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Gomez-Sierra MA, Sandoval A. Palmar midcarpal instability a narrative review of the literature: Have we reached a consensus on a treatment? Injury 2023; 54 Suppl 6:110722. [PMID: 38143144 DOI: 10.1016/j.injury.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 12/26/2023]
Abstract
Palmar midcarpal instability (PMCI) is a wrist condition that requires treatment through non-surgical rehabilitation programs or surgical stabilization. This condition's natural history is poorly understood, and the optimal treatment approach remains unknown. Non-surgical treatments are initially implemented, followed by surgical stabilization if necessary. Arthrodesis and soft tissue stabilization are the two main surgical options for PMCI, with no established gold standard for treatment. A systematic review of 12 articles comparing arthrodesis and soft tissue stabilization was conducted to identify the optimal treatment approach for PMCI. Arthrodesis techniques, such as lunotriquetral arthrodesis, showed high functional outcomes but also high reintervention rates due to nonunion. Soft tissue stabilization techniques showed superior functional outcomes with less mobility loss and lower reintervention rates compared to arthrodesis. However, more studies are required to determine the optimal soft tissue technique. Based on this review we created a treatment algorithm for PMCI starting with non-surgical treatment first, followed by surgical stabilization if needed. Soft tissue stabilization techniques are preferred over arthrodesis due to better functional outcomes and lower reintervention rates. However, each patient's treatment approach should be individualized and evaluated independently to determine the best course of action. PMCI is a rare wrist condition, and further research is needed to better understand its natural history and establish a gold standard for treatment. The lack of literature comparing the two surgical options underscores the need for further research to determine the optimal treatment approach. Nonetheless, the current evidence suggests that soft tissue stabilization is a promising alternative to arthrodesis, providing superior functional outcomes and lower reintervention rates.
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Affiliation(s)
- Maria Antonia Gomez-Sierra
- Fundación Valle del Lili, Department of Orthopedics and Traumatology, Cra 98 No. 18-49Cali, Colombia Universidad ICESI, Calle 18 No. 122-135, Cali, Colombia.
| | - Alejandro Sandoval
- Fundación Valle del Lili, Department of Hand Surgery, Cra 98 No. 18-49, Cali, Colombia Universidad ICESI, Calle 18 No. 122-135, Cali, Colombia
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2
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Okoro CK, Skalski MR, Patel DB, White EA, Matcuk GR. Imaging Diagnosis and Management of Carpal Trauma and Instability-An Illustrated Guide. Life (Basel) 2023; 13:1426. [PMID: 37511801 PMCID: PMC10381215 DOI: 10.3390/life13071426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/12/2023] [Accepted: 06/16/2023] [Indexed: 07/30/2023] Open
Abstract
Understanding the subtle signs of carpal instability and other unique injury patterns in the wrist is a critical skill for radiologists. Proper patient management and outcomes are directly dependent on the accurate interpretation of wrist imaging studies. This review will provide a detailed overview of typical imaging features of carpal trauma and instability, management, and complications, using multimodality imaging and original medical illustrations. A detailed overview of the osseous, ligamentous, arterial anatomy of the wrist, arcs of Gilula, and zones of vulnerability will be provided. Carpal fractures, dislocations, special radiographic views, and imaging pearls will be discussed. Instability patterns and the myriad of associate abbreviations (CID, CIND, CIC, CIA, VISI, DISI, SLD, LTD, MCI, SLAC, SNAC) will be clarified. Expected outcomes, potential complications, and management will be reviewed.
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Affiliation(s)
- Chukwuemeka K Okoro
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Matthew R Skalski
- Department of Radiology, Palmer College of Chiropractic-West Campus, San Jose, CA 95134, USA
| | - Dakshesh B Patel
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Eric A White
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - George R Matcuk
- Department of Imaging, Cedars Sinai Medical Center, Los Angeles, CA 90048, USA
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3
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Hung WC, Wang JP, Huang YC, Yin CY, Wu CY, Huang HK. Arthroscopic-assisted radiocarpal ligaments tensioning for dynamic radiocarpal instability. BMC Musculoskelet Disord 2022; 23:158. [PMID: 35177051 PMCID: PMC8851747 DOI: 10.1186/s12891-021-04857-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022] Open
Abstract
Background Dynamic radiocarpal instability is one of the causes of post-trauma radial-sided wrist pain. It is not easy to diagnose and may possibly be overlooked. The key ligaments responsible for dynamic radiocarpal instability are the radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments. Tensioning of these 2 ligaments could be a method of treatment for dynamic carpal instability. We proposed a method for arthroscopic thermal shrinkage of these 2 ligaments, and for setting a landmark arthroscopically to facilitate identification of these 2 ligaments during the combined open suture tensioning procedure. Methods Between January 2016 and May 2020, 12 patients treated with this method were enrolled. The mean age was 33.3 years (range, 18–57 years), and the mean duration from injury to operation was 7.8 months (range, 3–25 months). The diagnosis was mainly depended on the physical examinations and confirmed under arthroscopy. The mean follow-up was 17.7 months (range, 12–26 months). Results All the patients had marked improvement of pain, grip strength, the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), and the radiocarpal stability. The wrist range of motion showed significant decrease around 5o in both flexion and extension and around 4o in the ulnar deviation at the final follow-ups. All patients were able to return to their previous full level of work and activities. Conclusions We conclude that arthroscopic thermal shrinkage combined with open suture tensioning can be effective in treating dynamic carpal instability, while the arthroscopic-assisted landmark setting can help identify the accurate location of the RSC and LRL ligaments without dissecting too much soft tissue.
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Affiliation(s)
- Wei-Chen Hung
- Department of Orthopaedics, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi, Taiwan
| | - Jung-Pan Wang
- Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Chao Huang
- Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Yu Yin
- Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Yi Wu
- Department of Orthopaedics, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi, Taiwan
| | - Hui-Kuang Huang
- Department of Orthopaedics, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi, Taiwan. .,Department of Orthopaedics & Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan. .,Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Department of Food Nutrition, Chung Hwa University of Medical Technology, Tainan, Taiwan.
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4
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Bakker D, Kortlever JTP, Ring D, Patterson D, Napoli D, Harness NG, Reichel LM. Volar Tilt of the Lunate After Open Reduction Internal Fixation of a Distal Radius Fracture. J Hand Surg Am 2021; 46:520.e1-520.e6. [PMID: 32800374 DOI: 10.1016/j.jhsa.2020.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 05/14/2020] [Accepted: 06/24/2020] [Indexed: 02/02/2023]
Abstract
The pathophysiology of carpal adaptations after fracture of the distal radius is incompletely understood. We report 5 patients who had normal carpal alignment on injury radiographs that developed marked volar angulation of the lunate during recovery from volar plate fixation of a fracture of the distal radius. There were no signs of alteration of the carpal ligaments. Two patients had similar volar tilt on the contralateral side. The cause and optimal treatment of carpal malalignment after restoration distal radial alignment are unclear.
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Affiliation(s)
- Daniel Bakker
- Department of Surgery and Perioperative Care, Dell Medical School-The University of Texas at Austin, Austin, TX
| | - Joost T P Kortlever
- Department of Surgery and Perioperative Care, Dell Medical School-The University of Texas at Austin, Austin, TX
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School-The University of Texas at Austin, Austin, TX.
| | | | | | | | - Lee M Reichel
- Department of Surgery and Perioperative Care, Dell Medical School-The University of Texas at Austin, Austin, TX
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Ricks M, Belward P, Hargreaves D. Long-Term Results of Arthroscopic Capsular Shrinkage for Palmar Midcarpal Instability of the Wrist. J Wrist Surg 2021; 10:224-228. [PMID: 34109065 PMCID: PMC8169170 DOI: 10.1055/s-0040-1722331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/12/2020] [Indexed: 10/22/2022]
Abstract
Background Midcarpal instability is a term for a collection of poorly understood conditions where the proximal row of the carpus is unstable. The most common type of midcarpal instability is palmar midcarpal instability (PMCI). Treatment for PMCI includes nonoperative proprioceptive retraining of the wrist, splints, and strengthening. If this fails, various authors have suggested several different fusions, tenodesis procedures, or capsular shrinkage. There are no long-term case series in the literature. Objective The aim of this study is to assess the long-term results of arthroscopic capsular shrinkage when used for PMCI of the wrist. Methods A prospective cohort study of patients who underwent arthroscopic capsular shrinkage for PMCI was performed. Ethical board approval was given for this study. All patients were followed up and reviewed independently from the operating surgeon. Assessment included a structured questionnaire, disabilities of the arm, shoulder and hand (DASH) questionnaire, and clinical examination using a goniometer. PMCI was assessed objectively with the anterior drawer test and radiological imaging was only performed if clinically relevant to the residual symptoms. Results Thirteen patients (15 wrists) underwent arthroscopic capsular shrinkage for PMCI. Twelve patients (14 wrists) were available for clinical review with a follow-up rate of 92.3%. The mean time from index procedure to final review was 12 years (range: 10-14years). The symptoms of instability had completely resolved in nine wrists (7 patients). Only 2 of the 14 wrists had symptoms that were reproduced with a positive anterior drawer test. All other wrists were stable on objective assessment. The mean DASH score had improved from pre op of 34 to post op of 12.1 and at 12-year follow-up this had deteriorated minimally to 15.3. Assessment of the range of motion showed an average increase in range of flexion/extension by 22 degrees. Patient satisfaction was excellent. The patients rated that nine wrists were much better than presurgery, three as better, one unchanged, and one worse. Discussion/Conclusion There are no studies looking at the long-term natural history of treatments for PMCI. The lead author proposes a grading system for symptomatic PMCI that has been retrospectively applied to this cohort. It is a grading system from 1 to 4 and is based on a treatment algorithm. This is the first long-term study from any joint, where the results of capsular shrinkage have been maintained over time. In this series, we have not seen any deleterious effect from possible mechanoreceptor injury. We suspect that functioning mechanoreceptors are more relevant in the unstable joint, than the structurally stable joint. The authors propose that thermal capsular shrinkage is an effective and durable option for use in mild-to-moderate forms of PMCI.
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Affiliation(s)
- Matthew Ricks
- Upper Limb Unit, Wrightington Hospital, Lancashire, United Kingdom
| | - Peter Belward
- Department of Trauma & Orthopaedic Surgery, University Hospital Southampton, Southampton, Hampshire, United Kingdom
| | - David Hargreaves
- Department of Trauma & Orthopaedic Surgery, University Hospital Southampton, Southampton, Hampshire, United Kingdom
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Jing SS, Smith G, Deshmukh S. Demystifying Palmar Midcarpal Instability. J Wrist Surg 2021; 10:94-101. [PMID: 33815943 PMCID: PMC8012087 DOI: 10.1055/s-0040-1714688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 06/15/2020] [Indexed: 10/23/2022]
Abstract
Palmar midcarpal instability is an uncommon condition diagnosed clinically with a painful pathognomonic clunk on terminal ulnar deviation of the wrist. Various causes have been described, but congenital laxity of the carpal ligaments is thought to be a key contributor. Treatment commences with conservative measures. This includes proprioceptive training based on more recent concepts on the sensorimotor function of the wrist. When these measures plateau, surgery is considered. The lack of high-level evidence and consensus on its cause continue to hamper our understanding and knowledge of this condition. The purpose of this review is to examine the current evidence to conceptualize this mysterious, yet infrequent phenomenon, and to provide an algorithm on its management.
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Affiliation(s)
- Shan Shan Jing
- Royal Orthopaedic Hospital, The Woodlands, Bristol Road South, Birmingham, United Kingdom
| | - Gemma Smith
- Royal Orthopaedic Hospital, The Woodlands, Bristol Road South, Birmingham, United Kingdom
| | - Subodh Deshmukh
- Royal Orthopaedic Hospital, The Woodlands, Bristol Road South, Birmingham, United Kingdom
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Abstract
Technological advances in magnetic resonance imaging (MRI) have improved radiologists' ability to evaluate wrist ligaments. MRI interpretation often guides clinical management. This article aims to review the normal and pathologic appearance of intrinsic and extrinsic wrist ligaments with a focus on MRI. Variant anatomy, imaging pearls, and clinical significance are also discussed. Special attention is paid to key wrist ligaments that play a role in carpal stability.
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Sandow MJ. Computer Modelling of Wrist Biomechanics: Translation into Specific Tasks and Injuries. Curr Rheumatol Rev 2020; 16:178-183. [DOI: 10.2174/1573397115666190119095311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 12/28/2018] [Accepted: 01/07/2019] [Indexed: 11/22/2022]
Abstract
Background:
The carpus is a complicated and functionally challenged mechanical system,
advancements in the understanding of which have been compromised by the recognition that
there is no standard carpal mechanical system and no typical wrist. This paper covers components of
a larger project that seeks to develop a kinetic model of wrist mechanics to allow reverse analysis of
the specific biomechanical controls or rules of a specific patient’s carpus. Those rules, unique to
each patient, could be used to create a forward synthesis mathematical model to reproduce the individual’s
anatomical motion in a virtual environment.
Objective and Methods:
Based on the previous observations, the carpus essentially moves with only
two degrees of freedom-pitch (flexion/extension) and yaw (radial deviation/ulnar deviation)-while
largely preventing roll (pronation/supination). The objective of this paper is, therefore, to present the
background and justification to support the rules-based motion (RBM) concept, which states that the
motion of a mechanical system, such as the wrist, is the net interplay of four rules: morphology,
constraint, interaction, and load. The stable central column theory (SCCT) of wrist mechanics applies
the concept of RBM to the carpus, and by using a reverse engineering computational analysis
model, a consistent pattern of isometric constraints was identified, creating a “two-gear four-bar”
linkage. This study assessed the motion of the carpus using a 3D (three-dimensional) dynamic visualization
model. The hypothesis was that the pattern and direction of motion of the proximal row
and the distal row with respect to the immediately cephalad carpal bones or radius would be similar
in all directions of wrist motion. To identify the unique motion segments, 3D models were created
from five normal wrists that underwent CT scanning in multiple positions of radial and ulnar deviation
as well as flexion and extension. Each carpal row (proximal and distal) was animated in a virtual
environment with the cephalad carpal bones or radius held immobile. The rotational axis and
position of each bone and each row were then compared in sagittal (flexion-extension) and coronal
(radial and ulnar deviation) motion.
Results:
The carpus appeared to have only two degrees of freedom, and yet was stable in those arcs
with the loads applied proximally in the forearm. The proximal row moved in a singular arc, but
with a varying extent during sagittal and coronal motion. The isometric constraints were consistent
in both directions. The distal row moved on an axis formed by a pivot joint laterally (between the
trapezium and scaphoid) and a saddle joint medially (between hamate and triquetrum). The sagittal
and coronal alignment of this axis changed as the proximal row moved. This created a distinct pattern
of row motion to achieve the various required positions of wrist function. On wrist radial deviation,
the scaphoid (with the proximal row) was flexed and the distal row was extended, whereas, in
wrist flexion, the scaphoid flexed (with the proximal row) and so did the distal row. The pattern was
reversed in the opposite wrist movements. While the general direction of motion of each row was
consistent, the extent was quite variable.
Conclusion:
This review supports the SCCT of carpal mechanics and the carpus acting as a twogear
four-bar linkage, as well as the concept of RBM as a means to understand the biomechanics of
the wrist, and how this is translated into specific functional tasks. More sophisticated 3D modelling
will be required to further understand the specifics of carpal motion; however, reverse engineering
of the specific rules that define each individual wrist can also be applied to a mathematical model to
provide a “what if” test of particular surgical interventions for a variety of wrist injuries. The use of
quantitative 3D Computed Tomography Scan (CT) analysis, surgical planning and virtual surgical
intervention allows potential surgical solutions to be applied to a computer model of an injured wrist
to test the possible outcomes and prognosis of a proposed treatment.
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Affiliation(s)
- Michael J. Sandow
- Centre for Orthopaedic and Trauma Research, Department of Orthopaedics and Trauma, University of Adelaide and Wakefield Orthopaedic Clinic, 270 Wakefield Street, Adelaide, 5000, Australia
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Henrichon SS, Foster BH, Shaw C, Bayne CO, Szabo RM, Chaudhari AJ, Boutin RD. Dynamic MRI of the wrist in less than 20 seconds: normal midcarpal motion and reader reliability. Skeletal Radiol 2020; 49:241-248. [PMID: 31289900 PMCID: PMC6934906 DOI: 10.1007/s00256-019-03266-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/13/2019] [Accepted: 06/17/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe the normal motion pattern at the midcarpal compartment during active radial-ulnar deviation of the wrist using dynamic MRI, and to determine the observer performance for measurements obtained in asymptomatic volunteers. METHODS Dynamic MRI of 35 wrists in 19 asymptomatic volunteers (age mean 30.4 years, SD 8.6) was performed during active radial-ulnar deviation using a fast gradient-echo pulse sequence with 315 ms temporal resolution (acquisition time, 19 s). Two independent readers measured the transverse translation of the trapezium at the scaphotrapezium joint (STJ) and the capitate-to-triquetrum distance (CTD). Relationships between these measurements and laterality, sex, lunate type, and wrist kinematic pattern were evaluated. RESULTS At the STJ, the trapezium moved most in radial deviation, with an overall translation of 2.3 mm between ulnar and radial deviation. Mean CTD measurements were the greatest in ulnar deviation and varied 2.4 mm between ulnar and radial deviation. Mean CTD was greater in men than women in the neutral position (p = 0.019), and in wrists with type II lunate morphology during radial and ulnar deviation (p = 0.001, p = 0.014). There were no significant differences in trapezium translation or CTD with wrist laterality and kinematic pattern. Intraobserver and interobserver correlation coefficients were 0.97 and 0.87 for trapezium translation and 0.84 and 0.67 for CTD. CONCLUSION This study is the first to demonstrate the performance of dynamic MRI to quantify STJ motion and CTD. Dynamic MRI with a short acquisition time may be used as a tool to supplement static MRI in evaluation of the midcarpal compartment.
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Affiliation(s)
| | | | - Calvin Shaw
- Department of Radiology, University of California - Davis, Sacramento, CA 95817
| | - Christopher O. Bayne
- Department of Orthopaedic Surgery, University of California - Davis, Sacramento, CA 95817
| | - Robert M. Szabo
- Department of Orthopaedic Surgery, University of California - Davis, Sacramento, CA 95817
| | | | - Robert D. Boutin
- Department of Radiology, University of California - Davis, Sacramento, CA 95817
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Zelenski NA, Shin AY. Management of Nondissociative Instability of the Wrist. J Hand Surg Am 2020; 45:131-139. [PMID: 31866152 DOI: 10.1016/j.jhsa.2019.10.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/08/2019] [Accepted: 10/09/2019] [Indexed: 02/02/2023]
Abstract
Nondissociative carpal instability is instability of an entire carpal row and can lead to vague ulnar-sided wrist pain as well as a clunking wrist. The etiology of this process is most often generalized ligamentous laxity; however, it can infrequently occur as a result of trauma or malalignment of the radiocarpal joint. Whereas treatment remains controversial, the literature supports nonsurgical management and includes patient education, dynamic placement of orthoses, proprioceptive therapy, and extensor carpi ulnaris strengthening. If extensive nonsurgical therapy fails, surgical intervention includes soft tissue and bony procedures, all with high complication and failure rates and limited long-term outcome data.
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Moreno R, Bhandari L. FCR Interposition Arthroplasty for Concomitant STT and CMC Arthritis. Tech Hand Up Extrem Surg 2019; 23:10-13. [PMID: 30507723 DOI: 10.1097/bth.0000000000000214] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Arthritis of scaphotrapeziotrapezoid joint is common and can be seen in association with first carpal metacarpal (CMC) arthritis. Untreated scaphotrapeziotrapezoid arthritis may be a cause of residual pain after CMC arthroplasty. There are various treatment options described in the literature ranging from arthrodesis, resection arthroplasty, interpositional arthroplasty, and implant arthroplasty. We describe a novel technique of flexor carpi radialis (FCR) tendon interposition to tackle this condition. Our common treatment for CMC arthritis is trapezium resection with ligament reconstruction and tendon interposition with half of the FCR. With this procedure, through the same exposure, the proximal part of the trapezoid is resected. An anchor is placed into the trapezoid and the sutures are passed through a remnant of the FCR. Thus the FCR is pulled in between the scaphoid and the trapezoid and secured in place. We performed this procedure in 13 hands with average follow-up of 36 months. All patients were satisfied with the procedure and were pain free at their last follow-up. The advantage of this procedure is the use of the FCR, which is already available in the field and requires very little additional procedure.
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Affiliation(s)
- Rodrigo Moreno
- Christine M. Kleinert Institute, University of Louisville, Louisville, KY
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12
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Palmar Capsuloligamentous Plication in Dorsal Capitolunate Instability: Technique and Preliminary Results. Tech Hand Up Extrem Surg 2018; 23:22-26. [PMID: 30461571 DOI: 10.1097/bth.0000000000000216] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Midcarpal instability (MCI) is a form of the carpal instability nondissociative pattern and can be differentiated into dorsal, palmar, or extrinsic MCI. Dorsal MCI can frequently be observed in adolescent or adult patients due to trauma or hyperlaxity of the palmar intrinsic carpal ligaments. Clinical stress tests and cinematography are capable to depict the ligamentous instability centered around the capitolunate area. We describe a novel technique which aims to address palmar ligamentous hyperlaxity by plication of the radioscaphocapitate, radiolunotriquetral, and arcuate ligaments, thus closing the so-called space of Poirier. This palmar technique has been used in several cases in isolated form or in conjunction with other concomitant procedures. After the floor of the carpal tunnel and thus the palmar ligaments are exposed and the weak spot meticulously verified, 2 or rarely 3 deep FibreWire pulley sutures are used for capsuloligamentous plication. Among 11 patients, 4 cases (5 operated wrists) with isolated capitolunate capsuloligamentous plication were followed at an average of 2.6 years after surgery. The results were excellent with a mean postoperative Disabilities of the Arm, Shoulder and Hand Score of 9.7 (range, 6.9 to 15.0), mean numerical rating scale of 0 at rest and 1 (range, 0 to 2) during stress. All cases stated that they were very satisfied with the result and all would definitely elect to choose the surgery again. Palmar capsuloligamentous plication has been shown to be a quick, relatively easy and reliable procedure to reduce dorsal MCI in our patient cohort.
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13
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Mulders MAM, Sulkers GSI, Videler AJ, Strackee SD, Smeulders MJC. Long-Term Functional Results of a Wrist Exercise Program for Patients with Palmar Midcarpal Instability. J Wrist Surg 2018; 7:211-218. [PMID: 29922497 PMCID: PMC6005774 DOI: 10.1055/s-0037-1612594] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 11/07/2017] [Indexed: 10/18/2022]
Abstract
Background Patients with palmar midcarpal instability have symptoms of pain, combined with clinical signs of abnormal mobility on stressing the joint, an unpredictable blockade feeling, and a noticeable clunk, in the absence of an underlying trauma. No data are available on the effect of conservative treatment for these patients. Purpose The purpose of this study was to evaluate the effect and the long-term functional outcomes of a wrist exercise program in patients with palmar midcarpal instability. Patients and Methods All patients diagnosed with palmar midcarpal instability between 2005 and 2011 were included. Patients completed the Patient-Rated Wrist and Hand Evaluation (PRWHE) and the Short Form-36 health (SF-36) questionnaires, scaled their perceived pain before and after treatment, and indicated the effect of the received treatment. Results A total of 119 patients diagnosed with palmar midcarpal instability were included. The median follow-up time was 6 years (IQR 4.5-7.0). The median PRWHE score after hand therapy was 35.5 and the median mental component of the SF-36 score was 53.9 and the physical component was 45.2. The median perceived pain reduced from eight to four and the median therapeutic effect of the wrist exercise program was five. Conclusion Although palmar midcarpal instability remains to be a chronic disease, the effectiveness of our wrist exercise program is promising with acceptable long-term functional results and a good quality of life. Level of Evidence Level IV, retrospective cohort study.
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Affiliation(s)
- M. A. M. Mulders
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - G. S. I. Sulkers
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - A. J. Videler
- Hand and Wrist Center Amsterdam, Amsterdam, The Netherlands
| | - S. D. Strackee
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - M. J. C. Smeulders
- Department of Plastic, Reconstructive, and Hand Surgery, Academic Medical Center, Amsterdam, The Netherlands
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14
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Dorsal Wrist Plication for Midcarpal Instability. J Hand Surg Am 2018; 43:354-359. [PMID: 29241841 DOI: 10.1016/j.jhsa.2017.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 10/16/2017] [Accepted: 11/06/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Midcarpal instability (MCI) is a cause of chronic wrist pain for which treatment remains controversial. This study's purpose was to determine the outcome of a treatment algorithm for MCI that included immobilization and surgical interventions. METHODS We prospectively enrolled 23 consecutive patients (12 males, average age 27 years) with 27 symptomatic wrists. All had generalized wrist pain with an average duration of 22 months. All had MCI and a catch-up clunk that reproduced the symptoms. Initial treatment was full immobilization for 6 weeks. When necessary, recurrence after immobilization was treated with an anatomically based surgical procedure to plicate the dorsal capsule and extrinsic ligaments to stabilize the midcarpal joint. Failure of surgical plication was followed by 4-corner intercarpal arthrodesis when necessary. Patients were observed for instability, grip strength, wrist motion, and Patient-Rated Wrist Evaluation. RESULTS For 22 wrists there was partial relief of symptoms with full-time cast or orthosis immobilization; however, symptoms quickly returned with mobilization. The other wrists had previously been immobilized and patients refused further nonsurgical care. All patients underwent surgical plication of the dorsum of the wrists. Postoperative follow-up (35 months) showed statistically significant improvements in grip strength and Patient-Rated Wrist Evaluation scores. All patients had improved pain at final follow-up. Most improvement was in female patients aged under 25 years, with hypermobility and without major traumatic or work-related injuries. This contrasted with poorer outcomes in men aged over 25years who had moderate or severe trauma that was mostly work-related. Instability recurred in 2 patients who then had a 4-corner arthrodesis. CONCLUSIONS Immobilization was not successful in controlling pain and recurrence of instability in patients with MCI. Surgical midcarpal capsular plication was less effective in men with posttraumatic instability. The capsular plication procedure was successful in young female patients with ligament laxity and a history of only minor or repetitive trauma and no history of major trauma. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Abstract
The evidence behind management options for midcarpal instability (MCI) is scarce, relying solely on case series. Established treatments cause significant loss of wrist motion. As understanding of the condition has progressed, surgeons have been trying soft tissue techniques. The treatment option should be chosen for the appropriate type and grade of MCI. The Hargreaves grading system for palmar MCI aids treatment decision-making. A possible role for arthroscopy in treatment of MCI has been developed using arthroscopic thermal capsular shrinkage, appropriate for cases with dynamic instabilities. Static deformities require a soft tissue reconstruction or a partial wrist fusion.
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