Comparison of clinical results after pisiformectomy in patients with rheumatic versus posttraumatic osteoarthritis

Fracture Dislocation of the Pisiform Bone in 14-Year-Old Boy-A Case Report

We present the case of a 14-year-old patient who suffered fracture dislocation of the pisiform bone (PB) along with fractures of the scaphoid, proximal radius, and proximal phalanx of the thumb due to high-energy trauma directly to the extended wrist. This combination of fractures has not been previously reported in the literature. Currently, there is no consensus in the literature regarding the optimal treatment approach for such cases. In our management, initial attempts at closed and open reduction were unsuccessful, leading to the decision for primary pisiformectomy. Our report includes a follow-up of 3.5 years, demonstrating a very good outcome. Based on this case and a few similar published cases, primary pisiformectomy appears to be a viable and well-accepted option, particularly among young patients. Additionally, we conducted a review of radiographic criteria and management strategies for this specific injury and related conditions.

Carpal dislocations

Carpal dislocations result from sequential disruption of the complex relationship between the bones and ligaments of the wrist. Injuries to the carpus occur via predictable mechanisms, an understanding of which is critical to identify and treat these frequently missed patterns of injury and to avoid the sequela of chronic instability. Lunate dislocations are by far the most common, but isolated dislocation of other carpal bones can also occur. Open reduction and internal fixation still remains the gold standard for treatment regardless of the debate around the specific approaches. These high-energy injuries are associated with significant long-term morbidity even when identified promptly and appropriately treated. This review will focus on the evaluation and management of common forms of carpal dislocations.

Long-Term Results of Pisiformectomy in a Cohort of 57 Patients

Background  Excision of the pisiform is an infrequently used option for pisotriquetral joint dysfunction when nonoperative treatment is ineffective. This study reviews the patient-reported outcomes of patients treated with pisiformectomy, and furthermore focuses on the complications and the need for and time to revision procedure. Materials and Methods  Medical records of 57 patients were manually reviewed and assessed for complications, rate of unplanned reoperations, and type of reoperations. Thirty-seven patients (65%) completed patient-rated outcomes surveys at a median of 10 years after their procedure. Results  The complication rate was 13% ( n  = 7). Ulnar nerve symptoms were noted in three patients. No reoperations were performed after the pisiform excision. Out of the 16 patients who had preoperative symptoms of ulnar nerve compression at the wrist, 10 patients reported that their symptoms had completely resolved after the surgery. The median Quick Disability of Arm, Shoulder and Hand (QuickDASH) score after surgery was 4.5 (2.3-16), median score for pain 0 (interquartile range [IQR]: 0-2), and median score for overall satisfaction 10 (IQR: 8-10). Conclusions  Pisiformectomy is a surgery used sparingly in cases with refractory pain associated with arthrosis of the pisotriquetral joint or enthesopathy of the flexor carpi ulnaris/pisiform interface. When utilized in this fashion, patients report limited disability on patient-rated outcome measures, low pain scores, and high satisfaction at mid- to late follow-up.

Management of Pisotriquetral Instability

Pisotriquetral instability is an often-overlooked condition that can lead to ulnar-sided wrist pain and dysfunction. Various case series and biomechanical studies have been published regarding the diagnosis and treatment of this condition. We review current methods for examining, diagnosing, and treating pisotriquetral instability.

Joint Space Narrowing in Patients With Pisotriquetral Osteoarthritis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Observer Variability in Evaluating Pisotriquetral Osteoarthritis using Pisotriquetral View

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

Pisotriquetral joint disorders: an under-recognized cause of ulnar side wrist pain

Pisotriquetral joint disorders are often under-recognized in routine clinical practice. They nevertheless represent a significant cause of ulnar side wrist pain. The aim of this article is to present the main disorders of this joint and discuss the different imaging modalities that can be useful for its assessment.