[Piso-triquetral osteoarthritis. Thirteen case reports and review of the literature]

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.

[Is there pisotriquetral instability after carpal tunnel release? Retrospective study of 55 cases]

The aim of this study was to determine if pisotriquetral instability is present after neurolysis of the median nerve in the wrist. Fifty-five patients who underwent carpal tunnel release between December 2005 and March 2009 were included in this retrospective study. The surgical procedure consisted of cutting the transverse carpal ligament under local anesthesia through an anterior approach. Instability was evaluated clinically and radiologically by measuring the pisometacarpal angle. The mean patient age was 61years and the mean follow-up 42months. Only 9% of patients complained of pain on the ulnar side of wrist. The pisometacarpal angle in all the operated wrists was the same as in the non-operated wrists. Our findings suggest there is no pisotriquetral instability after median nerve neurolysis.

Enthesiopathy of the flexor carpi ulnaris at the pisiform: findings of high-frequency sonography

OBJECTIVES

Acute or chronic pain at the pisiform may be due to tendinopathy of the flexor carpi ulnaris tendon (FCU) insertion, mechanical overuse, bony fractures, and osteoarthritis of the pisiform-triquetral joint. Enthesiopathy of the FCU at the pisiform might exhibit abnormalities assessable for sonographic characterization. This study aimed to determine the most relevant sonographic features of tendinopathy of the FCU insertion at the pisiform.

MATERIALS AND METHODS

We retrospectively analyzed radiological findings of 9 patients admitted for high-frequency sonographic evaluation of a painful pisiform FCU insertion. The FCU insertion was assessed for active enthesiopathy in terms of tendon thickening and hyperemia, peritendinous effusion, peritendinous hyperemia, peritendinous soft tissue thickening, cystic fluid collections, erosive cortical irregularities, and osteoproliferative alterations at the pisiform.

RESULTS

Of all patients, 5 had inflammatory rheumatic disorders and the remainder had a painful pisiform FCU insertion related to overuse. While peritendinous effusion, pisiform erosive cortical irregularities, and peritendinous soft tissue thickening at the FCU insertion were exclusively found in rheumatic patients, active enthesiopathy of the FCU tendon, pisiform osteoproliferative alterations, and hyperemia of the peritendinous soft tissue were inconsistent and found in both groups. Cystic fluid collections from the pisiform-triquetral joint were only seen in patients with overuse.

CONCLUSIONS

In this small case series of patients with pain at the pisiform FCU insertion, we could reveal several typical sonographic features for insertion tendinopathy. Further studies should prove if these sonographic features could impact on the management of patients with pain at the pisiform.

Pisiform ligament complex syndrome and pisotriquetral arthrosis

PLC syndrome is a spectrum that encompasses PLC instability and ends with PTA. Early recognition and treatment of PLC instability may disrupt its progression to PTA. The pisiform tracking test is a provocative maneuver that aids in diagnosing PLC syndrome. Pisiformectomy with preservation of the soft tissue confluence remains the treatment of choice for severe PLC syndrome that does not respond to nonoperative treatment.

Kinematics of the wrist using 2D and 3D analysis: biomechanical and clinical deductions

Surgery of the wrist relies on the known notions of biomechanics of the wrist. But these notions are incomplete. For a better understanding of the movements of the wrist, we studied five wrists of healthy volunteers with CT scanning. Each wrist was studied in neutral position, and in the four extreme positions: flexion, extension, radial and ulnar deviations. Using oblique reformatted CT sections, we measured the angular displacements in frontal and sagittal views of every carpal bone in the different positions of the wrist. This allowed us to construct a table of intracarpal mobility. By comparing the angle values and the three-dimensional pictures of these wrists, we illustrate some fundamental points regarding intracarpal movement. The dynamics of the wrist are like those of two super-imposed mobile cups with different movements. The proximal row is malleable with flattening and torsion according to the transverse axis and its behavior is like that of an articular meniscus. The distal row, more rigid but deformable, behaves like a T-handle giving attachment to the hand and articulating under the proximal row around the head of the capitate and the proximal pole of the hamate. During radial and ulnar deviations of the wrist, the movement between the two rows is like an inverse pronation-supination shearing. During flexion-extension, the distortion of the two rows allows maximal congruence to be maintained between the different carpal bones.

[Traumatic dislocation of the pisiform bone: a case report and review of the literature]

Traumatic dislocation of the pisiform bone is uncommon. The authors report a case treated by primary excision with a good result. The literature is reviewed and treatment choices are discussed.