Lunocapitate versus four-corner fusion in scapholunate or scaphoid nonunion advanced collapse: a randomized controlled trial

This pragmatic randomized controlled trial compared lunocapitate fusion (LCF) and four-corner fusion (4CF) for scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) in 64 patients. The primary outcome was change in grip strength from preoperative to 1 year postoperatively. The secondary outcomes were Disability of the Hand, Arm, and Shoulder score, Patient Rated Wrist Evaluation score, EuroQol-5D-3L, range of motion, key pinch strength and complications 12 months postoperatively. Grip strength improved only to a small extent and there was no difference between the groups. No differences were found in the secondary outcomes. In conclusion, LCF is not inferior to 4CF regarding strength, range of motion or patient-reported outcome measures.Level of evidence: I.

Single- and Bicolumn Limited Intercarpal Fusion: A Solution for the SLAC or SNAC Wrist

Background  Single- or bicolumn limited intercarpal fusion, also called one- or two-column fusion, has been introduced as an alternative to four-corner fusion. The rationale behind this is obtaining less need for bone grafting and consequently improving the chances of the union. Method  From August 2014 to October 2020, 45 consecutive patients (15 women), with a mean age of 58.4 years (range: 35-79), have been treated for scapholunate advanced collapse or scaphoid nonunion advanced collapse wrist. In 33 cases, the surgery was performed as two-column fusion, and in 12 cases as one-column fusion. The union was determined by a computed tomography (CT) scan or X-ray follow-up studies. The pain assessments (visual analog score: 0-100), range of motion (ROM), grip strength, and Quick Disabilities of the Arm, Shoulder, and Hand score were prospectively included. Results  Of 45 patients, 43 were available for the follow-up, at a mean of 35 months (range: 12-68). All patients but two achieved union at a mean of 9.5 weeks (range: 5-25 weeks). Pain diminished from 60.3 (mean) preoperatively to 16.7 (mean) postoperatively ( p  = 0.0001). Grip strength slightly increased from 28.2 KgF (mean) to 29 KgF (mean) (not significantly, p  = 0.86). Quick Disability of the Arm, Shoulder, and Hand score improved from 39.5 (median) before the surgery to 11 (median) after the surgery ( p  = 0.0004). The postoperative ROM of 62/37 degrees (mean) were recorded for total dorsovolar/radioulnar flexions, respectively. Three patients were converted to total wrist fusion and one to total wrist arthroplasty. One had a rearthrodesis to two-column fusion, which united. Conclusion  One- and two-column fusion showed significant improvement in pain and function, with minimal impairment of the grip strength on the short- to mid-term follow-up. A union rate of 95% and an acceptable complication rate were achieved, without fusing all carpals. Level of Evidence  Prospective, cohort study, level III.

Effects of a neuromuscular joint-protective exercise therapy program for treatment of wrist osteoarthritis: a randomized controlled trial

BACKGROUND

Individuals with wrist osteoarthritis (OA) can suffer from pain, muscular weakness, and impaired motion of the wrist, which can reduce the quality of life. While there is strong evidence that all patients with OA should receive first-line treatment with education and exercises, this approach has not yet been proposed for individuals with wrist OA. Therefore, this trial aimed to evaluate the effectiveness of a first line neuromuscular joint-protective exercise therapy program compared to a training program with range of motion (ROM) exercises in patients with wrist OA.

METHODS

In this randomized controlled trial (RCT), 48 patients with symptomatic and radiographically confirmed wrist OA were randomly allocated to a 12-week self-management program with either a neuromuscular joint-protective exercise therapy program (intervention group) or a training program with ROM exercises only (control group). Our primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE) with secondary outcome measures of grip strength, range of wrist motion, the Numerical Pain Rating, Scale (NPRS), the Disabilities of the Arm, Shoulder, and Hand (DASH) and the Generalized Self-Efficacy Scale (GSES). The outcome measures were evaluated by a blinded assessor at baseline and 12 weeks. Between-groups differences were analyzed using the Mann-Whitney U test and within-group differences were analyzed with the Wilcoxon signed-rank test.

RESULTS

A total of 41 participants were analyzed at 12 weeks. There were no significant differences in PRWE between the groups at 12 weeks (p = 0.27). However, DASH improved significantly in the intervention group compared to the control group (p = 0.02) and NPRS on load within the intervention group (p = 0.006). The difference in DASH should be interpreted with caution since it could be due to a non-significant increase (worsening) from baseline in the control group in combination with a non-significant decrease (improvement) in the intervention group.

CONCLUSIONS

This RCT showed that the novel neuromuscular joint-protective exercise therapy program was not superior in reducing pain and improving function compared to a training program with ROM exercises at 12 weeks. Future research is warranted to evaluate the effectiveness of forthcoming exercise therapy treatment programs for patients with wrist OA.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05367817. Retrospectively registered on 10/05/2022. https://clinicaltrials.gov .

Evaluation of a newly designed deep learning-based algorithm for automated assessment of scapholunate distance in wrist radiography as a surrogate parameter for scapholunate ligament rupture and the correlation with arthroscopy

PURPOSE

Not diagnosed or mistreated scapholunate ligament (SL) tears represent a frequent cause of degenerative wrist arthritis. A newly developed deep learning (DL)-based automated assessment of the SL distance on radiographs may support clinicians in initial image interpretation.

MATERIALS AND METHODS

A pre-trained DL algorithm was specifically fine-tuned on static and dynamic dorsopalmar wrist radiography (training data set n = 201) for the automated assessment of the SL distance. Afterwards the DL algorithm was evaluated (evaluation data set n = 364 patients with n = 1604 radiographs) and correlated with results of an experienced human reader and with arthroscopic findings.

RESULTS

The evaluation data set comprised arthroscopically diagnosed SL insufficiency according to Geissler's stages 0-4 (56.5%, 2.5%, 5.5%, 7.5%, 28.0%). Diagnostic accuracy of the DL algorithm on dorsopalmar radiography regarding SL integrity was close to that of the human reader (e.g. differentiation of Geissler's stages ≤ 2 versus > 2 with a sensitivity of 74% and a specificity of 78% compared to 77% and 80%) with a correlation coefficient of 0.81 (P < 0.01).

CONCLUSION

A DL algorithm like this might become a valuable tool supporting clinicians' initial decision making on radiography regarding SL integrity and consequential triage for further patient management.

Arthroscopic Resection Arthroplasty for Scapholunate Advanced Collapse Wrist

Purpose  Scapholunate advanced collapse (SLAC) wrist results from an untreated scapholunate dissociation and is the most common type of degenerative arthritis of the wrist. The most common surgical treatments for SLAC wrist are proximal row carpectomy and four-corner fusion with scaphoid excision. Arthroscopic surgical treatment for SLAC wrist has been reported; however, only limited data on functional outcomes are available. The purpose of this study is to report our 5-year follow-up clinical outcomes for arthroscopic treatment for SLAC wrist. Methods  Thirty-one consecutive cases of arthroscopic resection arthroplasty for SLAC wrist were reviewed. Preoperative and postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) scores, range of motion, grip strength, and pain (on 0-10 scale) as well as postoperative satisfaction (0 = not satisfied, 5 = completely satisfied) were recorded. Grip and range of motion were measured by an occupational therapist. Results  The preoperative pain score was 7 and 0.18 postoperatively. The mean satisfaction at final follow-up was 4.8. Preoperative and final follow-up scores of the mean DASH was 48 and 3, respectively. The total arc of motion was 114 degrees preoperatively and 126.5 degrees postoperatively. Mean grip strength before surgery was 41 and 49 kg at final follow-up. Conclusion  Arthroscopic resection arthroplasty for SLAC wrist results in significant improvement in patient function as measured by DASH and pain scores. Type of Study/Level of Evidence  Therapeutic IV.

A project-oriented biochemistry laboratory for protein engineering and structure-function using small laccase enzyme from Streptomyces coelicolor

An understanding of structure-function relationships in proteins is essential for modern biochemical studies. The integration of common freely accessible bioinformatics tools available online with the knowledge of protein-engineering tools provide a fundamental understanding of the application of protein structure-function for biochemical research. In order for students to apply their prior knowledge of recombinant protein technology into the understanding of protein structure-function relationships, we developed a semester-long project-oriented biochemistry laboratory experience that is the second laboratory course of a series. For easier integration of knowledge and application, we organized this course into four sequential modules: protein structure visualization/modification, mutagenesis target identification, site-directed mutagenesis, and mutant protein expression, purification, and characterization. These tasks were performed on the protein small laccase (SLAC) that was cloned and characterized by students in the previous semester during the first biochemistry laboratory course of the series. This goal-oriented project-based approach helped students apply their prior knowledge to newly introduced techniques to understand protein structure-function relationships in this research-like laboratory setting. A student assessment before and after the course demonstrated an overall increase in learning and enthusiasm for this topic.

A self-managed exercise therapy program for wrist osteoarthritis: study protocol for a randomized controlled trial

BACKGROUND

Post-traumatic wrist osteoarthritis (OA) can eventually lead to pain, muscular weakness, and stiffness of the wrist, which can affect the function of the entire upper limb and reduce the quality of life. Although there is strong evidence that all patients with OA should be offered adequate education and exercises as a first-line treatment, an effective self-management program, including structured education and therapeutic exercises, has not yet been introduced for individuals with wrist OA. This trial aims to evaluate the effectiveness of an exercise therapy program with joint protective strategies to improve neuromuscular control (intervention group) compared to a training program with range of motion exercises (control group).

METHODS

This is a single-blinded randomized controlled trial (RCT) with two treatment arms in patients with symptomatic and radiographically confirmed wrist OA. The trial will be conducted at a hand surgery department. The participants will be randomly assigned either to a neuromuscular exercise therapy program or to a training program with range of motion exercises only. Participants in both groups will receive a wrist orthosis and structured education on wrist anatomy, pathophysiology, and joint protective self-management strategies. The programs consist of home exercises that will be performed twice a day for 12 weeks. The Patient-Rated Wrist Evaluation (PRWE) is the primary outcome measure of pain and function. Wrist range of motion (ROM), grip strength, the Numeric Pain Rating scale (NPRS), Disabilities of the Arm, Shoulder, and Hand (DASH), the General Self-Efficacy Scale (GSES), Global Rating of Change (GROC), and conversion to surgery are the secondary measures of outcome. Assessments will be performed at baseline and at 3, 6, and 12 months after baseline by a blinded assessor.

DISCUSSION

The upcoming results from this trial may add new knowledge about the effectiveness of a self-managed exercise therapy program on pain and function for individuals with wrist OA. If the present self-management program proves to be effective, it can redefine current treatment strategies and may be implemented in wrist OA treatment protocols.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05367817. Retrospectively registered on 27 April 2022. https://clinicaltrials.gov .

Radiologic Evolution after Scapholunate Dorsal Capsulodesis for Chronic Tears

Background  Many debates are still ongoing for the management of chronic scapholunate (SL) injuries. We have proposed an arthroscopic technique of dorsal capsulodesis with good clinical results. We now propose a radiological follow-up. Purpose  To determine if arthroscopic dorsal capsulodesis can improve the radiographic SL angle and maintain this correction over time. Methods  From January 2020 to January 2021, we included every patient with an SL instability and sorted them according to the European Wrist Arthroscopy Society (EWAS) classification. All patients had bilateral X-rays with a measurement of the radiolunate (RL) and SL angles for both the pathologic and healthy side. We also included patients with lunotriquetral or triangular fibrocartilage complex lesions. The exclusion criteria were the presence of arthritis and persistent intraoperative SL instability after capsulodesis. An arthroscopic dorsal capsulodesis was performed in all patients as originally described by Mathoulin. The RL and SL angles were then again measured on the immediate postoperative X-ray, and then again at 3, 6, and 12 months postoperatively. The statistical analysis was done using a paired Student's t -test with 145 degrees of freedom and α = 0.05. Results  We included a total of 146 patients with a 1-year follow-up. Both the RL angle and the SL angles approach the healthy side at 12 months postoperatively. The RL angle has increased from -7.23 degrees to 4.37 degrees; the difference is still statistically significative, but it is almost equal to the healthy side (5.16 degrees). The SL angle has lowered from 74.55 to 54.95; the difference is still statistically and radiologically significative (6.788 degrees) but has been lowered by 74.3%. Conclusion  This study shows that this technique can normalize the dorsal intercalated segment instability (DISI) over time without the need for any pinning or invasive ligament reconstructive surgery. Level of Evidence  Level IV, cohort study. Clinical Relevance  Dorsal capsulodesis should be considered in all reducible SL injuries, even when DISI is present.

Limited intercarpal fusion versus proximal row carpectomy in the treatment of SLAC or SNAC wrist, results after 3.5 years

The present study compares the postoperative clinical, radiological, and patient-reported functional results between the surgical procedures Proximal Row Carpectomy and Limited Carpal Fusion, in the treatment of SLAC and SNAC conditions of the wrist. 15 Proximal Row Carpectomy patients and 45 Limited Carpal Fusion patients were included in the study. Postoperative outcomes were assessed and compared for pain at load, range of motion, grip strength, Quick-DASH, and satisfaction. A radiological assessment was performed at the follow-up. The Proximal Row Carpectomy patients had a mean age of 60 years (range 31-77) and a mean follow-up of 42 months. The Limited Carpal Fusion patients had a mean age of 58 years (range 35-76) and a mean follow-up of 41 months. The patients treated with Limited Carpal Fusion performed significantly better regarding pain, radial-ulnar motion, and the Quick-DASH (p = 0.002, p = 0.003, and p = 0.002), respectively. The grip strength difference between the treatment groups was stratified for gender and was found significantly better for men in the LCF-treated patients, but not different for women (p = 0.03, p = 0.26), respectively. Differences in flexion-extension between the groups were insignificant (p = 0.525). A higher conversion rate to total wrist fusion was observed in the patients treated with the Proximal Row Carpectomy. All the Proximal Row Carpectomy patients had osteoarthritis at follow-up, whereas it was seen in 19% of the Limited Carpal Fusion patients. The patient-reported satisfaction was substantially better for the Limited Carpal Fusion patients. In conclusion, among patients treated for SNAC and SLAC wrist conditions, besides the findings of flexion-extension, and grip strength which were found without difference for women the findings are in favour of Limited Carpal Fusion compared to Proximal Row Carpectomy. Further, preferably prospective studies are needed to confirm or reject our findings.Level of evidence: Retrospective, comparative cohort study, level III.

Use of Wrist Denervation in the Treatment of SLAC and SNAC Wrist by ASSH Members

Background  Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) are common patterns of wrist arthritis, and surgical treatment options include partial and total wrist arthrodesis and wrist denervation, which maintains the current anatomy while relieving pain. Introduction  The purpose of this study is to elucidate current practices within the hand surgery community with respect to the use of anterior interosseous nerve/posterior interosseous nerve (AIN/PIN) denervation in the treatment of SLAC and SNAC wrists. Methods  An anonymous survey was distributed to 3,915 orthopaedic surgeons via the American Society for Surgery of the Hand (ASSH) listserv. The survey collected information on conservative and operative management, indications, complications, diagnostic block, and coding of wrist denervation. Results  In total, 298 answered the survey. 46.3% ( N  = 138) of the respondents used denervation of AIN/PIN for every SNAC stage, and 47.7% ( N  = 142) of the respondents used denervation of AIN/PIN for every SLAC wrist stage. AIN and PIN combined denervation was the most common standalone procedure ( N  = 185, 62.1%). Surgeons were more likely to offer the procedure ( N  = 133, 55.4%) if motion preservation had to be maximized ( N  = 154, 64.4%). The majority of surgeons did not consider loss of proprioception ( N  = 224, 84.2%) or diminished protective reflex ( N  = 246, 92.1%) to be significant complications. 33.5%, 90 respondents reported never performing a diagnostic block prior to denervation. Conclusion  Both SLAC and SNAC patterns of wrist arthritis can result in debilitating wrist pain. There is a wide range of treatment for different stages of disease. Further investigation is required to identify ideal candidates and evaluate long-term outcomes.

Proximal row carpectomy versus four-corner arthrodesis in the treatment of SLAC and SNAC wrist: meta-analysis and literature review

A systematic literature review was performed on 84 articles from 2000 to 2020 on proximal row carpectomy (PRC) or four-corner arthrodesis (FCA) in patients with posttraumatic wrist osteoarthritis. Qualitative assessment was conducted on 14 articles. Pain, range of motion (ROM), grip strength and complications were analyzed using weighted average means. Meta-analysis with a random effects model was performed for the flexion-extension arc and grip strength. A total of 1,066 PRCs and 2,771 FCAs were analyzed, with a mean follow-up of 9 and 7 years respectively. Mean flexion after PRC and FCA respectively was 36.2 ° and 31.1 °, mean extension 41.4 ° and 32.4 °, and mean grip strength 26.4 kg and 27.5 kg. PRC had a larger flexion-extension arc than FCA, with a standard mean difference (SMD) of 0.41 (range, 0.02-0.81). No significant difference was found for grip strength. Osteoarthritis occurred in 42.2% of PRC cases, independently of capitate shape. Conversion to wrist arthrodesis was performed in 10.1% of failed PRCs. Revision was chosen in 4.7% of FCAs and conversion to wrist arthrodesis in 4.6%. We conclude that the functional results of both techniques are similar, but prefer PRC to FCA because of the lower complications rate.

Current Concepts in Scapholunate Instability Without Arthritic Changes

Scapholunate instability (SLI) is the most common carpal instability described. SLI leads to a degenerative arthritic pattern known as scapholunate advanced collapse (SLAC). Diagnosis of SLI can be challenging in pre-dynamic and dynamic stages. CT arthrogram, MR arthrogram and dynamic fluoroscopy are helpful in diagnosis while arthroscopy remains the gold standard. SLI is a multi-ligament injury, which involves not only the scapholunate interosseous ligament (SLIL) but also the extrinsic carpal ligaments. Hence, it is better described as an injury compromising the 'dorsal scapholunate(dSLL) complex'. A repair can be attempted for acute SLI presenting within 6 weeks of injury. Reconstruction is the mainstay of treatment for chronic SLI without degenerative changes. Multiple repair techniques have been described which include capsulodesis and tenodesis procedures. The clinical outcomes of the techniques have improved over the years. However, a common problem of all these techniques is the lack of long-term data on the outcomes and deteriorating radiological parameters over time. SLI staging is an important factor to be considered in choosing the reconstruction techniques for a better outcome. Currently, there is a trend towards more biological and less invasive techniques. Regardless of the technique, it is important to preserve the nerve supply of the dorsal capsuloligamentous structures of the wrist. Arthroscopic techniques being minimally invasive have the advantage of less collateral damage to the capsuloligamentous structures. Rehabilitation involves a team approach where a protected dart thrower's motion is allowed after a period of immobilization. Strengthening SL-friendly muscles and inhibiting SL-unfriendly muscles is a key principle in rehabilitation.

Is the Repair of Acute Scapholunate Injuries Associated With Distal Radius Fractures Necessary at the Time of Osteosynthesis? A Systematic Review and Meta-Analysis

BACKGROUND

Acute scapholunate ligament injuries (SLIs) can occur in distal radial fractures (DRFs). This systematic review compares patient-reported outcomes and range of motion (ROM) between operative and nonoperative treatment of acute SLIs in association with surgical fixation of DRFs. We hypothesize that there is no clinical difference.

METHODS

A meta-analysis was used to evaluate the effectiveness of SLI repair versus no repair occurring with DRF with Disabilities of the Arm, Shoulder, and Hand (DASH) scores. We identified 154 articles of which 14 were eligible for review. Only 7 studies reported sufficient radiographic or clinical outcomes data and were included: 3 for meta-analysis and 4 underwent narrative analysis due to lack of homogeneity. We analyzed the patients in 2 groups: operative SLI (O-SLI) versus nonoperative SLI (NO-SLI). The primary outcomes were ROM and DASH scores with 1-year follow-up, where a pooled effect size was generated to determine a difference between groups.

RESULTS

A total of 128 patients were included (71 O-SLI and 57 NO-SLI), with a mean follow-up of 70.2 months (SD: 23.5). The overall effect size for ROM for flexion was 1.74 (95% confidence interval [CI], -3.48 to 6.95; P = .51) and for extension was 0.79 (95% CI, -3.41 to 4.99; P = .71), while the overall effect size for DASH scores was -0.28 (95% CI, -0.66 to 0.10; P = .14). Although NO-SLI led to better ROM and O-SLI led to lower DASH scores, these were not significantly different.

CONCLUSION

The acute surgical intervention of a scapholunate interosseous ligament injury is no different from conservative management in the setting of acute DRFs undergoing osteosynthesis. But the sample size for pooed analyses was small, hence the evidence to date is low to recommend either way.

Radiographic Scapholunate Interval in the Pediatric Population Decreases in Size as Age Increases

BACKGROUND

Widening of the scapholunate (SL) interval greater than 2 mm is diagnostic of an injury in adults; however, this absolute number cannot be used for skeletally immature individuals due to the ossification of the carpal bones. The purpose of this study was to determine age-appropriate normative values for the radiographic SL interval in the skeletally immature population.

METHODS

Normal pediatric wrist radiographs were identified. The radiographic SL interval was measured as the distance between the scaphoid and the lunate at the mid-joint space between the scaphoid and the lunate, and the SL and capitolunate angles were measured on lateral views. An initial inter-rater reliability assessment was completed with strong inter-rater reliability.

RESULTS

In all, 529 radiographic series of children (276 male), aged 4 to 17 years, were reviewed. A negative linear correlation between chronological age and distance at the mid-joint space was observed. The average values for the radiographic SL interval ranged from 9.07 to 1.57 mm. The average SL and capitolunate angles were 52.0° and 10.6°, respectively. No linear relationship was found between chronological age and SL or capitolunate angle (R = 0.07 and 0.03, respectively).

CONCLUSIONS

The visible radiographic distance between the scaphoid and the lunate decreases with increasing age as the carpal bones ossify. The normative values defined in this study can be used to determine whether a true widening of the SL interval is present in the pediatric population. No linear relationship exists between chronological age and SL or capitolunate angle.

Risk of Total Wrist Arthrodesis Following Proximal Row Carpectomy: An Analysis of 1,070 Patients

PURPOSE

Proximal row carpectomy (PRC) is a motion-sparing procedure with good patient-reported and clinical outcomes. Although some studies have investigated the risk of conversion to total wrist arthrodesis (TWA) after PRC, additional larger studies evaluating the specific risk factors that lead to failure are required. This study aimed to investigate the patient and procedure factors that are associated with increased risk for conversion to TWA in a large cohort of patients who underwent PRC.

METHODS

The current procedural technology codes identified patients in a National Veteran's Health database undergoing a PRC over a 26-year period. Risk factors of interest comprised age, posterior interosseous nerve neurectomy, wrist arthritis pattern, bilateral surgery, smoking, comorbidities, and preoperative opioid use. The primary outcome was the rate of conversion to TWA. Cox proportional hazard regression was used to create hazard ratios of selected factors for reoperation.

RESULTS

There were 1,070 PRCs performed, with a mean follow-up of 79.8 ± 59.6 months. A total of 5.3% (57/1,070) wrists underwent conversion to TWA. Younger age at the time of PRC (<50 years) significantly increased the risk of TWA (hazard ratio, 3.8; 95% confidence interval, 2.2-6.6). With every 1-year increase in age, there was a reduction of 4% (hazard ratio, 0.96; 95% confidence interval: 0.94-0.98) in the hazard of conversion to TWA. No other factors, including concomitant posterior interosseous nerve neurectomy or bilateral PRC, increased the risk of conversion to TWA.

CONCLUSIONS

Proximal row carpectomy is a motion-preserving salvage procedure with a low rate of conversion to wrist arthrodesis. Younger patient age increases the risk of conversion to arthrodesis, whereas posterior interosseous nerve neurectomy, bilateral PRCs, and comorbidity status do not appear to have an impact on the risk of arthrodesis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Does Midcarpal Joint Structure Affect Development of Arthritis in the Wrist

Background  Degenerative wrist arthritis develops in specific patterns because of forces acting on existing structural configurations. The most common pattern of wrist osteoarthritis is scapholunate advanced collapse (SLAC). Other patterns include isolated scaphotrapezial trapezoid (STT) joint and isolated midcarpal or radiolunate joint arthritis. One predictor of degeneration pattern is the structure of the wrist. Questions/Purposes  Our purpose was to evaluate the relationship between midcarpal joint structure and the pattern of degenerative arthritis. We hypothesized that a wrist type 2 will preferentially develop SLAC degeneration. Patients and Methods  We retrospectively evaluated 195 degenerative wrist radiographs. Radiographs were reviewed for lunate/wrist type, degeneration pattern, ulnar variance, radial and volar tilt, inclination, carpal height, scapholunate angle, gap, and presence of thumb carpometacarpal (CMC) joint, STT joint, and midcarpal joint arthritis. Results  We had 158 radiographs with SLAC degeneration and 37 with atypical patterns, 154 type 2 and 41 type 1 wrists. There was a significant correlation between wrist type and the pattern of wrist degeneration ( p  = 0.02). SLAC degeneration developed in wrists with type 2 lunate while isolated midcarpal arthritis was associated with type 1 wrist. Isolated midcarpal joint arthritis was associated with STT arthritis, p  < 0.01. Radial height, inclination, volar tilt, and ulnar variance, and scapholunate gap and angle were not associated with wrist type. Ulnar variance was associated with thumb CMC and STT joint arthritis while radial height was associated with isolated midcarpal joint arthritis. Conclusion  This study found significant relationships between midcarpal joint structure and pattern of degeneration. This contributes to understanding the development of degeneration and can aid in future prevention of arthritis. Level of Evidence  This is a Level IV, diagnostic study.

Factors Associated With Unplanned Reoperation After 4-Corner Arthrodesis: A Study of 478 Wrists

Purpose

The 4-corner arthrodesis (FCA) is a reliable, motion-sparing technique used to treat scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis, particularly in stage III wrists in which the capitolunate articulation is compromised. Surgical technique and patient-level variables may influence complications following FCA. We sought to evaluate the rate of complications in a large, combined database and manual chart review study.

Methods

Current Procedural Terminology codes were used to search the United States Veteran's Health Administration corporate database to identify wrists treated with FCA over a 24-year period. A retrospective chart review was completed to collect data regarding scapholunate advanced collapse/scaphoid nonunion advanced collapse stage, implant used, the use of a bone graft, smoking status, and comorbidities for all patients undergoing an FCA. A multivariable cox proportional hazards regression was used to assess hazard ratios for reoperation. Incidence rates and the standard error of the mean for reoperation and conversion to total wrist fusion were calculated after grouping patients by 10-year age categories.

Results

A total of 478 wrists underwent FCA during the study period, with a mean follow-up of 63 months. Seventy-three (16%) wrists required reoperation. The most frequent secondary procedures included unplanned implant removal (8.2%), total wrist arthrodesis (4.6%), and revision FCA (1.7%). Positive smoking history increased the risk of reoperation, whereas posterior interosseous nerve neurectomy, arthritis stage, and fixation type did not have a statistically significant association with reoperation. Younger age demonstrated an increased incidence of overall reoperation and wrist fusion.

Conclusions

The most common reason for reoperation after FCA was implant removal. Smoking history is associated with increased rates of reoperation and wrist arthrodesis. Knowledge of these factors may assist with accurately counseling and indicating patients for FCA.

Type of study/level of evidence

Therapeutic III.

Four-Corner Arthrodesis Using a Dedicated Dorsal Circular Plate

BACKGROUND

Scaphoid excision and 4-corner fusion is a standard procedure for advanced carpal collapse. The purpose of this study was to evaluate its effectiveness using a specific designed locking plate of the latest generation.

METHODS

Between October 2012 and December 2015, 12 patients underwent this procedure using the Flower (KLS Martin Group, Tuttlingen, Germany) circular locking plate. The surgical technique is standardized. Three patients were affected by a scapholunate advanced collapse and 9 patients by a scaphoid nonunion advanced collapse. All patients underwent a computed tomographic scan to study the real achievement of the fusion.

RESULTS

Only 2 patients did not show complete fusion. All the patients with successful fusion returned to previous work and manual activities.

CONCLUSIONS

Four-corner arthrodesis with circular locking plate is an alternative surgical treatment for carpal arthritic collapse.

Arthroscopic Midcarpal Tendon Interposition: A New Technique for Capitolunate Constraints

Conflicts of the capitolunate, causing midcarpal pain from friction can be isolated (e.g., avascular necrosis of the proximal pole of the capitate [AVNC], palmar midcarpal instability [PMCI]) or form part of a framework of more complex osteoarthritis phenomena (e.g., scaphoid pseudarthrosis [SNAC], and lesions of the scapholunate capsuloligamentous complex [SLAC]). We group in the term "conflict" all of the causes (with intact cartilage or not) causing midcarpal pain by friction. Treatment by capitolunar arthrodesis can be effective, but inevitably stiffening. In other more specific cases (i.e., AVNC), replacement of the proximal pole of the capitate with a synthetic implant or a tendon has shown variable results. In this work, we propose a management of these conflicts with a conservative arthroscopic technique, including capitolunate tendon interposition. We describe arthroscopic midcarpal tendon interposition (AMTI) for capitolunate conflicts. This technique prevents stiffness due to arthrodesis, but good experience in wrist arthroscopy is required to perform this operation.

Four-Corner Arthrodesis: Comparative Analysis of Open Technique Versus Percutaneous Technique with Arthroscopic Assistance

Introduction  Four-corner arthrodesis is a salvage technique for patients with carpal advanced osteoarthritis. Nowadays, percutaneous techniques with arthroscopic assistance have been described, achieving favorable results with minimally invasive techniques advantages over open surgery. Objective  To compare functional and radiological results in patients with SLAC or SNAC wrists operated with open surgical technique versus percutaneous surgery with arthroscopic assistance. Materials and Methods  Retrospective case-control study of clinical records and radiological images of patients with carpal advanced osteoarthritis operated with both surgical techniques. We studied demographic variables, pain with visual analog scale (VAS) score, function in ranges of mobility, time of consolidation, and correction of DISI deformity. Results  A total of 22 male patients with an average age of 32.5 years were studied. Thirteen patients in the case group (percutaneous technique with arthroscopic assistance) and nine patients in the control group (open surgery). Pain score in VAS at discharge was 3 for cases and 5 in controls ( p  = 0.008), and at 30 days postoperatively, it was 0 and 3 respectively ( p  = 0.00). The extension and flexion ranges were 52.6°and 38.7° in the cases and 35.7° and 32.4° in the control group ( p  = 0.119 and 0.0016, respectively). The capitolunate angle was 10°in the controls and 5°in the cases ( p  = 0.0008). The time of consolidation was 8.8 weeks in cases and 12.5 weeks in controls ( p  = 0.039). Conclusions  The percutaneous technique with arthroscopic assistance for the 4-courner arthrodesis is a reproducible technique and is effective in achieving consolidation, pain reduction and preservation of wrist motion. In the present study, we demonstrate superiority of this technique over the open surgery. Level of Evidence  This is a Level III, therapeutic study.

Secondary Wrist Arthritis in Active Workers: Does Capitate Pyrocarbon Resurfacing (RCPI) Improve Proximal Row Carpectomy? A Retrospective Cohort Study

Background: Proximal Row Carpectomy (PRC) is a widespread, safe and effective salvage surgical procedure for wrist arthritis. Some authors believe that PRC results in low grip strength (GS), due to the loss of carpal height, supporting the idea to discourage PRC in high-demanding patients. Resurfacing Capitate Prosthesis Implant (RCPI) allows extending the indication for PRC also in case of deformity and/or arthritis of the head of capitate, with possible implications of clinical outcomes, including GS. Methods: Retrospective multicentre study on a population of active workers, affected by secondary post traumatic wrist arthritis, who underwent PRC (27 patients) or PRC + RCPI (20 patients), Primary outcome was to assess GS between PRC and PRC + RCPI. Secondary outcome was to assess CHR and to search for any possible contributors to GS. Active range of motion (AROM), hand function (DASH, Work-DASH, VAS, PRWHE), pain, time to return to work, job maintenance, major complications and general satisfaction were also assessed. Results: PRC + RCPI results in more GS maintenance compared with PRC alone, with higher values of CHR. CHR values were associated with GS with a good correlation. According to linear regression model analysis within PRC + RCPI group (GS-CHR), it is esteemed that the increase in parameter CHR is associated with an increase in parameter GS. Looking at a multiple linear regression model analysis built on the whole sample (GS% increase - (group × CHR) + GS% pre-operative). It is estimated that the increase of one unit of the GS coefficient is associated with an increase in GS% increase. Furthermore, higher pre-operative GS values positively influence post-operative GS. No differences were revealed between the two treatments in terms of the remaining secondary outcomes. Conclusions: PRC alone and PRC + RCPI are both effective salvage procedures for wrist arthritis. RCPI provides a better GS preservation, in part due to the carpal height preservation.

Inter-Rater Reliability of Magnetic Resonance Imaging in Comparison to Computed Tomography and Wrist Arthroscopy in SLAC and SNAC Wrist

The aim of the study was to assess the inter-rater reliability of magnetic resonance imaging (MRI) in comparison to computed tomography (CT) and wrist arthroscopy in patients with scapholunate (SLAC) or scaphoid non-union advanced collapse (SNAC) as well as to evaluate a grading score of cartilage lesions. A total of 42 patients (36 male, 6 female) at a mean age of 45 years (range: 19-65 years) with a SLAC or SNAC wrist who had a preoperative MRI and CT scan as well as underwent arthroscopy of the wrist between 2013 and 2018 were included in this study. Cartilage lesions, as assessed by MRI, CT and wrist arthroscopy, were classified by two hand surgeons in three stages. Inter-rater reliability was evaluated using the Kendall Tau-b test as well as the chi-square test to analyze for trend. The correlation between cartilage lesions, classified by arthroscopy and MRI, was low. A moderate correlation between CT and arthroscopy staging was shown. The highest inter-rater correlation was found between MRI and CT staging. An additionally performed logistic regression showed that progression of cartilage lesions as shown in MRI scans correlates with a restriction of range of motion (ROM). The level of cartilage lesion may be more severely classified in an MRI than during arthroscopy. Arthroscopy remains the gold standard in detecting cartilage lesions and thus in the decision-making process of the definitive treatment in carpal collapse.

Scaphoid Excision and Bicolumnar Carpal Fusion with Retrograde Headless Screws

Background/Purpose  Scaphoid excision and partial wrist fusion is used for the treatment of scapholunate advanced collapse/scaphoid nonunion advanced collapse wrist arthritis. The purpose of this study was to report midterm functional and radiographic outcomes in a series of patients who underwent bicolumnar fusion of the lunocapitate and triquetrohamate joints using retrograde headless screws. Methods  Twenty-three consecutive patients (25 wrists) underwent surgery with this technique from January 2014 to May 2017 with a minimum follow-up of 1 year. Assessment consisted of range of motion, grip, and pinch strength. Patient-reported outcome measures included disabilities of the arm, shoulder, and hand (DASH) and patient-rated wrist evaluation (PRWE) scores. Fusion rates and the radiolunate joint were evaluated radiographically. The relationship between wrist range of motion and midcarpal fusion angle (neutral position vs. extended capitolunate fusion angle > 20 degrees) was analyzed. Results  Average follow-up was 18 months. Mean wrist extension was 41 degrees, flexion 36 degrees, and radial-ulnar deviation arc was 43 degrees. Grip strength was 39 kg and pinch 9 kg. Residual pain for activities of daily living was 1.6 (visual analog scale). The mean DASH and PRWE scores were 19 ± 16 and 28 ± 18, respectively. Patients with an extended capitolunate fusion angle trended toward more wrist extension but this did not reach statistical significance ( p  = 0.17). Conclusions  With retrograde headless compression screws, the proximal articular surface of the lunate is not violated, preserving the residual load-bearing articulation. Patients maintained a functional flexion-extension arc of motion with grip-pinch strength close to normal. Capitolunate fusion angle greater than 20 degrees may provide more wrist extension but further studies are needed to demonstrate this. Level of Evidence  This is a Level IV study.

Progressing arthrosis and a high conversion rate 11 (4-19) years after four corner fusion

Four corner fusion (4CF) is a limited wrist arthrodesis offered to patients with painful wrists due to scaphoid non-union advanced collapse (SNAC) or scapho-lunate advanced collapse (SLAC). A retrospective study of 42 wrists (in 36 patients), operated with 4CF using K-wires and autologous bone graft followed up after 11 (4-19) years was performed, 25 were male and mean age at surgery was 51 (22-71) years. During the follow-up period, 13 wrists were converted to total wrist arthrodesis or wrist arthroplasty, and one is scheduled for conversion (14/42, 33%) due to non-union (3), DISI and progressing arthrosis (7) or progressing arthrosis (4). Non-union was seen in 3/42 (93%) wrists, all were later converted. At the final follow-up, the patients reported residual pain, VAS = 15 and 36 at rest and activity, respectively, and QDASH/PRWHE = 32 and 31, respectively. Active range of motion (AROM) was 38% and grip-strength was 76% compared to the uninjured side. Degenerative changes were seen in 88% on CT scans at follow-up. 4CF renders an acceptable pain reduction and function in the majority of patients, but increased degeneration and a high number of conversions after a longer follow-up time is concerning.

Long-term radiological changes and functional outcomes after proximal row carpectomy: Retrospective study with 3 years' minimum follow-up

INTRODUCTION

The aim of this study was to analyze the radiological changes and determine the clinical and functional outcomes of proximal row carpectomy (PRC) over the long term.

HYPOTHESIS

Radiological changes after PRC occur in every patient while the clinical and functional outcomes remain stable over time.

METHODS

This was a retrospective single-center study of patients who underwent PRC between January 2004 and December 2014. A clinical assessment (range of motion, grip strength), functional assessment (Mayo Wrist score and QuickDASH) and radiographic assessment (radiocapitate osteoarthritis, radiocapitate congruency) was done in every patient at the longest follow-up.

RESULTS

Thirty-one patients were reviewed with a mean follow-up of 97.9 months. The indications for PRC were SLAC (n=10), SNAC (n=5), Kienböck disease (n=9) and other conditions (n=7). The radiocapitate index, which is the radius of curvature of the tip of the capitate divided by the mean radius of curvature of the lunate fossa, went from 0.68 immediately postoperative to 0.74 at the final assessment (p=0.035). The mean flexion/extension arc was 93°. The mean grip strength was 25 kg. The mean QuickDASH was 29 and the mean Mayo Wrist score was 69. Fifteen patients had radiocapitate osteoarthritis. Seven patients (22%) required revision surgery for wrist fusion after a mean of 18.6 months.

CONCLUSION

Radiological adaptation in the radiocapitate joint after PRC was found in this study. PRC is a reliable solution and yields stable outcomes over time for treating radiocarpal osteoarthritis, except in young adults and manual laborers who had a notable early revision rate.

LEVEL OF EVIDENCE

IV - retrospective study.

Resurfacing capitate pyrocarbon implant after proximal row carpectomy: A litterature review

Up to a decade ago, to treat patients with chronic wrist pain due to advanced stages of arthritis, surgeons had four main solutions: partial or total wrist arthrodesis, total wrist prosthesis and proximal row carpectomy (PRC). Since 2010, a new technique has been described in literature using the Resurfacing Capitate Pyrocarbon Implant (RCPI), combined to PRC. The aim of this article is to review the literature and determine the indications, outcomes and complications associated with RCPI. An electronic literature research was carried out and pertinent articles were selected. Surgical technique, results and complications described in those articles are presented. From this review of the literature, authors conclude that Resurfacing Capitate Pyrocarbon Implant can be considered as a good alternative to arthrodesis and total wrist arthroplasty, at any ages, when proximal row carpectomy alone would not be indicated.

Total wrist denervation: Retrospective study of 39 wrists with 56 months' follow-up

INTRODUCTION

The objective of this study was to analyze patient satisfaction after total wrist denervation.

HYPOTHESIS

Total wrist denervation provides reliable and durable results.

MATERIAL AND METHOD

A single-center multi-surgeon retrospective study included a cohort of 39 wrists. Mean age was 58 years. The dominant side was operated on in two-thirds of cases. SLAC wrist and SNAC wrist accounted for 41% of etiologies. All patients were seen again in consultation and were evaluated for pain, strength, mobility and limb function. Failure was defined as any reoperation.

RESULTS

Mean follow-up was 56 months, with no loss to follow-up. Pain improved in 79.5% of cases. Median DASH score was 27.27. Strength on Jamar® dynamometer improved from 60% to 75% compared to the contralateral side (p=0.012). Range of motion improved by 5° (p=0.052). At last follow-up, 31% of patients showed aggravation of radiological osteoarthritis. There were 4 revision procedures (total wrist fusion), and 4 complications.

DISCUSSION

The present results were comparable to those in the literature in terms of satisfaction, functional scores and number of complications and revision procedures. Total wrist denervation is a reliable and reproducible surgical technique in terms of pain relief preservation of function in painful osteoarthritic wrists. It thus has an essential place in the therapeutic algorithm of patients presenting with chronic pain in a wrist that is still mobile, whatever the initial etiology.

LEVEL OF EVIDENCE

IV, Retrospective cohort.

The Learning Curve and Pitfalls of Arthroscopic Four-Corner Arthrodesis

Background  Midcarpal "four-corner" wrist arthrodesis may be done from an open arthrotomy or arthroscopically. Purpose  This study aimed to examine the results of the recently described arthroscopic four-corner arthrodesis and whether the procedure seems to have any merit compared with the open technique. Patients and Methods  We retrospectively identified eight patients with nine cases of arthroscopic four-corner arthrodesis performed at our institution, 2014 to 2017. The underlying pathologies were scapholunate advanced collapse ( n  = 6), Preiser's disease ( n  = 1), radioscaphoid ( n  = 1), or capitolunar ( n  = 1) osteoarthritis. Osteosynthesis was done with cannulated compression screws. Results  Operating time for the first surgery was 198 minutes while the final one lasted 132 minutes. All patients achieved fusion. Three patients required a reoperation; one for screw malposition with screw removal, one for tendon reconstruction and screw removal due to a tendon injury induced by a retracted screw, and one for scaphoid impingement with removal of the scaphoid remnants. One patient experienced a probable superficial radial nerve injury. The follow-up time was 5 to 16 months. Conclusion  The arthroscopic approach is technically extremely demanding and has a learning curve. Thorough resection of the scaphoid is recommended to avoid potential impingement. Level of Evidence  This is a level IV, retrospective case series.

Outcomes after Scaphoid Excision and Midcarpal Arthrodesis for SNAC and SLAC Wrist Arthritis

BACKGROUND

Persistent, long-lasting pseudoarthrosis of the scaphoid or scapholunate dissociation results in arthrosis of the radio-scaphoid joint termed scaphoid non-union advanced collapse (SNAC) or scapholunate advanced collapse (SLAC), which causes pain, reduction in wrist movements and weakness of the hand grip. Scaphoid resection followed by "four-corner" midcarpal arthrodesis is a recognized treatment for this condition.

MATERIAL AND METHODS

The study evaluated the results of treatment of 27 patients with arthrosis of the wrist type SNAC (n = 15) and SLAC (n = 12) after an average of 4 years after surgery (range from 2 to 8 years) Results. The mean numerical pain score for wrist movements was 3.6 (range: 1-5). The mean active range of wrist movement (affected vs healthy hand) was: flexion 27° vs 58° (46%), extension 27° vs 52° (53%), ulnar deviation 16° vs 26° (62%), radial deviation 9° vs 17° (53%), total grip strength 22 kG vs 29 kG (76%), The mean DASH score was 22 (range: 4-36) and the mean Mayo score was 72 (range: 65-80). None of the patients required revision surgery. Of the 16 patients employed prior to the surgery, 10 returned to work after a mean of 4 months of sick leave.

CONCLUSIONS

1. The results of the treatment presented in this stu-dy, after a relatively long follow-up period, show a beneficial effect of the surgery on pain intensity and improvement of hand dexterity, at the cost of a mild reduction in wrist movements. 2. It seems that this technique offers good, predicta-ble outcomes and may be recommended for Wa-t-son 2° and 3° SNAC or SLAC wrist arthrosis.

Small laccase from streptomyces coelicolor-an ideal model protein/enzyme for undergraduate laboratory experience

A one semester undergraduate biochemistry laboratory experience is described for an understanding of recombinant technology from gene cloning to protein characterization. An integrated experimental design includes three sequential modules: molecular cloning, protein expression and purification, and protein analysis and characterization. Students perform the tasks of cloning, expression, purification, analysis, and characterization of small laccase (SLAC) from Streptomyces coelicolor. SLAC is an extremely robust well-characterized protein/enzyme, which serves as an ideal model for undergraduate teaching laboratories. Also, this goal-oriented research-like approach helps students to unite the concepts of biochemistry and molecular biology and appreciate the utility of the methods more effectively. A student assessment before and after the course demonstrated an overall increase in learning and enthusiasm on the topic of modern protein chemistry. © 2017 by The International Union of Biochemistry and Molecular Biology, 46(2):172-181, 2018.

Locking Dorsal Plate in Four-Bone Arthrodesis in SLAC and SNAC 3 Wrist

Purpose  The aim of this study was to evaluate the effectiveness and the safety of performing a four-bone arthrodesis (FBA) with dorsal locking plate in patients suffering from stage III scapholunate advanced collapse/scaphoid nonunion advance collapse (SLAC/SNAC) wrist. Methods  We evaluated retrospectively 20 patients surgically treated by a FBA with the use of locking dorsal plate. All the patients were clinically evaluated at follow-up for grip strength, range of motion, and pain (visual analog scale), and with the Disability of the Arm, Shoulder and Hand score and the Mayo wrist score. Imaging evaluation was performed on standard X-rays. Results  The mean follow-up was 6 years (range: 1-11 years). During follow-up, the patients showed good clinical outcomes in terms of pain relief and grip strength. Revision surgery was necessary only in one case because of screws loosening. In all cases, a solid bone fusion was achieved except in one patient, who presented a healing of lunocapitate joint. This condition did not affect the clinical outcomes. Conclusion  FBA performed using a dorsal locking plate is a salvage procedure effective in treating stage III SLAC/SNAC wrist. In our study, this technique provided good clinical outcomes at mid-term follow-up with a very low complication rate. Level of Evidence  Level IV, therapeutic case series.

Four-Corner Arthrodesis: Description of Surgical Technique Using Headless Retrograde Crossed Screws

BACKGROUND

Four-corner fusion has been shown to be a reliable option of treatment of wrist arthritis, but there is no consensus about which implant and surgical procedure should be used in the arthrodesis. The present study aimed to describe a surgical technique using 2 crossed screws as implants, inserted in a retrograde manner, and to demonstrate preliminary results of the use of the technique.

METHODS

A retrospective study was conducted using medical records and imaging tests (radiographs and computed tomography) of all 15 patients who underwent a standardized 4-corner fusion technique, between December 2011 and July 2015, in the Department of Hand Surgery of Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, Brazil. We collected data on the following variables: fusion rate, time to fusion, and percentage of patients who had any complications or needed another surgical procedure on the same wrist.

RESULTS

All but one patient achieved fusion of arthrodesis. The average time to union was 5.54 months (SD = 3.84). Only the patient who developed nonunion of the 4-corner fusion required another surgery on the same wrist.

CONCLUSIONS

The procedure described in this study demonstrated a low complication rate and high fusion rate, and can therefore be considered a reliable surgical technique for 4-corner fusion.

Incidence and Functional Outcomes of Scapholunate Diastases Associated Distal Radius Fractures: A 2-year Follow-Up Scapholunate Dissociation

BACKGROUND

The Scapholunate Interosseous Ligament (SLIL) is the first intrinsic carpal ligament to be injured in wrist trauma, present in up to 64% of the distal radius fractures. However, it remains unclear what patients develop symptoms, making primary treatment of these injuries accompanying distal radius fractures remains questionable.

OBJECTIVE

The aim of this study was to evaluate the functional outcomes of patients with scapholunate diastasis associated with distal radius fractures.

METHODS

We evaluated 391 patients with a distal radius fracture. Using Computer Tomography (CT) scans the scapholunate interval was measured. We identified 14 patients with an SLD (>3mm) of the injured wrist, which underwent a CT-scan of the contralateral wrist. To evaluate the functional outcomes at a mean follow up of 136±90 weeks, we used the Quick Disabilities of the Arm, Shoulder and Hand (qDASH) Score.

RESULTS

There were 8 patients with bilateral SLD and 6 patients with unilateral SLD. Five patients had a qDASH score of 0 and one patient showed a qDASH score of 18.2. The patient with a poor score had bilateral preexisting osteoarthritis of the wrist. No patient had additional surgery of the SLIL.

CONCLUSION

In patients with distal radius fractures, more than half of the 14 patients with an SL gap on CT had widening on the contralateral side. It is therefore worthwhile to image the contralateral wrist before diagnosing a SLD. The patients with unilateral SLD should not be surgically treated at initial presentation because they may have good functional outcomes after a follow up of 2 years.

Arthroscopic-Assisted Partial Wrist Arthrodesis

Partial wrist arthrodesis (PWA) is a well-known procedure for treating degenerative or posttraumatic wrist conditions. Four-corner fusion (4CF) is mostly used for scapholunate advanced collapse and scaphoid nonunion advanced collapse. The author performed 39 procedures, including 4CFs, 2-corner fusions, 3-corner fusions, scaphoid-capitate/scaphoid-capitate-lunate fusions, scaphoid-trapezium-trapezoid arthrodeses, and radioscapholunate arthroscopic PWAs (A-PWAs). There were 8 revision cases including 4 partial nonunions. All A-PWAs healed satisfactorily after revision surgery. This article discusses the surgical techniques and tips to avoid mistakes. The pros and cons for open versus arthroscopic techniques and for screws versus Kirschner wires are also discussed.

Four-Year Outcomes of Midcarpal Hemiarthroplasty for Wrist Arthritis

PURPOSE

The purpose of this study was to review the average 4-year outcomes of a cohort of patients with wrist arthritis, treated by a single surgeon with a novel prosthetic hemiarthroplasty of the midcarpal joint. We hypothesized that midcarpal hemiarthroplasty would improve range of motion and grip strength of patients with wrist arthritis, with a complication profile comparable with that of alternative solutions for wrist arthritis.

METHODS

We reviewed a series of 20 patients treated with a midcarpal hemiarthroplasty at an average of 4 years following surgery. Patients were evaluated objectively with grip strength, wrist range of motion, serial radiographs, and subjectively surveyed with Disabilities of the Arm, Shoulder, and Hand (DASH) and Mayo scores.

RESULTS

Range of motion increased by a mean 33° in flexion-extension and 10° in radial-ulnar deviation compared with preoperative range of motion. Mean grip strength improved to 20.8 kg from 14.1 kg, and Mayo and DASH scores also significantly improved. Three patients had a manipulation under anesthesia for stiffness. One patient required open reduction internal fixation of an unstable fourth carpometacarpal joint after falling. Two patients were revised to a total wrist arthroplasty and 1 to a wrist fusion.

CONCLUSIONS

Midcarpal hemiarthroplasty provides improved wrist range of motion, grip strength, and patient-reported outcome scores compared with preoperative values, with a complication profile comparable with that of other surgical options for patients with wrist arthritis. Advantages of midcarpal arthroplasty include retention of the native distal carpal row, preservation of midcarpal motion, as well as the option for conversion to a total wrist arthroplasty should revision be required.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Dorsal Scaphoid Subluxation on Sagittal Magnetic Resonance Imaging as a Marker for Scapholunate Ligament Tear

PURPOSE

To evaluate the diagnostic utility of scaphoid dorsal subluxation on magnetic resonance imaging (MRI) as a predictor of scapholunate interosseous ligament (SLIL) tears and compare this with radiographic findings.

METHODS

Thirty-six MRIs were retrospectively reviewed: 18 with known operative findings of complete Geissler IV SLIL tears that were surgically repaired, and 18 MRIs performed for ulnar-sided wrist pain but no SLIL tear. Dorsal subluxation of the scaphoid was measured on the sagittal MRI cut, which demonstrated the maximum subluxation. Independent samples t tests were used to compare radiographic measurements of scapholunate (SL) gap, SL angle, and capitolunate/third metacarpal-lunate angles between the SLIL tear and the control groups and to compare radiographic measurements between wrists that had dorsal subluxation of the scaphoid and wrists that did not have dorsal subluxation. Interrater reliability of subluxation measurements on lateral radiographs and on MRI were calculated using kappa coefficients.

RESULTS

Thirteen of 18 wrists with complete SLIL tears had greater than 10% dorsal subluxation of the scaphoid relative to the scaphoid facet. Average subluxation in this group was 34%. Four of 18 wrists with known SLIL tears had no subluxation. No wrists without SLIL tears (control group) had dorsal subluxation. The SL angle, capitolunate/third metacarpal-lunate angle and SL gap were greater in wrists that had dorsal subluxation of the scaphoid on MRI. Interrater reliability of measurements of dorsal subluxation of the scaphoid was superior on MRI than on lateral x-ray.

CONCLUSIONS

An MRI demonstration of dorsal subluxation of the scaphoid, of as little as 10%, as a predictor of SLIL tear had a sensitivity of 72% and a specificity of 100%. The high positive predictive value indicates that the presence of dorsal subluxation accurately predicts SLIL tear.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Failure of Wrist Hemiarthroplasty

BACKGROUND

Wrist hemiarthroplasty has emerged as a motion-sparing option for severe wrist arthritis. It is technically easy with advantages of limited bone resection and no risk of nonunion. Given the relative infancy of the procedure in clinical practice, there are limited data on patient outcomes.

METHODS

Eleven patients were treated with wrist reconstructive hemiarthroplasty. Indications included 1 patient with scaphoid nonunion advanced collapse, 9 patients with scapholunate advanced collapse, and 1 patient with capitolunate arthritis. Average age was 63 years; average follow-up was 4 years. Objective parameters included Disabilities of the Arm Shoulder and Hand (DASH), grip strength, and range of motion. Implant failure defined by necessity of revision procedure.

RESULTS

DASH scores initially improved postoperatively but were not statistically significant. Grip strength was 60% of contralateral side. Postoperative range of motion at 6 months was flexion 40.3°, extension 39.3°, supination 87.0°, pronation 77.8°, radial deviation 14.5°, and ulnar deviation 13.8°. A 45% failure rate was observed. Complications included failure with conversion to Total Wrist Arthroplasty (TWA; n = 2) or wrist fusion (n = 3) secondary to development of ulnar-sided wrist pain. One additional patient experienced severe wrist pain but declined additional surgery.

CONCLUSIONS

Wrist hemiarthroplasty in our series had a significant failure rate. In each case of failure, the patient developed ulnar-sided wrist pain. In the presence of more reliable procedures, wrist hemiarthroplasty is not indicated in its current incarnation.

Denervation of the wrist with two surgical incisions. Is it effective? A review of 33 patients with an average of 41months' follow-up

The goal of wrist denervation is to decrease pain at the wrist, whether caused by an intra- or extra-articular problem or even when the reason for the pain is unknown. It is an alternative to partial or total arthrodesis and proximal row carpectomy. Our hypothesis was that wrist denervation with a two-incision technique was a reliable and efficient way to treat painful degenerative wrists. Thirty-three patients, 48years old on average, were included in this study. Indications were scapholunate advanced collapse (SLAC) in 18 cases, scaphoid nonunion advanced collapse (SNAC) in 10, distal radius fracture sequelae with advanced radiocarpal osteoarthritis in 4, and post-traumatic ulnocarpal impingement in 1 case. At 41 months' follow-up (12-161), there was a 75% reduction in pain levels, decreasing from 7.1 to 1.8 on a visual analog scale (VAS). There were no modifications related to wrist range of motion or grip strength. The QuickDASH averaged 23 points (5 to 70). Radiographic evaluation showed progression of intracarpal degeneration in 6 patients. All but 2 patients returned to their previous work. Persistent dysesthesia was observed in 7 patients; it resolved in 3 cases and persisted in 4. One patient developed complex regional pain syndrome (CRPS). A midcarpal arthrodesis with scaphoidectomy was performed in one patient because of disabling pain 5months after surgery. Wrist denervation with a two-incision technique for post-traumatic osteoarthritis led to satisfactory results in 75% of cases with reduction in pain, preservation of range of motion and grip strength. However, this technique does not stop the progression of osteoarthritis. It can be discussed as a therapeutic alternative to proximal row carpectomy or intracarpal arthrodesis to treat degenerative painful wrists.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Four-corner arthrodesis employing the native scaphoid as the principal donor graft for advanced collapse deformity of the wrist: technique and outcomes

The purpose of this study was to determine the functional, radiographic, and subjective outcome of the authors' technique of four-corner arthrodesis using the en bloc excised scaphoid as the principal donor bone graft coupled with Kirschner wire fixation. The study comprised 40 consecutive patients with progressive Stage II and III scapholunate advanced collapse or scaphoid nonunion advanced collapse deformities. Preoperative and postoperative range of motion, grip strength, carpal height, and Michigan Hand Outcomes Questionnaire responses were assessed with a mean follow-up of 4.4 years. At an average of 7 weeks, all patients demonstrated radiographic fusion. Moreover, postoperatively, improvement in the Michigan Hand Outcomes Questionnaire domains of overall function, activities of daily living, work performance, pain, and satisfaction were statistically significant. Complications were few and no patient required revision surgery. In this study, the authors' technique results in a reliable four-corner arthrodesis with a low expectation of complications or revision surgery.

LEVEL OF EVIDENCE

IV.

Proximal row carpectomy on manual workers: 17 patients followed for an average of 6 years

Proximal row carpectomy (PRC) is indicated for the treatment of SNAC or SLAC wrist with preservation of the midcarpal joint. Our hypothesis was that PRC is not appropriate for treating advanced wrist osteoarthritis in patients who carry out heavy manual work. Twenty-three PRCs were performed on 21 patients, 5 women and 16 men with an average age of 54 years (33-77). All patients performed manual work; 11 of them performed heavy manual work. Etiologies were: SLAC wrist in 14 cases (2 stage III, 11 stage II, and 1 stage I) and SNAC wrist in 9 cases (6 stage IIIB and 3 stage IIB). At an average 75 months' follow-up (24-153), five patients were lost to follow-up. Radiocarpal arthrodesis was performed in one patient 10 years after the PRC. In the 17 remaining patients (18 wrists), pain (VAS) averaged 2.2, with residual pain of 5. Flexion-extension range was similar to preoperative levels (67% of contralateral wrist). Wrist strength was decreased by 34% compared to preoperative. The QuickDASH score averaged 26 points and the PRWE 20 points. Radiocapitate distance decreased by 0.3mm on average with joint line narrowing in 6 patients. The carpal translation index was 0.33mm, which was unchanged relative to preoperative values. Three patients had work-related limitations that required retraining and one patient had to be reassigned. PRC preserved the preoperative range of motion and reduced pain levels. However, significant loss of strength was observed, resulting in 23% of manual workers needing retraining or reassignment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Management of complications of ligament injuries of the wrist

Despite advances in understanding the anatomy and biomechanics of wrist motion, intrinsic carpal ligament injuries are difficult to diagnose and treat. Even when an accurate diagnosis is made, there is no consensus on the most appropriate and reliable treatment. Injury predisposes to a progressive decline in wrist function and a predictable pattern of degenerative arthritis. To prevent inadequate outcomes, many treatment options exist, all having inherent benefits and complications. This article reviews the complications of intrinsic carpal ligament injuries and complications of their treatment. Methods to prevent and principles to manage the complications are discussed.

Scapholunate interosseous ligament injuries: a retrospective review of treatment and outcomes in 82 wrists

PURPOSE

To compare outcomes of treatment for scapholunate instability between acute (< 6 wk from injury) and chronic (> 6 wk) injuries, between complete and partial tears, and among surgical techniques; identify risk factors for surgical failure; and compare ligament reconstruction with repair with or without capsulodesis in the chronic period.

METHODS

We performed a retrospective chart review of 82 primary scapholunate interosseous ligament surgeries, with median follow-up of 150 days. A total of 27 patients underwent surgery in the acute period and 50 in the chronic period. (In 5 patients we were unable to determine acuity or chronicity of injury.) In the chronic period, 16 patients underwent repair with or without capsulodesis, 27 underwent ligament reconstruction, and 7 underwent other procedures.

RESULTS

Surgical intervention in the acute setting involved more complex injuries, most commonly used direct repair, and produced a significantly lower failure rate than chronic intervention. In the chronic setting, the most common technique was ligament reconstruction, which produced superior radiographic outcomes compared with repair with or without capsulodesis. Isolated scapholunate interosseous ligament injuries undergoing chronic surgical intervention composed the majority of failures. Workers' compensation status and chronic intervention were significant risk factors for failure.

CONCLUSIONS

For chronic injuries, ligament reconstruction produced better radiographic outcomes than repair with or without capsulodesis. Acute intervention (within 6 wk) was preferable to chronic intervention for scapholunate interosseous ligament injuries, and a substantial number of isolated injuries failed to receive treatment in the acute period.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Arthroscopic Resection Arthroplasty of the Radial Column for SLAC Wrist

Background Symptomatic advanced scapholunate advanced collapse (SLAC) wrists are typically treated with extensive open procedures, including but not limited to scaphoidectomy plus four-corner fusion (4CF) and proximal row carpectomy (PRC). Although a minimally invasive arthroscopic option would be desirable, no convincing reports exist in the literature. The purpose of this paper is to describe a new surgical technique and outcomes on 14 patients who underwent arthroscopic resection arthroplasty of the radial column (ARARC) for arthroscopic stage II through stage IIIB SLAC wrists and to describe an arthroscopic staging classification of the radiocarpal joint for patients with SLAC wrist. Patients and Methods Data were collected prospectively on 17 patients presenting with radiographic stage I through III SLAC wrist who underwent ARARC in lieu of scaphoidectomy and 4CF or PRC. Fourteen patients (12 men and 2 women) subject to 1-year follow-up were included. The average age was 57 years (range 41 to 78). The mean follow-up was 24 months (range 12 to 61). Arthroscopic resection arthroplasty of the radial column is described for varying stages of arthritic changes of the radioscaphoid joint. Midcarpal resection was not performed. Results The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 66 preoperatively and 28 at final follow-up. The mean satisfaction (0 = not satisfied, 5 = completely satisfied) at final follow-up was 4.5 (range 3 to 5). The pain level (on 0-10 scale) improved from 6.6 to 1.3. The total arc of motion changed from 124° preoperatively to 142° postoperatively following an ARARC. Grip was 16 kg preoperatively and 18 kg postoperatively. Radiographic stages typically underestimated arthroscopic staging. Although four of our patients appeared to be radiographic stage I, all were found to have arthritis involving some or all of the radioscaphoid articulation at the time of arthroscopy. Clinical Relevance Pain relief is rapid and remains consistent over time following ARARC. ARARC may be a viable surgical option for patients with SLAC wrist who desire a minimally invasive procedure. Radiographic stages underestimate the degree of arthritic change. Accurate staging requires arthroscopy. The indications and long-term outcome are not well defined; continued surveillance is warranted. Level of Evidence Level IV, Therapeutic study.

Isolated lunocapitate osteoarthritis-an alternative pattern of osteoarthritis

Introduction Osteoarthritis (OA) in the wrist usually develops in a pattern described as scapholunate advanced collapse (SLAC). We observed an alternative pattern of OA that involves the lunocapitate joint in isolation with minimal involvement of the radioscaphoid articulation. Case Series The series was observed from a series of 100 wrist radiographs that were retrospectively reviewed. In order to characterize the alternative pattern of OA, we compared demographic data, presentation, and physical and radiographic examination characteristics between the patients with lunocapitate OA and SLAC wrists. Fifteen radiographs showed OA, nine had a SLAC pattern, and six had lunocapitate OA. The demographics were similar, but the clinical presentation was different. The patients with lunocapitate OA had less tenderness over the snuffbox (P < 0.03), and a lower percentage of a positive scaphoid shift test (P <  0.005). Isolated lunocapitate OA had a higher association with scaphotrapeziotrapezoidal (STT) arthritis (P < 0.004). The SLAC group had an increased scapholunate gap (P = 0.0003). Discussion  The presentation of lunocapitate OA differs from SLAC wrist in a number of ways. Further study is necessary to understand the clinical implications of this pattern. Level IV evidence Case series.

Recruitment and diversification of an ecdysozoan family of neuropeptide hormones for black widow spider venom expression

Venoms have attracted enormous attention because of their potent physiological effects and dynamic evolution, including the convergent recruitment of homologous genes for venom expression. Here we provide novel evidence for the recruitment of genes from the Crustacean Hyperglycemic Hormone (CHH) and arthropod Ion Transport Peptide (ITP) superfamily for venom expression in black widow spiders. We characterized latrodectin peptides from venom gland cDNAs from the Western black widow spider (Latrodectus hesperus), the brown widow (Latrodectus geometricus) and cupboard spider (Steatoda grossa). Phylogenetic analyses of these sequences with homologs from other spider, scorpion and wasp venom cDNAs, as well as CHH/ITP neuropeptides, show latrodectins as derived members of the CHH/ITP superfamily. These analyses suggest that CHH/ITP homologs are more widespread in spider venoms, and were recruited for venom expression in two additional arthropod lineages. We also found that the latrodectin 2 gene and nearly all CHH/ITP genes include a phase 2 intron in the same position, supporting latrodectin's placement within the CHH/ITP superfamily. Evolutionary analyses of latrodectins suggest episodes of positive selection along some sequence lineages, and positive and purifying selection on specific codons, supporting its functional importance in widow venom. We consider how this improved understanding of latrodectin evolution informs functional hypotheses regarding its role in black widow venom as well as its potential convergent recruitment for venom expression across arthropods.

Molecular evolution and diversity of dimeric alpha-amylase inhibitor gene in Kengyilia species (Triticeae: Poaceae)

Kengyilia Yen et J. L. Yang is a group of allohexaploid species with StYP genomic constitutions in the wheat tribe. To investigate the evolution and diversity of dimeric alpha-amylase inhibitor genes in the Kengyilia, forty-five homoeologous DAAI gene sequences were isolated from sampled Kengyilia species and analyzed together with those of its close relatives. These results suggested that (1) Kengyilia species from Central Asia and the Qinghai-Tibetan Plateau had different origins from those of the geographically differentiated P genome; (2) the St and P genomes of Kengyilia were donated by Pseudoroegneria and Agropyron, respectively, and the Y genome had an independent origin and showed an affinity with the St genome; (3) purifying selection dominated the DAAI gene members and the St-DAAI gene was evolving at faster rate than the P- and Y-DAAI genes in Kengyilia; and (4) natural selection was the main factor on the codon usage pattern of the DAAI gene in Kengyilia.

Patterns of evolutionary selection pressure in the immune signaling protein TRAF3IP2 in mammals

TRAF3 interacting protein 2 (TRAF3IP2) is important for immune responses to pathogens, inflammatory signals and autoimmunity in mammals. In the present study, we collected 19 mammalian TRAF3IP2 sequences and investigated the various types of selection pressure acting on them. Maximum likelihood estimations of nonsynonymous (dN) to synonymous (dS) substitution (dN/dS) ratios for the aligned coding sequences indicated that, as a whole, TRAF3IP2 has been subject to purifying selection. However, the N-terminus of the protein has been subject to higher selection pressure than the C-terminal domain. While eight amino acid residues within the N-terminus appear to have evolved under positive selection, no evidence for such selection was found in the C-terminus. The positively selected residues, which fall outside the currently known functional sites within TRAF3IP2, may have novel functions. The different selection pressures acting on the N- and C-terminal regions are consistent with their protein structures: the C-terminal structure is an ordered structure, whereas the N-terminus is disordered. Taken together with the results of previous studies, it is plausible that positive selection on the N-terminus of TRAF3IP2 may have occurred by competitive coevolution between mammalian hosts and viruses.

[Capitolunate arthrodesis: 12 patients followed-up an average of 10 years]

The aim of the study was to evaluate long-term results of capitolunate arthrodesis for the treatment of posttraumatic degenerative wrist disorders. A capitolunate arthrodesis was performed on 12 patients, three women and nine men, of 45 years on average (28-66). Ten patients were manual workers. Dominant side was involved in seven cases. Indications were nine scapholunate dissociations (SLAC) and three scaphoid non-unions (SNAC) with degenerative lesions. Fixation of the arthrodesis was performed with K-wires in seven, K-wires and staples in two, and only staples in three. Patients were reviewed at 118 months of average follow-up (72-168). One complete wrist arthrodesis was necessary one year after the capitolunate arthrodesis for an evolutive painful osteoarthritis. For the 11 remaining patients, pain on visual analogic scale (VAS) was 0.5. The flexion/extension arc was decreased of 25° and strength of 6kg compared to preoperative values. DASH score was equal to 33.7 points, Cooney score to 77.2 points and Mayo score to 82.8 points. Radiolunate and capitolunate angles were decreased of 4.9° and 6.2° respectively compared to preoperative values. Some complications occurred: evolutive osteoarthritis between triquetrum and lunate in two, non-union of the arthrodesis in one, and reflex sympathetic dystrophy in two. Nine patients were able to return to their previous professional activities. Capitolunate arthrodesis allowed restoring a pain free and functional wrist in eight out of the 11 patients reviewed. Results were maintained with follow-up. It is a satisfactory therapeutic alternative to four corners fusion for chronic instability of the wrist with osteoarthritis.

LEVEL OF EVIDENCE

IV.

Proximal row carpectomy: minimum 20-year follow-up

PURPOSE

Proximal row carpectomy (PRC) is a motion-sparing procedure for degenerative disorders of the proximal carpal row. Reported results at a minimum 10-year follow-up consistently show maintenance of strength, motion, and satisfaction with an average conversion rate to radiocarpal arthrodesis of 12%. We hypothesized that PRC would continue to provide a high level of satisfaction and function at a minimum of 20 years.

METHODS

Seventeen wrists in 16 patients, including 7 laborers, underwent PRC for symptomatic degenerative disorders of the proximal carpal row at an average age of 36 years. Patients returned for radiographic and clinical evaluation, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire and Patient-Related Wrist Evaluation were used for subjective assessment. Follow-up was a minimum of 20 years (average, 24 y).

RESULTS

Eleven wrists (65%) underwent no further surgery at a minimum 20-year follow-up. The average time to failure of PRC, defined as the time from PRC to radiocarpal arthrodesis, was 11 years (range, 8 mo to 20 y). Ten of 11 patients who did not undergo radiocarpal arthrodesis continued to be satisfied, with minimal decrease in motion and grip strength compared with the uninvolved side. Average score for QuickDASH was 16 and for Patient-Related Wrist Evaluation was 26. The flexion-extension arc was 68°, and grip strength was 72% of the contralateral side. All patients returned to their original employment. There was no correlation between degenerative radiographic changes and satisfaction level. The predicted probability of failure revealed a higher risk in patients who underwent PRC at a younger age, which leveled off at age 40 years.

CONCLUSIONS

PRC provides satisfaction at a minimum of 20 years with a survival rate of 65%. Whereas we recommend a minimum age for PRC between 35 and 40 years, young patients should not be excluded as PRC candidates; these patients should undergo appropriate preoperative counseling of their increased failure risk secondary to their young age.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Rib cartilage graft for posttraumatic or degenerative arthritis at wrist level: 10-year results

Background Posttraumatic arthritides of the radiocarpal joint, secondary to scaphoid nonunion advanced collapse (SNAC), scapholunate advanced collapse (SLAC), or Kienböck disease or in cases of intraarticularmalunion of the distal radius, are classically solved by some type of arthrodesis procedure. Osteochondral grafting provides a possible motion-sparing option that can diminish pain in the active patient. Description of Technique A chondrocostal graft harvested from the ninth rib was inserted and fixed with a plate in place of the articular defect in cases of a malunited intra-articular distal radius fracture (7 cases) or to replace the proximal pole of the scaphoid in cases of SNAC or SLAC (18 cases). In Kienböck disease, the graft was inserted as a free cartilage spacer (4 cases). Results Harvesting the graft from the ninth rib had minimal morbidity without pleural injury in the reported series. Graft union was achieved in all cases of fixation. No graft resorption or necrosis were observed on X-ray and magnetic resonance imaging (MRI) evaluation at the longest follow-up of 10 years. Histological analysis performed at the time of plate removal showed the vitality of the graft. Two thirds of the patients had excellent or good results using the Green and O'Brien score. Conclusions Reconstruction of a partially destroyed articular surface using a costal graft is reliable and provides an alternative option for resurfacing the articular surface with viable cartilage.