Management of wrist injuries

Perilunate Injury Timing and Treatment Options: A Systematic Review

Introduction  Perilunate injuries are uncommon yet challenging and often missed injuries, representing 7% of all carpal traumas. Two types of injuries can be identified as follows: perilunate dislocations (PLD) and perilunate fracture-dislocations (PLFD). The purpose of this study was to conduct a systematic review and meta-analysis to establish which surgical treatment is superior for patients with perilunate injuries and the significance of delayed treatment. Methods  A total of 2056 articles were screened, and 16 articles were included. Risk of bias for case-control series and case series were assessed through the National Institute of Health study quality assessment tool. Qualitative outcomes of clinical scores for hand function were compared between different time points (acute, < 7 days; delayed 7-45 days; chronic > 45 days), open and closed reduction, and PLD and PLFD. Results  Overall, the clinical outcome scores of patients treated within 7 days are good. The results suggest that closed reduction and internal fixation (CRIF) offers slightly better outcomes than open reduction and internal fixation (ORIF) for PLFD. Patients treated 6 weeks or more after the initial injury seem to have the worst overall outcomes than patients in the acute or delayed setting. The results suggest that patients with chronic PLD have even worse outcomes than patients with chronic PLFD. Conclusions  Timing of surgery is essential for an optimal outcome. When there is a delay of treatment, the outcomes are inferior to those treated acutely. Early referral to centralized treatment units for perilunate injuries would allow for targeted treatment and facilitate research on this difficult wrist injury.

Distal Row Carpectomy-A Possible Salvage Procedure of Severe Carpal Trauma

Complex fracture dislocations of the wrist often result in posttraumatic arthrosis. In trying to avoid total arthrodesis, alternative treatment strategies have been investigated. For this purpose, we present the case of a 56-year-old male patient who sustained a direct trauma during a circular saw accident, resulting in the destruction of the distal carpal row among other things. However, the proximal carpal row was found completely intact. We indicated an emergency distal row carpectomy. Eighteen months postoperatively, the patient showed very good range of movement with no pain, and radiologically, the proximal carpal row was still intact, with no signs of an incipient radiocarpal arthrosis. This case demonstrates the successful removal of the distal carpal row in terms of a distal row carpectomy.

[Isolated capitate fractures in the frontal plane]

Isolated fractures of the capitate in the frontal plane are both very rare and most of the time very discreet. There is a great risk to miss such fractures with potential longterm consequences. The following report of two independent patients highlights the importance of computed tomography in order to verify fractures and initiate adequate treatment.

Generative surgery of cultured autologous auricular chondrocytes for nasal augmentation

BACKGROUND

Conventional treatment for nasal augmentation utilizes autologous grafts, allografts, or synthetic implants such as silicon implants. Silicon implants could protrude/expose or induce nasal bone resorption. Autologous grafts are usually associated with donor site morbidity and the volume of harvested tissue is limited. We had developed a new method for nasal augmentation using cultured autologous chondrocytes (CAC). The current report presents the results of a study using that method with a larger number of patients and an improved graft technique for the nasal tip.

METHODS

Approximately 1 cm2 of cartilage was harvested from the auricular concha and treated with collagenase, and then chondrocytes were obtained. In our multilayer culture system the chondrocytes formed immature cartilaginous tissues with a gelatinous chondroid matrix. They were injection-grafted into the subcutaneous pocket of the nasal dorsum.

RESULTS

The chondrocytes with a gelatinous chondroid matrix change from a soft gel to hard neocartilage tissue within 2 to 3 weeks and then stabilize. The authors have used this procedure over a 6-year period on 75 cases: 58 secondary augmentation rhinoplasties following silicon implantation and 17 primary augmentation cases. The results have been satisfactory and long-lasting.

CONCLUSION

Grafting of CAC is an optional method for nasal augmentation and could be used for a wide range of facial augmentation cases.

Wrist anatomy and biomechanics

Anatomic and biomechanical research of the wrist has yielded a substantial amount of information that improves our basic knowledge of carpal morphology and function of the wrist and provides information to better assess and improve treatment(s) for various problems of the wrist joint. A precise knowledge of the anatomy and biomechanics of the wrist is useful not only for diagnosis of traumatic ligamentous injuries or degenerative change of the wrist joint but also for treatment for wrist dysfunction.

Generating ears from cultured autologous auricular chondrocytes by using two-stage implantation in treatment of microtia

BACKGROUND

Microtia is a congenital ear hypoplasia associated with auricular defects. Conventional treatment involves implanted costal cartilage. The impact of surgical invasion and donor-site morbidity can be particularly severe in pediatric patients, and the collectable volume of autologous cartilage is limited. The authors therefore developed a new technique for microtia and applied it to treat four patients.

METHODS

Through the development of a multilayer chondrocyte culture system and two-stage implantation technique, the authors successfully generated human ears. In culture, the chondrocytes are expanded to a sufficiently large volume, produce rich chondroid matrix, and form immature cartilaginous tissues. In the authors' two-stage implantation, the cultured chondrocytes are injection-implanted into the lower abdomen of the patient, where the cells grow into a large, newly generated cartilage with neoperichondrium in 6 months. This cartilage is harvested surgically, sculptured into an ear framework, and implanted subcutaneously into the position of the new ear.

RESULTS

The cultured chondrocytes formed a mature cartilage block with sufficient elasticity for use as an auricular cartilage. The formed block had the same histologic origin as elastic cartilage. The ear framework produced from this block was implanted into the auricular defect area, and an auricle with a smooth curvature and shape was subsequently configured. In the 2 to 5 years of postoperative monitoring, the neocartilage maintained good shape, without absorption.

CONCLUSIONS

The authors' four patients are the first successful cases of regenerative surgery for microtia using cultured ear chondrocytes. The benefits of the technique include minimal surgical invasion, lower donor-site morbidity, lessened chance of immunologic rejection, and implantation stability.

Treatment of scaphoid fractures and nonunions

Scaphoid fractures are common but present unique challenges because of the particular geometry of the fractures and the tenuous vascular pattern of the scaphoid. Delays in diagnosis and inadequate treatment for acute scaphoid fractures can lead to nonunions and subsequent degenerative wrist arthritis. Improvements in diagnosis, surgical treatment, and implant materials have encouraged a trend toward early internal fixation, even for nondisplaced scaphoid fractures that could potentially be treated nonoperatively. Despite the advent of newly developed fixation techniques, including open and percutaneous fixation, the nonunion rate for scaphoid fractures remains as high as 10% after surgical treatment. Scaphoid nonunions can present with or without avascular necrosis of the proximal pole and may show a humpback deformity on the radiograph. If left untreated, scaphoid nonunions can progress to carpal collapse and degenerative arthritis. Surgical treatment is directed at correcting the deformity with open reduction and internal fixation with bone grafting. Recently, vascularized bone grafts have gained popularity in the treatment of scaphoid nonunions, particularly in cases with avascular necrosis. This article reviews current concepts regarding the treatment of scaphoid fractures and nonunions.