Scaphotrapeziotrapezoid arthrodesis: a follow-up study

Scaphocapitate Arthrodesis for Wrist Deformities: A Systematic Review

Background

Scaphocapitate arthrodesis (SCA) is a described technique for chronic wrist pathology such as Kienbock disease and carpal instability. The technique aims to preserve motion, while maintaining carpal height, preserving the radioscaphoid articulation, and offloading the lunate. Limited case series evaluate the outcomes of this previously described technique. We aim to determine if the collective, updated literature on outcomes of SCA support its continued application by the wrist surgeon. Furthermore, we investigated if any technical variations offer an advantage in improving patient-reported outcomes after SCA.

Methods

A literature search was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles selected for critical review were examined for patient demographic data, functional outcomes, radiographic outcomes, and complications. A qualitative analysis was then performed to synthesize the available date.

Results

A total of 18 unique articles published between 1991 and 2022 were identified, representing a total of 285 individual cases of SCA. Nonunion rate ranged 0%-22%. Preoperative visual analog scale pain scores ranged from 3.2 to 10, whereas postoperative visual analog scale pain scores ranged from 0 to 4. Patient-reported outcomes are reported by validated instruments, including the Disabilities of the Arm, Shoulder, and Hand, QuickDASH, Patient-rated Wrist Evaluation, and Mayo Wrist Score.

Conclusions

SCA is a viable treatment option for patients with Kienbock disease. SCA offers reliable improvements in patient pain, grip strength, and patient-reported outcomes.

Biomechanical evaluation of the wrist after scaphotrapeziotrapezoid arthrodesis

BACKGROUND

The main objective of the present study was to present the biomechanical properties of the wrist in patients who underwent scaphotrapeziotrapezoid arthrodesis when compared to a healthy control hand.

METHODS

The study group consisted of 29 consecutive patients who underwent a scaphotrapeziotrapezoid wrist arthrodesis at least 1 year before the research onset. Both hands of all patients were examined in 4 main categories.

RESULTS

Average score obtained in the VAS, before the surgery, without motion of the wrist was 5.21 (SD = 3.04), whereas with wrist motion, it was 8.10 (SD = 1.37). Nineteen (65.52%) patients exhibited weakened wrist muscle strength. After the surgery, only 5 (17.24%) patients declared pain in the wrist. Furthermore, the results obtained in the VAS statistically significant differed from the ones before (p < 0.05). Twenty-eight (96.55%) patients were able to resume their profession. Twenty-seven (93.10%) patients stated that they would opt for the operation again. The peak torque during the analysis of extension of the wrist in the isometric protocol was found to be 8.1 Nm (SD = 2.9), 7.9 Nm (SD = 2.3), and 7.9 Nm (SD = 2.5) in the operated hands and 10.9 Nm (SD = 3.2), 9.6 Nm (SD = 2.9), and 9.1 Nm (SD = 3.8) in non-operated hand for 30° extension, no-flexion, and 30° flexion positions, respectively (p < 0.05).

CONCLUSION

The current study is the first to present the biomechanical parameters of flexor and extensor muscles of the wrist and fingers in patients after the said procedure. Biomechanical assessments with additional isometric, isotonic, and isokinetic tests provide an opportunity to objectify treatment outcomes and guide appropriate rehabilitation by monitoring its effects.

LEVEL OF EVIDENCE

III.

Arthroscopic Scaphotrapeziotrapezoid Joint Fusion for Osteoarthritis

Background: Arthroscopic scaphotrapeziotrapezoid (STT) fusion (ASTTF) has emerged in the recent decade as an option for traditional open surgery. This retrospective study describes our technique and results of ASTTF. Methods: Medical records and radiological data of patient who had undergone ASTTF between 2014 and 2022 in two tertiary hospitals were reviewed. Results: Five ASTTF in four patients were identified. The mean age of the patients were 52.4 years. Fusion was achieved in four out of five wrists (80%). The mean postoperative radio-scaphoid angle was 48°, grip 32 kg (70% compared to contralateral hand), extension 54° (86%) and flexion 46° (93%). The mean follow-up time was 18 months (range 5 months to 4 years). One wrist (20%) developed STT non-union requiring a reoperation 2 years after index surgery. Conclusions: ASTTF is a technically challenging procedure with a long learning curve and surgery time. However, ASTTF is less invasive compared to the open procedure and our results were like the open procedures described in literature. Further studies are needed to compare the benefits and results of open and ASTTF in a prospective and randomised setup. Level of Evidence: Level IV (Therapeutic).

Management of Scaphotrapeziotrapezoid Osteoarthritis: A Critical Analysis Review

» The scaphotrapeziotrapezoid (STT) joint is a common location of degenerative osteoarthritis (OA) in the wrist.» STT OA may occur in isolation or with concomitant thumb carpometacarpal joint (CMCJ) OA or scapholunate advanced collapse (SLAC) and other wrist OA patterns.» Nonoperative management strategies include activity modification, bracing, anti-inflammatory medications, occupational therapy, and injections.» Surgical treatment may be determined by whether the STT OA occurs in isolation or with concomitant thumb CMCJ or SLAC OA and includes STT arthrodesis, distal scaphoid excision with or without interposition or implant arthroplasty, trapeziectomy with proximal trapezoid excision, four-corner fusion in combination with scaphoid/radial column excision, and proximal row carpectomy.

Modified Graner's Technique with\without Vascularized Capitate Lengthening for Kienböck Disease Stage IIIb-A Pilot Study

Background  Intercarpal fusions are used to treat stage IIIb Kienböck disease. They increase force transfer across the radioscaphoid articulation with predisposition to arthritis. Description of Technique  This technique is excision of lunate followed by proximal transfer of capitate, with scaphocapitate and triquetrocapitate fusion to increase area of load transfer mimicking wrist hemiarthroplasty. Our purpose is to evaluate mid-term results of this technique. Patients and Methods  A prospective case series study was conducted on 11 patients with stage IIIb and IIIc. In seven cases, transfer of the capitate was performed by osteotomizing the capitate just distal to its waist, proximal migration to replace the excised lunate then bone grafting. In four cases, proximal transfer of vascularized pedicled capitate was done. Clinical outcome measures included pain (visual analog scale), grip strength, range of motion, and functional evaluation by modified Mayo wrist score and scoring system of Evans. Radiological outcome measures included healing of fusion mass, progression of the disease, and occurrence of avascular necrosis to the capitate. Results  Follow-up period averaged 54 months. Scaphocapitate fusion healing averaged 11 weeks. Union of the lengthened capitate occurred in 10 patients only. There was postoperative improvement in pain scores, grip, Evans, and modified Mayo wrist score. There was postoperative decrease in wrist flexion and extension. One patient showed resorption of the capitate head with progressive radioscaphoid arthritis-necessitated wrist fusion. Conclusion  The mid-term results of this technique may be satisfactory due to low incidence of degenerative arthritis in the radioscaphoid joint. However, longer follow-up with recruiting larger number of patients is needed.

Intercarpal arthrodesis: A systematic review

Intercarpal arthrodesis is a well-established option to treat various disorders of the carpus, such as localized osteoarthritis, carpal instability, and Kienböck's disease. This is a non-conservative procedure aimed at obtaining a stable and congruent interface between the radius and the proximal carpal row, which restores wrist function by minimizing pain and restoring grip strength. These procedures generally yield good predictable results that are maintained over time. However, all intracarpal arthrodesis procedures cause a loss of wrist range of motion. To optimize outcomes and minimize complications, especially nonunion, this surgery may require a learning curve. A precise surgical technique for preparing the bone surfaces, bringing enough bone graft, and using reliable fixation is essential. Since the late 1960s, several intracarpal arthrodesis procedures have been described. Commonly used fusions target the scaphotrapeziotrapezoid, scaphocapitate, four corners, capitolunate or capitohamatolunate regions. Lesser used fusions focus on specific lesions such as the scapholunate, scapholunocapitate, lunotriquetral and triquetrohamate. Here, we propose a systematic review of the various types of intercarpal arthrodesis procedures described in the literature. After having described each arthrodesis, we specify their indications, the variations of the surgical techniques, and then present an overview of the results and complications. Finally, we discuss how these surgeries affect wrist biomechanics. LEVEL OF EVIDENCE: III.

The INCA® implant to treat isolated scaphotrapeziotrapezoid osteoarthritis: Preliminary results at a minimum 2 years' follow-up

We report results with the INCA® distal scaphoid pole resurfacing implant anchored within the scaphoid for isolated scaphotrapeziotrapezoid osteoarthritis. Thirty-five implants in 27 patients (mean age, 69 years) were retrospectively included with a minimum follow-up of 2 years. Outcome criteria were pain (VAS), PROMs (QuickDASH, PRWE and MMWS), wrist motion, pinch and grip strength, and radiographic assessment. The average follow-up was 4.6 years. There was a significant improvement in pain, PROMs, grip and pinch strength. Radial deviation and wrist extension showed slight but significant postoperative decrease (-4° for both). Dorsal intercalated segment instability (DISI) was significantly improved postoperatively (7 cases versus 21 preoperatively). There were 2 cases of implant loosening (6%) within the first 10 months: 1 keel malpositioning and 1 insufficient postoperative immobilization. These findings suggest that the INCA® implant is an effective and reliable medium-term solution for isolated scaphotrapeziotrapezoid osteoarthritis. By restoring scaphoid length and gliding on the trapeziotrapezoid surface, the implant contributes to restoring normal bone alignment of the wrist.

Scaphotrapeziotrapezoid Arthrodesis: A 10-Year Follow-up Study of Complications in 58 Wrists

BACKGROUND

Scaphotrapeziotrapezoid (STT) arthrodesis is a procedure used for specific degenerative arthritis and instability patterns of the wrist. This study evaluates nonunion rate and risk factors for reoperation after STT arthrodesis in the Veterans Affairs Department patient population. The purpose of our study was to assess the long-term nonunion rate following STT arthrodesis and to identify factors associated with reoperation.

METHODS

The national Veterans Health Administration Corporate Data Warehouse and Current Procedural Terminology codes identified STT arthrodesis procedures from 1995 to 2016. Frequencies of total wrist arthrodesis (TWA) and secondary operations were determined. Univariate analyses provided odds ratios for risk factors associated with complications.

RESULTS

Fifty-eight STT arthrodeses were performed in 54 patients with a mean follow-up of 120 months. Kirschner wires (K-wires) were the most common fixation method (69%). Six wrists (10%) required secondary procedures: 5 TWAs and 1 revision STT arthrodesis. Four patients underwent additional procedures for nonunion (7%). Twenty-four patients required K-wire removal, 8 (14%) of these in the operating room, which were not included in regression analysis. Every increase in 1 year of age resulted in a 15% decrease in likelihood of reoperation (95% confidence interval: 0.77-0.93; P < .0001). Opioid use within 90 days before surgery (P = 1.00), positive smoking history (P = 1.00), race (P = .30), comorbidity count (P = .25), and body mass index (P = .19) were not associated with increased risk of reoperation.

CONCLUSIONS

At a mean follow-up of 10 years, patients undergoing STT arthrodesis have a 10% risk of reoperation, and this risk decreases with older patient age. There was a symptomatic nonunion rate of 7%, similar to prior published rates. Patient demographics, comorbidity, smoking history, and opioid use did not appear to increase risk of reoperation.

Pyrocardan Scaphotrapeziotrapezoid Joint Arthroplasty for Isolated Osteoarthritis: Results after a Mean Follow-Up of 5 Years

Background  Isolated scaphotrapeziotrapezoid (STT) osteoarthritis (OA) mainly develops in women over 50 years of age in a bilateral manner. Many surgical treatments are available, including distal scaphoid resection with or without interposition, trapeziectomy, and STT arthrodesis. However, there is a controversy about which procedure is the most effective. Purposes  The purpose of this study was to report the outcomes of the Pyrocardan implant for treating STT isolated OA at a mean follow-up of 5 years. Patients and Methods  Consecutive patients who underwent STT arthroplasty using the Pyrocardan were reviewed retrospectively by an independent examiner who performed a clinical and radiological evaluation. Results  The mean follow-up time was 5 years (range 3-8 years). Thirteen patients (76%) were followed for more than 5 years. Between the preoperative assessment and the last follow-up, pain levels decreased significantly. There was no significant difference in the mean Kapandji opposition score. Grip and pinch strengths were 88 and 91% of the contralateral side. The active range of motion in flexion-extension and radioulnar deviation was not significantly different to the contralateral side (119° vs. 121° and 58° vs. 52°, p  > 0.1). Functional scores were improved significantly. No identifiable differences were found in the radioscaphoid, capitolunate, and scapholunate angles before and after surgery. In three cases, the preoperative dorsal intercalated scapholunate instability (DISI) failed to be corrected. In one case, DISI appeared after the procedure. There was one asymptomatic dislocation of the implant. Calcification around the trapezium and/or distal scaphoid was found in four cases. The survival rate of the implant without reoperation was 95%. Conclusions  In the medium term, Pyrocardan implant is an effective treatment for STT OA as it reduces pain, increases grip strength, and maintains wrist mobility. This is consistent with the results of other published case series using pyrocarbon implants. It provides a high rate of patient satisfaction. Nevertheless, the surgical procedure must be done carefully to avoid STT ligament damage, periarticular calcifications, or dislocation.

Scaphotrapeziotrapezoid Arthrodesis: Systematic Review

PURPOSE

Scaphotrapeziotrapezoid (STT) arthrodesis surgery is used for various types of wrist pathologies. The objective of our study was to perform a systematic review of complications and outcomes after STT arthrodesis.

METHODS

Several major databases were used to perform a systematic literature review in order to obtain articles reporting complications and outcomes following STT arthrodesis. The primary purpose was to identify rates of nonunion and conversion to total wrist arthrodesis. Secondary outcomes included wrist range of motion, grip strength, and Disabilities of the Arm Shoulder and Hand scores. A multivariable analysis was performed to evaluate factors associated with the primary and secondary outcomes of interest.

RESULTS

Out of the 854 records identified in the primary literature search, 30 studies were included in the analysis. A total of 1,429 procedures were performed for 1,404 patients. The pooled nonunion rate was 6.3% (95% CI, 3.5-9.9) and the rate of conversion to total wrist arthrodesis following the index STT was 4.2% (95% CI, 2.2-6.7). The mean pooled wrist flexion was 40.7° (95% CI, 30.8-50.5) and extension was 49.7° (95% CI, 43.5-55.8). At final follow-up, the mean pooled grip strength was 75.9% (95% CI, 69.3-82.5) of the nonsurgical contralateral hand. Compared with all other known indications, Kienbock disease had a statistically significant lower nonunion rate (14.1% vs 3.3%, respectively). Mixed-effects linear regression using patient-level data revealed that increasing age was significantly associated with complications, independent of occupation and diagnosis.

CONCLUSIONS

Our study demonstrated a low failure rate and conversion to total wrist arthrodesis after STT arthrodesis and acceptable postoperative wrist range of motion and strength when compared to the contralateral hand.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Incidental Bilateral Scaphotrapezial Coalition in a High-Level Throwing Athlete: A Case Report

CASE

Scaphotrapezial coalition is a rare carpal coalition and historically associated with congenital syndromes because it spans 2 carpal rows. We present the case of an 18-year-old collegiate baseball pitcher who was incidentally found to have bilateral scaphotrapezial coalition. He had no history of wrist pain and no functional limitations on physical examination. He had no family history of this condition and no personal history of congenital abnormalities.

CONCLUSIONS

Bilateral scaphotrapezial coalition can be an incidental and asymptomatic finding that is present even in high-level throwing athletes.

Scaphotrapeziotrapezoid arthrodesis for isolated osteoarthritis: results at a mean 8 years' follow-up

The aim of this retrospective study was to report medium- to long-term outcome of scaphotrapeziotrapezoid (STT) arthrodesis with staple fixation to treat painful isolated osteoarthritis (OA). Twenty-one consecutive patients (22 wrists) who had undergone STT arthrodesis were retrospectively reviewed by an independent examiner. Clinical and radiological evaluation was performed. At a mean follow-up of 8 years (range 2-20 years), pain levels were significantly decreased, and functional scores were significantly improved. Grip and pinch strength were 86% and 82% of those of the contralateral side. Wrist range of motion in flexion-extension and radial-ulnar deviation was significantly less than on the contralateral side at last follow-up (104° vs. 131° and 38° vs. 55°, respectively). Non-union was found on X-ray in 4 wrists (18%), but in 2 cases showed as partial non-union on CT, with complete scaphotrapezial consolidation; 1 of the 4 wrists required surgical revision. Another patient was re-operated on for symptomatic external staple displacement without non-union. There were 8 cases (36%) of radiographic narrowing of the styloscaphoid joint space; contact between the staple and styloid was found in all 8 cases. Four patients (18%) had narrowing of the scaphocapital joint space; protrusion of the proximal part of the staple into the joint space was noted in all 4 wrists. No differences were found for the radioscaphoid, capitolunate and scapholunate angles before and after surgery. STT arthrodesis with staple fixation to treat isolated STT OA led to a significant reduction in pain, with improved strength and functional scores. To avoid styloid impingement, we recommend systematic styloidectomy. Complete non-union seems to be overestimated on radiographs. Partial non-union with scaphotrapezial union should not be considered as a complication. LEVEL OF EVIDENCE: IV.

Scaphotrapeziotrapezoid osteoarthritis: From the joint to the patient

Scaphotrapeziotrapezoid osteoarthritis (STT OA) is common and often associated with thumb basal joint arthritis. Pain at the base of the thumb on the volar aspect and during resisted extension is characteristic of symptomatic STT OA. If conservative treatment fails, surgical treatment may be offered. In case of STT OA, treatment may range from arthrodesis to trapeziectomy (isolated or associated with ligament reconstruction and/or interposition). Any preoperative intracarpal instability (DISI) can be exacerbated by resecting more than 3 or 4 mm of the distal pole of scaphoid. For peritrapezial osteoarthritis, trapeziectomy is the logical solution, but it exposes the patient to known complications: loss of strength, long recovery, trapeziometacarpal impingement. Initial treatment of thumb basal joint arthritis by arthroplasty is also an option. Treatment of both sites is also possible by interposition of pyrocarbon implants. In all cases (isolated or associated STT OA) and no matter the technique chosen, maintaining the scaphoid height (arthrodesis, resection < 3 mm and/or associated interposition) and performing oblique trapezoidal osteotomy (to prevent scaphoid-metacarpal impingement) are the two crucial elements of surgical treatment.

Introducing the “SOAC Wrist”: Scaphotrapeziotrapezoid Osteoarthritis Advanced Collapse

Despite being the second most common osteoarthritis of the wrist, little is known about scaphotrapeziotrapezoid osteoarthritis. Not all patients with this type of osteoarthritis have symptoms, and, even in those symptomatic patients, the intensity of the complaint is not proportional to the severity of the degeneration. In symptomatic patients, when the conservative treatment fails, grading classifications to help define the surgical treatment are solely based on the joint characteristics, and fail to assess the rest of the carpus.

In general, most carpal degenerative processes show the same evolution pattern, which varies according to the initial injury, along with the type of deformity and the inherent instabilities. Thus, we hypothesize that the degenerative evolution due to primary osteoarthritis of the scaphotrapeziotrapezoid joint also follows a logical evolutionary sequence, similar to the one that occurs in cases of scapholunate advanced collapse (SLAC), scaphoid nonunion advanced collapse (SNAC), scaphoid malunion advanced collapse (SMAC), and scaphoid chondrocalcinosis advanced collapse (SCAC), thus resulting in scaphotrapeziotrapezoid osteoarthritis advanced collapse (SOAC). We have divided the SOAC into three groups, and considered that their treatment shall be guided by the evolutionary stage of the disease, and not by the surgeon's preferred technique.

[Revision surgery after failed (partial-) arthrodesis of the wrist]

(Partial) arthrodeses of the wrist have been proven cornerstones to treat many lesions for decades, especially in the case of revision surgery. Four-corner, scapho-trapezo-trapezoidal (STT), radio-scapho-lunate (RSL) and total wrist fusions are very common techniques in hand surgery. However, even these proven surgical procedures have significant non-fusion rates. Prior to revising a failed arthrodesis, it is essential to analyse the latter failure precisely. A technically adequate revision is only feasible when based on a correct and meticulous analysis. The understanding of the biological processes and technical aspects of the implants are the basis for solving this issue.

Osteonecrosis of the Lunate: Kienböck Disease

Kienböck disease, osteonecrosis of the lunate, is a well-known but poorly understood complication seen by hand surgeons. This review presents the background and important patient-specific parameters of the disease and reviews the numerous treatment options that exist for the disease.

The effect of surgery for basal osteoarthritis of the thumb on dart thrower's motion

This study aimed to identify the effects of basal thumb surgery on the range of dart thrower's motion. Thirteen fresh-frozen cadaveric specimens were placed in a customized jig. Simulated scaphotrapeziotrapezoid joint fusion was carried out on all specimens. Half the specimens then underwent trapeziectomy and the rest had excision of the distal pole of the scaphoid. Simulated scaphotrapeziotrapezoid fusion reduced the range of dart thrower's motion to 89% of the range in the intact wrists, from a mean of 117° to 104°. Although this reduction is not large, it was statistically significant. Simulated trapeziectomy caused a very small increase in dart thrower's motion range compared with the range in the intact wrists. Simulated distal pole of scaphoid excision did not change the range of dart thrower's motion. These results may inform preoperative decisions for surgical management of basal osteoarthritis of the thumb.

Surgical Management of Scaphotrapeziotrapezoid Arthritis

Scaphotrapeziotrapezoid (STT) arthritis occurs commonly with basal joint arthritis, but can also occur in isolation or in conjunction with other patterns of wrist arthritis, such as scapholunate advanced collapse. Surgical options depend on the specific clinical scenario encountered. Isolated STT arthritis was classically managed with arthrodesis, but is now often addressed with distal scaphoid resection (open or arthroscopic), trapeziectomy (partial or complete) and partial trapezoid resection, or implant arthroplasty. Development of postoperative dorsal intercalary segment instability is a notable concern with any of these techniques. STT arthritis in conjunction with basal joint arthritis can be managed effectively with trapeziectomy and either partial trapezoid excision or distal scaphoid excision. STT arthritis with scapholunate advanced collapse is uncommon, but can be managed with proximal row carpectomy or scaphoidectomy and four-corner fusion. If basal joint arthritis is also present, trapeziectomy can additionally be performed, but grip strength is likely to be substantially diminished.

Evaluation and Management of Scaphoid-Trapezium-Trapezoid Joint Arthritis

Degenerative arthritis at the articulation of the scaphoid, trapezium, and trapezoid (STT or triscaphe joint) is a common degenerative disease of the wrist. Pain and weakness with grip strength reduction and functional limitations when performing routine daily tasks are common complaints of patients with STT arthritis. Initial conservative treatments for STT arthritis include splinting, bracing, activity modification, anti-inflammatory medication, and steroid injections for pain relief. Failure of conservative treatment is the main indication for surgery, which may include distal scaphoid excision, with or without filling of the void after excision, trapeziectomy, STT arthrodesis, or STT implant arthroplasty.

Arthroscopic Distal Scaphoid Resection for Isolated Scaphotrapeziotrapezoid Osteoarthritis

PURPOSE

To investigate the radiographic and clinical results of arthroscopic distal scaphoid resection for isolated scaphotrapeziotrapezoid (STT) osteoarthritis and analyze the radiographic parameters associated with the functional outcomes.

METHODS

From 2008 to 2014, 17 wrists with symptomatic isolated STT osteoarthritis without carpal deformity underwent arthroscopic distal scaphoid resection. We evaluated visual analog scale (VAS) scores for pain, grip strength, pinch strength, and Patient-Rated Wrist Evaluation (PRWE) scores before surgery and at the final follow-up. We analyzed correlations between the resection height and the radiographic and functional outcomes.

RESULTS

The average follow-up period was 42 months. The average VAS score improved from 6.1 ± 2.3 before surgery to 1.7 ± 1.9 after surgery. The average grip strength improved from 18 ± 6 to 19 ± 9 kg, pinch strength from 2.5 ± 1.1 to 4.4 ± 1.7 kg, and PRWE score from 52 ± 23 to 32 ± 24. Carpal deformity (C-L angle of > 15°) was seen in 2 patients at the final follow-up. The deformity was more likely to occur when the resection height was greater than 3 mm.

CONCLUSIONS

Arthroscopic distal scaphoid resection alone can reduce pain and improve functional outcomes for early to mid-stage isolated STT osteoarthritis in patients without dorsal intercalated segment instability deformity. Resection of greater than 3 mm of the distal scaphoid may result in carpal malalignment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Distal Pole Resection of the Scaphoid for the Treatment of Scaphotrapeziotrapezoid Osteoarthritis

BACKGROUND

Distal pole resection of the scaphoid is one of the surgical techniques applied for the treatment of painful scaphotrapeziotrapezoid osteoarthritis (STT-OA).

METHODS

In this retrospective study, we evaluated midterm outcomes in a consecutive series of patients who underwent distal pole resection of the scaphoid: 13 patients (15 wrists) with a mean follow-up of 4.1 years. We examined objective functional and patient-reported outcome measures. In addition, we assessed the degree of dorsal intercalated segment instability (DISI) and postoperative complications.

RESULTS

All patients scored within a normal range on objective functional and patient-reported outcome measures. We observed a mild postoperative DISI deformity with an average lunocapitate angle of 22° (range, 0°-44°), which did not correlate with pain scores. In the opposite wrists, with and without STT-OA, the average lunocapitate angle was 6° (range, 0°-20°).

CONCLUSIONS

According to this study, midterm results for distal pole resection of the scaphoid are satisfactory.

Distal Radioulnar Joint Replacement in the Scarred Wrist

Background  Radiocarpal or midcarpal arthritis can occur simultaneously with arthritis of the distal radioulnar joint (DRUJ), leading to functional impairment of the wrist. Treatment often involves wrist arthroplasty or arthrodesis, either with simultaneous or secondary procedures, addressing the DRUJ. Successful treatment of solitary DRUJ arthritis with DRUJ replacement has been reported. However, outcomes in patients with multiple prior wrist surgeries are lacking. Surgery in these wrists is challenging because surgical scarring and advanced bone deformities make implant positioning more difficult. Therefore, the aim of this study was to evaluate the outcomes in patients that underwent total wrist arthrodesis and DRUJ replacement after multiple prior wrist surgeries. Methods  We prospectively enrolled patients that underwent total wrist arthrodesis and replacement of the DRUJ, either simultaneously or during separate procedures from 1999 to 2012. We included 14 patients with a median age of 43 years (interquartile range [IQR]: 35-47). As objective outcomes range of motion, weight-bearing ability, grip strength, was measured. For the subjective outcomes, we used an analogue pain score and the disabilities of the arm shoulder and hand (DASH) scores. Results  At a median follow-up of 5.6 years (IQR: 3.2-7.1). The average DRUJ range of motion and weight lifting ability significantly improved. As for the subjective evaluations, postoperative pain scores improved significantly, as did the DASH scores. Four of the patients had a postoperative complication, including infection and heterotopic ossification, of which two required reoperations. Additionally, 5 patients developed pisotriquetral arthritis requiring, pisiform excision, triquetrum excision, or the combination of both. Conclusion  Distal radioulnar joint replacement with a semiconstrained prosthesis was an effective method to restore the function of the wrist and forearm. As the surgical anatomy and soft tissue envelope were compromised in these patients, additional surgical exposure is necessary, adding to the complexity in these patients. No radiographic loosening Level of Evidence  This is a therapeutic level IV study.

Arthroscopic Management of Scaphoid-Trapezium-Trapezoid Joint Arthritis

Scaphoid-trapezium-trapezoid (STT) joint arthritis is a common condition consisting of pain on the radial side of the wrist and base of the thumb, swelling, and tenderness over the STT joint. Common symptoms are loss of grip strength and thumb function. There are several treatments, from symptomatic conservative treatment to surgical solutions, such as arthrodesis, arthroplasties, and prosthesis implant. The role of arthroscopy has grown and is probably the best treatment of this condition. Advantages of arthroscopic management of STT arthritis are faster recovery, better view of the joint during surgery, and possibility of creating less damage to the capsular and ligamentous structures.

Isolated scaphotrapeziotrapezoid osteoarthritis treatment using resurfacing arthroplasty with scaphoid anchorage

OBJECTIVE

The aim of this study is to show the results of scaphotrapeziotrapezoid (STT) joint osteoarthritis treatment performing resurfacing arthroplasty with scaphoid anchorage.

MATERIAL AND METHOD

An observational, descriptive and retrospective study was performed. Ten patients with isolated STT joint osteoarthritis were studied between 2013 and 2015. The mean follow-up time was 26months. Clinical results, functional and subjective scores were reviewed.

RESULTS

The patients were satisfied, achieving an average of 2.1 (0-3) on the VAS score and 16 (2 to 28) in the DASH questionnaire, and returning to work in the first three months post-surgery. Recovery of range of motion compared to the contralateral wrist was 96% in extension, 95% in flexion, 87% in ulnar deviation and 91% in radial deviation. The average handgrip strength of the wrist was 95% and pinch strength was 95% compared to the contralateral side. There were no intraoperative complications or alterations in postoperative carpal alignment.

CONCLUSION

Resurfacing arthroplasty is proposed as a good and novel alternative in treating isolated SST joint arthritis. Achieving the correct balance between the strength and mobility of the wrist, without causing carpal destabilisation, is important to obtain satisfactory clinical and functional results.

Flexor Tendon Ruptures After Distal Scaphoid Excision for Scaphotrapeziotrapezoid Osteoarthritis

BACKGROUND

Distal scaphoid excision is one treatment option for osteoarthritis of the scaphotrapeziotrapezoid (STT) joint following failure of conservative measures. Potential complications of this procedure include injury to the carpal ligaments, cartilage, and radial artery.

METHODS

A single case was identified by the senior author, and the medical record was reviewed for surgical notes, progress notes, and radiographs.

RESULTS

A 68-year-old male sustained ruptures of the flexor digitorum superficialis (FDS) and flexor digitorum profundus to the index finger 3 years following a distal scaphoid excision for symptomatic STT osteoarthritis. He required a flexor tendon reconstruction using the remaining FDS tendon for graft incorporated with a Pulvertaft weave. His midcarpal pain continued after recovery of his index finger function, eventually requiring a 4-corner fusion of the wrist.

CONCLUSIONS

Flexor tendon rupture is a previously unreported complication of distal scaphoid excision for STT arthritis.

Scaphotrapeziotrapezoid Joint Arthritis: A Pilot Study of Treatment with the Scaphoid Trapezium Pyrocarbon Implant

Isolated scaphotrapeziotrapezoid osteoarthritis is rare but can cause weakness and wrist pain. We present the results of a pilot study of interposition arthoplasty with a scaphoid trapezium pyrocarbon implant (STPI) by an open and arthroscopic approach for this problem. We performed this procedure in 10 hands in eight patients, all women, with a mean age of 60.5 (range 51–70) years. The average follow-up was 19 (range 2–24) months. Pre-operative X-rays in all cases identified an isolated degenerative arthritis of the scaphotrapeziotrapezoid joint. Average DASH evaluation pre-operatively of 49 was reduced to 39. All of the patients had functional improvement and returned to daily activities after 3 months. The results of this pilot study suggest that the STPI may prove a useful compromise treatment for this problem.

Arthroscopic Resection of Distal Pole of the Scaphoid for Scaphotrapeziotrapezoid Joint Arthritis: Comparison between Simple Resection and Implant Interposition

BACKGROUND

Isolated scaphotrapeziotrapezoid is a relatively rare condition, and there is still not complete consensus on the treatment of this pathology.

PURPOSE

The aim of the present study is to assess the utility of implant interposition after arthroscopic scaphoid distal pole resection for scaphotrapeziotrapezoid arthritis.

MATERIAL AND METHODS

The authors present a prospective study after the arthroscopic resection of the distal pole of the scaphoid in 24 patients. In a group of 11 patients, the simple resection was performed while in the other 13 patients the scaphoid resection and pyrocarbone implant interposition.

RESULTS

All patients were clinically evaluated with disability of arm, shoulder, hand score. Dorsal intercalated segment instability deformity was also measured from X-ray analysis. Grip and pinch strength were measured too, and patients were also given a visual analog scale questionnaire. Both clinical and radiographic assessments were done at 24 months postoperatively.

CONCLUSIONS

The study showed comparable results with both the techniques.

LEVEL OF EVIDENCE II

A prospective comparative study.

Management of complications of wrist arthroplasty and wrist fusion

The human wrist joint is unique from functional and anatomic standpoints. Numerous articulations exist within the wrist that allow for many options for partial wrist fusion and arthroplasty. In cases of pancarpal disease, fusion or arthroplasty of the entire wrist joint can be performed. Because of the high functional demand of the wrist, many of these surgical options can fail, leading to devastating complications. This article addresses the types of fusions and arthroplasties available for the wrist and discusses the potential complications associated with each. Methods to prevent these complications are presented and those to treat them once they have occurred are discussed.

Scaphocapitate arthrodesis for treatment of late stage Kienbock disease

Symptomatic lunate collapse owing to Kienböck disease is difficult to treat. To define the potential role of scaphocapitate arthrodesis, we reviewed ten patients who underwent scaphocapitate arthrodesis for stage IIIB-IV Kienböck disease at a mean follow-up of 8.75 years (range 1.3-18.6). Clinical variables included ranges of motion, grip strength, pain, return to work, and QuickDASH (disabilities of the arm, shoulder and hand) scores. Radiographs were evaluated for union, carpal height, alignment, ulnar translation, and radiocarpal arthritis. The procedure resulted in functional ranges of motion and good grip strengths. Pain was substantially reduced. The mean QuickDASH score was 27 (range 9.1-56.3). Radiographic analysis showed union in nine patients, maintenance of carpal height with a corrected radioscaphoid angle, and no evidence of ulnar translation. The long-term clinical benefits of scaphocapitate arthrodesis for treatment of collapsed Kienböck disease are demonstrated. However, radiographic signs of radioscaphoid arthritis were often observed in patients with follow-up greater than 10 years.

Scaphotrapeziotrapezoid arthrodesis and lunate excision for advanced Kienböck disease

PURPOSE

To analyze the outcomes of lunate excision combined with scaphotrapeziotrapezoid arthrodesis for the treatment of advanced Kienböck disease.

METHODS

Sixteen patients with Lichtman stage IIIB Kienböck disease were treated with scaphotrapeziotrapezoid arthrodesis and lunate excision and were followed for a mean of 67 months (range, 49 to 108 mo). The indications for lunate excision included pain and limited motion associated with a collapsed lunate. Clinical evaluation included range of motion, grip strength, and modified Mayo wrist score. Based on plain radiographs, the carpal height ratio, ulnar carpal distance ratio, scaphoid translation ratio, and radioscaphoid angle were measured and any presence of degenerative changes was assessed. To investigate the effects of lunate excision on the radiologic results, we compared 12 patients with stage IIIB Kienböck disease who had only scaphotrapeziotrapezoid arthrodesis as the control group.

RESULTS

Range of motion tended to be preserved, with a trend toward an increase in extension after surgery. Grip strength and modified Mayo score improved significantly. Fourteen patients with lunate excision demonstrated radiographic ulnar translation of the scaphoid beyond the scapholunate ridge, and radioscaphoid arthritis was observed in 4 patients. Compared to initial postoperative radiographs, the scaphoid translation ratio was significantly decreased, but neither ulnar carpal distance ratio nor radioscaphoid angle showed significant differences. In the control group, neither ulnar translation of the scaphoid nor significant changes of radiologic parameters was found between initial postoperative and final radiographs.

CONCLUSIONS

Scaphotrapeziotrapezoid arthrodesis with lunate excision for advanced Kienböck disease provided favorable clinical results in terms of pain relief and functional improvement. With the absence of the lunate, however, the scaphoid had a tendency to shift toward the lunate fossa. This study suggests the risk of early development of radioscaphoid arthritis as a negative effect of lunate excision.

Decision making for partial carpal fusions

Limited wrist fusions are effective surgical procedures for providing pain relief while preserving motion of the wrist in patients with localized arthritis of the carpus. In deciding which motion-preserving procedure to perform, the etiology of the arthritis, which joints are involved, and which are spared should be determined. The main principle is to fuse the involved joints and to allow motion through the uninvolved joints. In this article, we discuss the various traumatic and nontraumatic conditions causing arthritis of the wrist and the treatment options for those conditions. Common indications for limited wrist fusions include scapholunate advanced collapse and scaphoid nonunion advanced collapse. Options for treating these conditions include three- and four-corner fusions as well as a proximal row carpectomy. This paper discusses which procedures are the most appropriate as well as the outcomes of these procedures. If the basic principles of limited wrist fusions are adhered to, a good outcome can be obtained. The authors' surgical technique and decision-making processes are discussed.

Modified total trapezial and partial trapezoidal excision and ligament reconstruction tendon interposition reduces symptoms in isolated scaphotrapezial-trapezoid arthritis of the wrist

Trapezial excision arthroplasty with ligament reconstruction and tendon interposition (LRTI) modified to include proximal trapezoid excision was performed on 12 wrists in 10 patients with symptomatic, isolated scaphotrapezial-trapezoid (STT) arthritis. Wrist range of motion, lateral pinch and grip strength, and analog pain scores were measured pre- and post-operatively. Mean follow-up was 18 (11-42) months. Post-operatively, reported pain scores uniformly decreased (p < 0.0001). Mean range of wrist flexion increased from 48 to 53° (p < 0.05) and extension from 51 to 55° (p < 0.05). There was also an overall increase in mean grip strength from 15.6 to 19.2 kg and pinch strength from 3.5 to 4.3 kg. Modified Mayo Wrist Scores were excellent in six cases, good in three, and fair in one. Our results suggest that modified total trapezial, partial trapezoidal excision and LRTI could be an effective surgical alternative in cases of isolated STT arthritis.

LIMITED WRIST ARTHRODESIS VERSUS RADIAL OSTEOTOMY FOR ADVANCED KIENBÖCK'S DISEASE — FOR A FRAGMENTED LUNATE

Thirty-eight patients with advanced Kienböck's disease treated by limited wrist arthrodesis (LWA: n = 10) or radial osteotomy (RO: n = 28) for a fragmented lunate were retrospectively examined after an average of 47.9 and 68.1 months, respectively. Compared with pre-operative values, the active flexion-extension range of motion decreased by about 16.0° in LWA and increased approximately 9.7° in RO and the grip strength improved by approximately 7.5 kg in LWA and 8.0 kg in RO. In both groups, radiographs showed no significant progression of carpal collapse. Although LWA caused some decrease in wrist flexion-extension, both procedures are appropriate for surgical treatment of advanced Kienböck's disease. Most patients experienced a reduction in pain and were able to return to work.

ISOLATED SCAPHOTRAPEZIOTRAPEZOID OSTEOARTHRITIS: PRELIMINARY RESULTS OF TREATMENT USING A PYROCARBON IMPLANT

The scaphotrapeziotrapezoid (STT) joint is the second most common site in the wrist affected by degenerative arthritis. STT fusion has been the traditional treatment for patients with isolated STT arthritis but there are concerns about the complication rate and loss of wrist movement post-surgery. The current study presents the results of an interposition arthroplasty using a scaphoid trapezium pyrocarbon implant (STPI, BIOProfile). Ten STPI's were implanted in nine patients (mean age 66, 58–76 years) with isolated STT arthritis. The mean follow-up was 16.4 (3–35) months. Following surgery, VAS pain scores improved significantly and most patients had minimal restrictions in function, with a mean DASH score of 21. The mean wrist flexion-extension arc was 126° and radioulnar deviation was 43°. Mean grip strength was 82% and pinch strength 85% compared to the non-operated side. Patients were highly satisfied with the results of their surgery (mean VAS score 9.1). No surgical complications were encountered and no significant changes in carpal alignment were noted on radiographs. The results of this study suggest that STPI interposition arthroplasty may be a good alternative to STT fusion for isolated STT arthritis.

Chronic scapholunate instability treated by scaphocapitate fusion: a midterm outcome perspective

INTRODUCTION

Chronic scapholunate instability can lead to functional deficits and radiocarpal osteoarthritis. A number of procedures, namely scapho-trapezio-trapezoid (STT) fusion, scaphocapitate (SC) fusion or soft tissue reconstruction procedures, aim to improve function while protecting the wrist from osteoarthritis.

HYPOTHESIS

Define the role of scaphocapitate fusion in comparison to STT fusion and capsulodesis and ligament reconstruction.

MATERIAL AND METHODS

A clinical, radiographic and functional evaluation was performed on 31 SC fusion cases with an average follow-up of 5 years.

RESULTS

Range of motion was 41° in flexion and 39° in extension. Radial-ulnar deviation was 43°. Strength was 32.5 kgf (Jamar). The DASH was 27% and the PRWE was 25%. Fifty percent of the wrists were pain-free at rest. Ninety-four percent of patients were satisfied with the procedure. Seventy-eight percent of patients had returned to their occupation. Radiographic analysis revealed that consolidation was obtained at 10.1weeks. The postoperative radioscaphoid angle was 55° with good radioscaphoid congruence. There was no osteoarthritis in the radioscaphoid joint in 84% of the cases. The non-union rate was 13%.

DISCUSSION

These data are similar to the few series that exist. STT fusion leads the same clinical results, but it is technically more difficult and has a higher rate of complications. Capsulodesis and ligament reconstruction provide the same functional results as SC fusion, but with slightly less stiffening. However, these techniques do not seem to protect the wrist from arthritic degeneration at longer follow-up. SC fusion is superior to STT fusion for the treatment of chronic scapholunate instability. This is a pain-relieving intervention with good clinical results and preservation of scaphoid stability. As a component of the surgeon's armamentarium, it can be held in the same regard as capsulodesis and ligament reconstruction for cases of chronic scapholunate instability with a non-reducible scaphoid, or after failure of a soft tissue reconstruction procedure.

LEVEL OF EVIDENCE

Level 4, retrospective study.

Complications of limited and total wrist arthrodesis

Partial and total wrist arthrodeses have become common procedures for treating degenerative diseases arising from numerous conditions, including posttraumatic arthrosis, intercalated segment instability, inflammatory arthropathy, and carpal osteonecrosis. The goals of these two procedures are to provide pain relief and improved function by fusing arthritic or unstable joints. A thorough understanding of the complications and the best practices to avoid them is critical for the surgeon in the preoperative, intraoperative, and postoperative management of candidates for total or limited wrist arthrodesis.

Dorsal intercarpal ligament capsulodesis for predynamic and dynamic scapholunate instability

We treated a prospective series of 18 patients (nine men and nine women) with a mean age of 35 years (range 15 to 57), with chronic predynamic or dynamic scapholunate instability by a dorsal intercarpal ligament capsulodesis using the modified Mayo technique. All the patients were assessed by the modified Mayo wrist score and DASH questionnaire. Wrist arthroscopy was done in all patients before open surgery in order to grade the scapholunate instability and correlate the findings with the radiographic and MRI results. At an average follow-up of 45 months (range 34 to 60) pain significantly diminished (P < 0.05) with improvement in the grip strength (P < 0.005) in all 18 cases. Wrist motion remained almost the same. The mean Mayo wrist score improved from 62 to 84 (P < 0.005).We recommend dorsal capsulodesis by using the dorsal intercarpal ligament flap for the treatment of scapholunate dissociation, when the ligament is still repairable.

[Rotatory subluxation of the scaphoid: pathology and surgical management]

The interosseous scapholunate ligament (IOSLL) is the main stabilizer of the scapholunate (SL) couple but a static instability can appear only in the event of an associated injury of the extrinsic ligaments. Thus, SL dissociation covers a broad spectrum in which only static instability leads with certainty to osteoarthritis. Classically described as a rotatory subluxation of the scaphoid with DISI collapse, static SL instability manifests itself as a complex deformity with dorsolateral subluxation of the unit formed by the scaphoid and the distal carpal row. This deformity explains the dorsolateral radioscaphoid conflict and capitolunar decentering that is the origin of the radioscaphoid and midcarpal osteoarthritis that later appears. It is only within the first 4 to 6 weeks that a repair of the IOSLL, possibly associated with a capsulodesis, makes it possible to expect a good result and can prevent osteoarthritis. Beyond that time, no soft tissue procedure will modify the natural history of the condition. For us, surgery is indicated only for acute injuries and for symptomatic chronic instabilities. Before the occurrence of osteoarthritis, with new-found knowledge of the medium-term results of capsulodesis, it seems reasonable to favour a limited fusion. But in the event of failure, the patient is likely to remain in pain even after a total fusion. It is thus not aberrant to perform a capsulodesis in a sedentary person but it is necessary to inform the patient that osteoarthritis will occur. After occurrence of osteoarthritis, if it is symptomatic, proximal row carpectomy, SLAC procedure, total wrist fusion and denervation, can be considered, depending on the stage, the mobility of the wrist and the wishes of the patient. Denervation of the wrist can give good results with few risks, and does not jeopardize the results of a subsequent procedure.

Treatment of scaphotrapezio-trapezoid arthritis

Arthritis of the scaphotrapeziotrapezoid (STT) joint presents with deep thenar eminence and thumb basilar pain and is often coexistent with carpometacarpal arthritis of the thumb. Conservative treatment includes splinting and corticosteroid injections. Operative treatment consists primarily of fusion of the STT joint, although alternatives include trapeziectomy, fibrous arthroplasty, and prosthetic replacements. When STT arthritis is coexistent with carpometacarpal arthritis, excision of the trapezium and proximal 2 mm of trapezoid has been recommended. Complications of surgery include pericarpal arthrosis, superficial radial nerve injury, and nonunion.

Functional disability of the wrist: direct correlation with decreased wrist motion

PURPOSE

Motion-limiting wrist procedures have demonstrated both efficacy and reproducibility as a treatment for alleviating painful wrist conditions, but the reduction of pain achieved is necessarily accompanied by a marked loss of wrist motion. However, no study demonstrates a functional difference between variable degrees of wrist motion. The hypothesis of this study is that wrist motion is directly correlated with functional ability.

METHODS

Using a prospective, randomized, crossover design, we randomized 42 men and women above 45 years of age with normal wrists to wear both a partially restricted and a highly restricted splint for 24 hours each. Serving as their own controls, objective and subjective outcome measurements were taken at baseline and after each of the 2 splinting periods. The specific measurements included range of motion parameters (flexion/extension, radioulnar deviation, supination/pronation, circumduction), subjective surveys (Disabilities of the Arm, Shoulder, and Hand; Patient Rated Wrist Evaluation; and Modern Activity Subjective Survey), and an objective timed test (Modern Activity Timed Test; MATT).

RESULTS

The simulated flexion/extension arc of motion for baseline, partially restricted, and highly restricted conditions were 138 degrees , 58 degrees , and 20 degrees , respectively. Median Disabilities of the Arm, Shoulder, and Hand scores for the 3 conditions significantly increased from 1.8 to 14.4 and 20.8 (p <.01), respectively. In addition, Patient Rated Wrist Evaluation results increased from 2.5 to 16.4 and 27.1, and the Modern Activity Subjective Survey results increased from 0.3 to 9.1 and 14.9 across restricted motion conditions. Modern Activity Timed Test results matched the perceived difficulty reflected by the subjective surveys, demonstrating significant increases in performance time for 6 of the 8 individual MATT items as well as significant differences for the sum of all tasks (MATT score) between the highly and partially restricted conditions.

CONCLUSIONS

Use of low-profile splinting to restrict wrist motion demonstrates a direct correlation between restriction of wrist motion and functional disability.

Treatment of advanced-stage Kienböck's disease with proximal row carpectomy: an average 15-year follow-up

PURPOSE

The purpose of this study was to evaluate the long-term clinical results of a proximal row carpectomy with an average 15-year follow-up for the primary treatment of advanced-stage (Lichtman IIIA and IIIB) Kienböck's disease. This study is a follow-up to a paper by the senior author in a similar cohort of patients where the clinical results of a proximal row carpectomy were evaluated for the treatment of advanced-stage Kienböck's disease at an average 3-year follow-up.

METHODS

Seventeen patients with a minimum of 10 years of follow-up were identified who met criteria for inclusion. Thirteen of these patients were located and agreed to participate. Patients were seen, examined, and queried regarding their wrists. Range of motion, grip strength, and subjective patient satisfaction were all obtained and quantified using a clinical outcomes scale.

RESULTS

Twelve of 13 patients demonstrated excellent or good results based on the clinical outcomes scale used (5 excellent, 7 good, 1 fair, and none poor). Total arc of motion averaged 73% of the uninvolved side. Grip strength averaged 92% of the uninvolved side. Compared with preoperative values, range of motion improved an average of 16% and grip strength improved an average of 129%, an overall average improvement of 12 degrees and 18 kg, respectively. At the most recent follow-up, all patients remained employed. Seven patients held manual labor positions, 2 were nurses, and 4 were employed in sedentary vocations. All patients demonstrated some degree of degenerative changes, usually localized to the radiocapitate articulation in the lunate fossa. Clinical results did not correlate with radiographic degeneration.

CONCLUSIONS

This study demonstrates proximal row carpectomy to be a reliable motion-preserving procedure with good clinical results maintained out to an average of 15 years postoperatively.

Pisotriquetral dysfunction following limited and total wrist arthrodesis

PURPOSE

We report a series of pisotriquetral arthritis cases following wrist and intercarpal arthrodesis, offer an anatomic and biomechanical rationale, and introduce intraoperative considerations to avoid this potential complication.

METHODS

Nine patients with pisotriquetral arthritis requiring pisiform excision following wrist and intercarpal arthrodesis were retrospectively evaluated at 2 institutions. Five paired cadaver wrists were tested for alterations in pressure and kinematics of the pisotriquetral joint following four-corner and total wrist fusions.

RESULTS

Nine patients were successfully treated with pisiform excision for pisotriquetral arthritis following wrist and intercarpal fusions. Biomechanical cadaver testing demonstrated profound alterations in pisotriquetral kinematics and pressure changes in measured degrees of wrist position following wrist and intercarpal fusions.

CONCLUSIONS

Patients undergoing four-corner and/or wrist arthrodesis should be assessed for pisotriquetral discomfort before surgery, including a physical examination and a 30 degrees supinated radiograph to look for degenerative changes. Attempts should be made intraoperatively to ensure that the proximal row is not fused in an extended position. After surgery, if discomfort develops and conservative treatment fails, then pisiform excision can successfully alleviate the pain.