulnaris and the PT ligament complex we maintain their biomechanical function, while at the same time, reducing scar tenderness and postoperative discomfort with better esthetic results and less recovery time. In addition to standard dorsal portals, a direct PT portal was used to have access to the PT space and as a working portal to complete the pisiform excision.

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.

Does pisiform subluxation affect the postoperative outcomes in a cohort of patients with distal radius fractures?

Background

In this study, we retrospectively surveyed the presence or absence of pisiform subluxation in surgically treated distal radius fractures (DRF) cases. In addition, we investigated whether or not the postoperative short-term treatment outcome differs due to the presence of pisiform subluxation.

Materials and methods

The subjects were 134 DRF patients treated with volar locking plate fixation (53 males and 81 females, mean age: 64 years old). The pisotriquetral joint was observed on a preoperative CT to investigate the presence or absence of pisiform subluxation according to the criteria reported by Vasilas. 134 patients divided into subluxation group and non-subluxation group, and the clinical outcomes were compared between these groups.

Results

Pisiform subluxation was noted in 23.1% (31 patients, 15 males and 16 females, mean age 61 years). No significant difference was noted in patient background in both groups. The postoperative pronation angle in the non-subluxation group was significantly greater than that in the subluxation group, but there was no significant difference in any other parameter (the range of motion of the wrist, grip strengths, VAS, Q-DASH scores, and Mayo score) between these 2 groups. However it concomitantly occurred in 23.1% of DRF cases in our series, there was no significant difference in the postoperative treatment outcome between these 2 groups.

Conclusions

Therapeutic intervention of pisiform subluxation is unnecessary during treatment of DRF, since pisiform subluxation does not affect the postoperative clinical outcomes of distal radius fractures.

•

Pisiform subluxation occurred in 23.1% of distal radius fracture cases, suggesting that it is not a rare pathology.

•

Therapeutic intervention of pisiform subluxation may be unnecessary during treatment of distal radius fracture.

•

The therapeutic intervention of pisotriquetral joint disorders should be considered when they develop.

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.

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.

Joint Space Narrowing in Patients With Pisotriquetral Osteoarthritis

BACKGROUND

Patients with suspected pisotriquetral osteoarthritis may show joint space narrowing. However, the extent of joint space narrowing and its deviation from the joint space width (JSW) in normal anatomy is unknown. In this pathoanatomic study, we therefore compared the JSW in the pisotriquetral joint between osteoarthritic patient wrists and healthy wrists.

METHODS

We reviewed preoperative computed tomography (CT) scans of 8 wrists of patients with ulnar-sided wrist pain who underwent a pisiformectomy with confirmed pisotriquetral osteoarthritis at surgery. We also reviewed CT scans of 20 normal wrists from healthy volunteers serving as control group. Three-dimensional CT models of the pisiform and triquetrum were obtained from both affected and normal wrists, after which the minimum JSW was calculated in an automated fashion.

RESULTS

In the patient group, the median (interquartile range) of the minimum JSW was 0.1 mm (0.0-0.2), and in the control group, 0.8 mm (0.3-0.9) ( P = .007).

CONCLUSIONS

We showed that the pisotriquetral joint space in osteoarthritic patient wrists was significantly narrowed compared with healthy wrists. These results suggest that JSW evaluation has a potential diagnostic value in the work-up of patients with suspected pisotriquetral osteoarthritis. This is an interesting area for future clinical research, especially because no gold standard for diagnosing pisotriquetral osteoarthritis has been established yet.

Observer Variability in Evaluating Pisotriquetral Osteoarthritis using Pisotriquetral View

A pisotriquetral (semilateral) view of the wrist may improve the assessment of pisotriquetral osteoarthritis (OA), but its reliability and reproducibility are unclear. The purpose of this cross-sectional observer study was to investigate (1) the inter- and intraobserver agreement of evaluating pisotriquetral OA using pisotriquetral views with a special focus on sclerosis, joint space width (JSW) narrowing and osteophyte formation, and (2) the incidence of these latter radiographic features in patients suspected for pisotriquetral OA. Five independent observers rated independently at two different occasions 27 pisotriquetral views from patients treated for ulnar-sided wrist pain suspected for pisotriquetral OA requiring a pisiform resection. The agreement was calculated using kappa statistic. Agreement between observers ranged from 0.38 (fair) to 0.56 (moderate). Average intraobserver agreement ranged from 0.43 (moderate) to 0.52 (moderate). In 36% of the ratings, JSW narrowing was observed, followed by osteophyte formation (30%) and sclerosis (28%). Observers found it especially difficult to detect JSW narrowing. Despite the availability of a pisotriquetral view to enhance visualization of the pisotriquetral joint, assessment of the specific features indicating pisotriquetral OA leads to only fair-to-moderate agreement. This limits the applicability of a radiographic assessment. A rationale for a more reliable radiologic approach in assessing the level of pisotriquetral OA is needed, which may require the use of more advanced imaging techniques.

Hand and Wrist Injuries in Golfers and Their Treatment

A thorough understanding of the swing phases and mechanisms of injury in golf allows accurate diagnosis, treatment, and future prevention of injuries. Recommended initial treatment starts with cessation of practice to rest the wrist, a splint or orthotic brace, and nonsteroidal antiinflammatory drug medication with corticosteroid injection and swing modification. Pisiform excision is the best treatment of the most severe chronic cases of pisiform ligament complex syndrome. Delayed diagnosis of hook of hamate fracture may lead to complications, including flexor tendon rupture. Prompt surgical resection is recommended to hasten return to sport and to prevent further complications.

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.