Midcarpal Research Articles

Single-Portal Arthroscopy Improves the Assessment of Radial-sided Disorders of the Wrist

Abstract Purpose This study aimed to describe the technique, indications, and advantages of the single-portal arthroscopic approach for the diagnosis and staging of chronic radial-sided disorders, including scapholunate interosseous ligament (SLIL) tear, scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) deformities. Methods The single portal technique was used in 138 patients affected by suspected SLIL lesions, SLAC and SNAC wrist injuries with positive clinical symptoms and inconclusive imaging (X-ray and MRI). It was used to grade the nature of the SLIL lesion and the extension of the osteochondral damage in the SLAC and SNAC wrist deformity to guide appropriate treatment. Results Patients were divided into group 1 (SLIL: 45 cases), group 2a (SLAC: 65 cases), and group 2b (SNAC: 28 cases). In group 1, stage 4 SLIL lesions were confirmed in 36 cases and 9 were assessed as SLAC wrist deformity. In group 2a, single-portal arthroscopy confirmed the preoperative diagnosis in 74% of cases. In the remaining 26% of patients, arthroscopy modified the preoperative diagnosis: 1 case of SLAC 1 resulted in SLAC 2, 14 cases of SLAC 2 resulted in SLAC 3, 1 case of SLAC 3 resulted in SLAC 2. A case of SLAC 2 turned out to be an SLIL lesion stage 4. In group 2b, single-portal arthroscopy confirmed the preoperative diagnosis in 86% of cases. In the remaining 14% (4 cases), it modified the preoperative diagnosis: 1 of SNAC 1 resulted in SNAC 2 and the other in SNAC 3, 1 case of SNAC 2 turned out to be an SNAC 3, and 1 case of SNAC 3 resulted in SNAC 4. Conclusion Single-portal wrist arthroscopy modified the preoperative diagnosis of wrist pathology in 42 patients over 138 cases. The use of single-portal wrist arthroscopy should be considered in the evaluation of the radiocarpal and midcarpal joints to allow accurate visualization of the joint surfaces for surgeon and patient planning. Type of Study/Level of Evidence Observational study level of evidence IV.

The Relationship between Structure of the Wrist and Function in a Japanese and Caucasian Population.

Background: Factors such as age and joint structure affect normal wrist motion. The midcarpal joint participates in flexion/extension, radial-ulnar/deviation (RUD), and since lunate/wrist type-2 is likely more stable than a lunate/wrist type-1, we suggest that midcarpal joint structure will affect wrist motion. Our purpose was to compare wrist motion in Caucasian and Japanese populations and to associate motion with midcarpal joint morphology. We hypothesised that radiographic structure would correlate with wrist motion. Methods: A total of 164 patients with normal wrist radiographs were included. Clinical measurements included wrist extension, flexion and RUD. Radiographic measurements included the radiocarpal joint: ulnar variance, radial height, radial inclination, volar inclination and carpal joint measurements: lunate type, capitate circumference and each of its joints contact measured and calculated as a proportion of capitate circumference. Results: The groups differed in wrist motion and in multiple radiographic measurements. When the two populations were analysed together, there were no significant associations between midcarpal joint type and wrist motion. The radiocarpal joint: ulnar variance was correlated with extension and radial deviation. Radial height was directly related to flexion, and both radial height and radial inclination were directly correlated with ulnar deviation. The intracarpal measurements: The main measurement affecting motion was the contact between the capitate and the scaphoid (as a proportion of capitate circumference) with lesser correlations of the contact of the capitate with the trapezoid and hamate. The most significant measurement associated with a lunate type-2 was scaphoid contact with the capitate p = 0.01. Logistic regression demonstrated that the measurements most associated with wrist motion were scaphoid contact with the capitate/capitate circumference and hamate contact with the capitate/capitate. Conclusions: This study supports discrepancies in wrist motion amongst different racial cohorts, and a relationship between bone/joint structure in the wrist and wrist motion. This can help treat wrist pathology. Level of Evidence: Level III (Diagnostic).

Medial Femoral Trochlea Osteochondral Flap Reconstruction of the Previously Unsalvageable Kienbock-Associated Lunate With a Coronal Split

Patients with Kienbock disease can present with coronal fracture and collapse of the proximal lunate (Unified B2/Bain grade 1, 2B). Traditionally, this was considered unsalvageable. However, medial femoral trochlea (MFT) osteochondral reconstruction, used to recreate the proximal lunate surface, can be paired with reduction and repair of the coronal plane fracture, thus restoring midcarpal congruity. The purpose of this study was to report radiographic and clinical outcomes following lunate coronal fracture fixation at the time of MFT osteochondral reconstruction. This was a retrospective study performed at a single institution. We identified patients with Kienbock disease who underwent MFT osteochondral reconstruction from 2014 to 2023. Patients were included if they had a coronal fracture of the lunate distal articular surface fixed at the time of surgery. Radiographic and clinical parameters were evaluated, including carpal height ratio, union rate, presence of heterotopic ossification, need for revision surgery, and patient-reported outcome measures. Thirty-three patients were included, with a mean age of 27.5 years (range: 15-41); 19 (58%) were women. Mean radiographic follow-up time was 5.8 months, and mean clinical follow-up time was 22.6 months. Union was achieved in 30/33 patients (91%). Carpal height ratio improved from 1.32 to 1.4. Two patients (6%) required reoperation, one for removal of heterotopic ossification and another for conversion to proximal row carpectomy. Patients demonstrated meaningful improvement in brief Michigan Hand Questionnaire and Patient-Reported Outcomes Measurement Information Upper Extremity scores. Range of motion before and after surgery was similar. Lunate coronal fracture fixation with MFT osteochondral reconstruction represents an additional management option in select patients with Kienbock disease. This technique restores the midcarpal joint during lunate reconstruction and may allow patients to avoid salvage procedures. Early radiographic and clinical outcomes are promising. Therapeutic IV.

Radiocarpal and midcarpal kinematics in scapholunate instability: a four-dimensional CT study in vivo.

The distribution of motion between the radiocarpal and midcarpal joints in scapholunate instability is poorly understood. This has potential implications in predicting degenerative changes and in selecting salvage procedures. We studied 19 healthy wrists and 19 wrists with scapholunate instability using dynamic computed tomography during wrist extension to flexion and ulnar to radial deviation. Radiocarpal and midcarpal kinematics of the scaphoid and the lunate were computed. In scapholunate instability, in the radial column, there was increased motion in the radiocarpal joint when the wrist was radially deviating beyond 10° or moving from 70° to 40° extension. In both groups, the capitolunate joint was the dominant articulation in the central column. In scapholunate instability, there was significantly more capitolunate motion during 70° to 30° extension. These changes may predict the development of radioscaphoid arthritis and enable identifying a kinematically abnormal wrist. The motion distribution in scapholunate instability was abnormal beyond 10° of radial deviation and between 70° and 40° of wrist extension.Level of evidence: III.

Synovial Lipomatosis With Extra-articular Extension in the Arthritic Wrist: An Unexpected Diagnosis.

Synovial lipomatosis is a rare condition characterized by adipocyte proliferation within joint synovial tissue. It most commonly affects the knee and is typically intra-articular. Only 5 published case reports describe extra-articular synovial lipomatosis of the wrist. We present a case of a sexagenarian patient seen for his wrist arthropathy. His x-ray revealed pan-wrist arthritis and inflammatory soft tissue swelling. The patient was slated for a wrist fusion and Darrach procedure. Following the dorsal skin incision in the operating room, an unusual adipose mass was identified infiltrating all extensor compartments: midcarpal, radiocarpal, and distal radioulnar joints. The mass was excised and sent to pathology prior to proceeding with the slated surgery. Synovial lipomatosis was diagnosed postoperatively based on histopathology. Six weeks postoperatively, the wrist fusion had healed clinically and radiographically, and his pain had improved. There was no evidence of recurrence. Synovial lipomatosis is a rare entity that may imitate multiple other pathologies. It is possible that synovial lipomatosis may represent a secondary occurrence following degenerative articular disease or trauma in older patients. This is the first case report to date describing synovial lipomatosis of the wrist with extra-articular extension in the setting of pan-carpal wrist arthritis.

Scapholunate Advanced Collapse (SLAC) and Scaphoid Nonunion Advanced Collapse (SNAC): A Review of Treatment Options for Stage II.

Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) represent clinical entities identified by a pattern of predictable degenerative changes. They are the most common causes of wrist arthritis. Both entities can remain asymptomatic for many years and may go undiagnosed. Diagnosis is usually confirmed through clinical examination, which reveals progressive wrist pain and instability. Radiographically, degenerative changes in the radiocarpal and midcarpal joints are present, as well as nonunion of the scaphoid fracture in SNAC. The management differs according to the stage. Particularly in this review article, we reviewed the treatment options for stage II SLAC and SNAC wrist. In addition to the well-described surgical techniques such as proximal row carpectomy and four-corner fusion, alternatives such as capitolunate arthrodesis, three-corner fusion, and soft tissue procedures like capsulodesis and tenodesis are available. Proximal row carpectomy and partial arthrodeses yield comparable results. Soft tissue procedures are viable alternatives and are preferred in younger patients to avoid early salvage operations.

Clinical Features and Classification of Proximal Carpal Fracture Dislocation Through the Radiocarpal Joint.

Background: The most common types of wrist dislocation are trans-scaphoid lunate dislocation (TLD) and trans-scaphoid perilunate dislocation, in which the lunate and proximal scaphoid are dislocated through the midcarpal joint. There is another rare type of dislocation in which the proximal carpi are dislocated through the radiocarpal joint. The purpose of this study is to examine the clinical features of this type of dislocation. Methods: Six cases of the proximal carpal fracture dislocation via the radiocarpal joint were retrospectively reviewed. All patients underwent open reduction and internal fixation with the ligament reconstruction. A Mayo wrist score was assigned to each patient based on the assessment of pain, functional status, range of motion and grip strength at the last follow-up. Clinical subjective evaluation of function and pain was assessed using the patient-rated wrist evaluation (PRWE) method. Results: All patients were male and injured with a median age of 33.5 years. The median follow-up period was 10 months. There were three types of dislocations: Scaphoid fracture dislocation, TLD and scaphoid-lunate dislocation. All patients had satisfactory results with an average PRWE of 7.2 ± 4.7. The preoperative VAS was 6.7 ± 1.0 and the postoperative VAS was 0.7 ± 0.7 (p < 0.01). Postoperative grip strength accounted for 89.2% ± 9.8% of the contralateral side; the Mayo wrist score averaged 90.0 ± 6.5, with four patients obtaining excellent and two good results. Conclusions: Fracture dislocation of the proximal carpal bones through the radiocarpal joint is an independent type of wrist dislocation that tends to occur in young men with high-energy impact. The wrist is most often injured in a pronation hyperextension position. If treatment is timely and appropriate, the prognosis is quite good. Level of Evidence: Level IV (Therapeutic).

Excision of the Distal Pole of the Scaphoid and the Midcarpal Joint

Abstract Background Excision of the distal pole of the scaphoid is used to treat arthritis of the scaphotrapezial trapezoid (STT), radioscaphoid joint, and arthritis following scaphoid nonunion. Some patients develop midcarpal instability limiting utilization of this technique. Why some wrists develop postoperative instability while others do not, remains unclear. Questions/Purposes To identify the wrists prone to developing midcarpal joint instability we evaluated the effect of midcarpal joint structure on force transfer through the wrist, we hypothesized that the force transfer will be further altered when a distal pole excision is performed and that midcarpal joint structure will affect force transfer. Patients and Methods We used finite element analysis based on 19 computer tomography wrist scans. Nine type 1 (lunate has a facet with the capitate alone) and 10 type 2 (lunate has facets with both the capitate and hamate) models were prepared. A 200 N force was evenly split and applied to the dorsal crests of the trapezoid and capitate (100 N along each crest) to replicate the performance of a knuckle push-up. Displacement of the trapezoid, trapezium, scaphoid, capitate, and hamate was measured along each axis after the applied load. The simulation model was used to predict motion at the capitate and STT joint with excision of the distal pole. Results Excision of the distal pole of the scaphoid affected the transfer of forces significantly (∼200% all bones in all directions) in all wrists. There are significant differences in force transfer between type 1 and type 2 wrists in the amount of force transferred (type 1 &gt; type 2), in the percent difference from an intact wrist (type 1 &gt; type 2) and in the direction of displacement (type 1 the bones moved in different directions while type 2 wrists moved as one block). Conclusion This study suggests that midcarpal joint structure affects force transfer through the wrist and may predict wrist behavior following excision of the distal pole of the scaphoid. Specifically, type 1 wrists may be more prone to midcarpal joint collapse after excision. Level of evidence: 1.

Surgical Feasibility Study on Cadaver for Vascularized Wrist Joint Transplantation

Despite modern advancements in the treatment of late stages of wrist joint degeneration, few reliable options exist for patients requiring motion-preserving reconstruction of their radiocarpal and midcarpal joints. Vascularized composite allotransplantation (VCA) could be considered an option for wrist reconstruction in the future. The goal of this study was to describe the relevant anatomy and design a potential surgical technique for wrist VCA. Anatomic studies were performed on 17 human upper extremities. The arterial system of each cadaver was injected with latex dye or radiographic contrast. After injecting a contrast medium visible on a computerized tomography (CT) scan, the initial three specimens were examined using microCT. This confirmed joint vascular patency and allowed for the dissection of the other specimens that were injected with latex for the study of joint vascularization and the design of the wrist VCA. We then outlined a donor and recipient surgical technique for transplant based on recipient CT scans. Customized cutting guides were designed for the transplant procedure. After the procedure, we performed angiography of the VCA to determine the vascularity of the transplant. Using a combined volar and dorsal approach, we were able to perform a complete wrist VCA procedure. After the completed transplant procedure, angiographic imaging of the specimens demonstrated that the flap dissection and transplantation preserved the nutrient endosteal supply to the distal end of the radius and ulna, as well as to the carpal bones and the metacarpal bases. The dissection of the donor, recipient, and the entire vascularized joint transplant procedure served to illustrate the anatomical feasibility of the cadaveric surgical technique. This establishes an anatomic basis for the possibility of future human clinical applications. This study helps investigate the anatomical feasibility of a wrist VCA.

Ultrasonographic study of hand joints erosions in rheumatoid arthritis: Relation to clinical characteristics, disease activity and functional status

BackgroundRheumatoid arthritis (RA) is a commonly diagnosed chronic inflammatory arthritis. Bone erosion can occur early during RA and is considered as an important predictor of a severe clinical course. Aim of the workTo assess ultrasound-detected bone erosions in RA patients and establish their associations with clinical and laboratory variables. Patients and methodsThis study included sixty RA patients. The dorsal and volar joint aspects of the wrist (midcarpal and radiocarpal joints), the first to the fifth metacarpophalangeal (MCP) and proximal interphalangeal joints were scanned in the long and short axes for synovial hypertrophy, tenosynovitis, and erosions. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), and anti-cyclic citrullinated peptide (anti-CCP) were performed. The disease activity score (DAS28) and health assessment questionnaire (HAQ) was evaluated ResultsThe mean age of the patients was 43 ± 11.04 years with median disease duration of 5 (0.1–20) years and there were 57 females. Forty-one patients had bone erosions and 19 did not. Erosions were most frequently found in the MCP joints (48.3 % of examined patients). There was no significant difference between the two groups regarding age (p = 0.36), gender (p = 1), RF (p = 0.4), and anti-CCP (p = 0.6). The bone erosion scores significantly correlated with swollen joint count (p = 0.001), tender joint count (p = 0.018), patient global health (p = 0.024), DAS28 (p = 0.003), HAQ (p = 0.032), ESR (p = 0.005), presence of synovitis (p = 0.005), and synovitis score (p < 0.001). ConclusionsThe US-detected bone erosions are predominant in RA, most frequently at the MCP joints, and are associated with disease activity, inflammatory markers, and synovitis.

Scapholunate and lunotriquetral joint dynamic stabilizers and their role in wrist neuromuscular control and proprioception

Recent research interest has grown in exploring the role of muscles, isometric contraction, proprioception, and neuromuscular control in addressing dynamic scapholunate and lunotriquetral joint instability, marking a shift in the understanding of wrist stability. To present a comprehensive review of the carpal ligaments anatomy and wrist biomechanics, with a particular focus on the role of proprioception in dynamic carpal stability and their role in managing scapholunate (SL) and lunotriquetral (LTq) dynamic instabilities. We conducted a systematic search of the literature and review of the most relevant papers published and indexed in pubmed, related to wrist biomechanics, proprioception and its contribution to carpal dynamic stability. The study involved a comprehensive review of neuromuscular mechanisms in dynamic stabilization of the carpus, based on cadaver studies. The 3D position of the scaphoid, triquetrum, and capitate was monitored before and after tendon loading. The extensor carpi ulnaris (ECU) and the flexor carpi radialis (FCR) are identified as the primary pronators of the midcarpal joint. The ECU's pronation effect can potentially strain the scapholunate ligament, while the supinator muscles, the abductor pollicis longus (APL), the extensor carpi radialis longus (ECRL), and the flexor carpi ulnaris (FCU), have a protective role, particularly in cases of scapholunate ligament dysfunctions. The FCR, despite being a pronator of the distal row, has a beneficial effect as it provokes supination of the scaphoid. Comprehending carpal dysfunctions and instabilities hinges on understanding carpal anatomy and normal biomechanics. Proprioception, encompassing joint position sensation and neuromuscular control, is pivotal for stability. Biomechanical research informs tailored muscle strengthening for specific carpal issues. Supinator muscles should be strengthened for SL injuries, and ECU-focused strengthening and proprioceptive training are key for dynamic LTq instabilities. Ongoing research should delve into the intricate relationship between carpal ligaments, muscles, and proprioception to enhance wrist stability.

Comparison of Hand-Wrist Findings of Rheumatoid Arthritis Patients According to the Use of Synthetic and Biological Disease-Modifying Antirheumatic Drugs (DMARDs): A Clinical, Radiographic, and Ultrasonographic Study.

The aim of this study is to evaluate the hand-wrist findings in patients with rheumatoid arthritis (RA) using synthetic and a combination of synthetic and biological disease-modifying antirheumatic drugs (DMARDs) in terms of ultrasonographic, clinical, and radiographic data. The study is designed as a cross-sectional study, and 31 RA patients followed up in the rheumatology outpatient clinic were enrolled. Nineteen patients were using only synthetic DMARDs, and 12 patients were using a combination of synthetic and biological DMARDs. The clinical data of each patient were recorded simultaneously. Disease Activity Score-28 (DAS-28) was used for the assessment of disease activation, and the Health Assessment Questionnaire (HAQ) score was used for the evaluation of general health status. Bilateral proximal interphalangeal (PIP), metacarpophalangeal (MCP) joints, and the radiocarpal, ulnocarpal, and midcarpal joints of the patients were examined by ultrasonography (US). The Sharp-van der Heijde modified score was used to determine the radiographic damage. There was no significant difference between the two groups in terms of demographic data, clinical findings, ESR, and CRP. When the groups were compared in terms of right and left PIP, MCP, and radiocarpal, ulnocarpal, and midcarpal synovitis grade total scores, no significant difference was found between the two groups. Radiographic total joint space scores were significantly lower in the group receiving only synthetic DMARD treatment (p=0.047) and 25-OH vitamin D levels were significantly higher (p=0.008). This study revealed that there was no significant difference between groups except radiographic total joint space scores.

Perilunate Dislocations: Reduction and Stabilization.

The all-dorsal scapholunate reconstruction technique is indicated for the treatment of scapholunate injuries in cases in which the carpus is reducible and there is no arthrosis present. The goal of this procedure is to reconstruct the torn dorsal portion of the scapholunate ligament in order to stabilize the scaphoid and lunate. A standard dorsal approach to the wrist, extending from the third metacarpal distally to the distal radioulnar joint, is utilized. The extensor pollicis longus is transposed and retracted radially, and the second and fourth extensor compartments are retracted ulnarly. A Berger ligament-sparing capsulotomy is utilized to visualize the carpus. Volarly, an extended open carpal tunnel release is also utilized to relieve any median nerve compression and to aid in reduction. The contents of the carpal tunnel can be retracted radially, allowing for visualization of the carpal bones. Joystick pins are placed in order to reduce the scaphoid and lunate. Reduction is held provisionally by clamping the pins until 4 pins can be placed across the carpal bones. For scapholunate reconstruction, 3 holes are made: in the lunate, proximal scaphoid, and distal scaphoid. Suture tape is then utilized to hold the scaphoid and lunate in their proper position. The dorsal wrist capsule and extensor retinaculum are repaired during closure. The pins are cut near the skin and are removed in 8 to 12 weeks. Several other methods of scapholunate reconstruction have been described, including capsulodesis, tenodesis, and bone-tissue-bone repairs. Additionally, in patients who are poor candidates for scapholunate reconstruction, wrist-salvage procedures can be utilized as the primary treatment. Scapholunate reconstruction has the advantage of preserving the native physiologic motion of the wrist, in contrast to the many different wrist-salvage procedures that include arthrodesis or arthroplasty. Avoiding arthrodesis is specifically advantageous in patients who have not yet developed arthrosis of the wrist bones. Outcomes of scapholunate reconstruction vary widely; however, there is a nearly universal decrease in range of motion and strength of the wrist. Wrist range of motion is typically 55% to 75% of the contralateral side, and grip strength is typically approximately 65% of the contralateral side. In a prior study, 50% to 60% of patients whose work involved physical labor were able to return to their same level of full-time work. Disabilities of the Arm, Shoulder and Hand scores average between 24 and 30. Specific patients at risk for inferior outcomes are those with delayed surgical treatment, poor carpal alignment following reduction, or open injuries. Patients are counseled preoperatively regarding the likelihood of permanent wrist stiffness and the possibility of scapholunate diastasis even in the setting of technically successful repair.Traction and dorsally directed pressure on the lunate through an extended carpal tunnel incision can aid in reduction of the lunate.The joystick pin position in the dorsal scaphoid is angulated from distal to proximal and that in the lunate is angulated from proximal to distal in order to help correct flexion of the scaphoid and extension of the lunate by clamping together the Kirschner wires. Modifying the distance of the clamp from the carpus can allow precision in the degree of scapholunate angle fixation.Intercarpal Kirschner wire fixation of the scapholunate, lunotriquetral, and midcarpal joints (scaphocapitate and triquetrohamate) is best performed with 0.062-in (1.6-mm) Kirschner wires. The insertion angle is best visualized when the Kirschner wire is introduced from inside the incision through the skin, "inside out," in order to best envision the trajectory on the dorsal carpus and define the starting point on the bone. The Kirschner wire is then advanced through the carpus from outside-in at a slightly more volarly translated (but not angulated) position. The Kirschner wires are then cut beneath the skin at a depth that will allow them to be retrieved but will not cause them to become exposed once swelling decreases.The wrist is generally immobilized until the pins are removed at 3 months postoperatively. ROM = range of motionK-wire = Kirschner wireDASH = Disabilities of the Arm, Shoulder and HandDISI = dorsal intercarpal ligament instability.

Radiocarpal Joint Reconstruction with a Double Free Metatarsophalangeal Joint Transfer.

Destruction of the radiocarpal and midcarpal joints causes loss of wrist motion, pain, and reduced grip strength. A novel technique for radiocarpal reconstruction is presented. Two patients who had radiocarpal and midcarpal destruction and osteoarthritis underwent reconstruction using simultaneous bilateral microvascular second metatarsophalangeal joint transfer. The insetting was performed, inverting the distal-proximal orientation of both metatarsophalangeal joints and fixing them with two 2.0 screws in proximal and Kirschner wires in distal. Radiocarpal extension and flexion without pain were preserved after a minimum of 4 years follow-up. Both patients could return to recreational activities. No secondary procedures were needed. This technique could be an alternative for radiocarpal reconstruction, although longer follow-up and more cases are needed.

Trabecular bone structure of the proximal capitate in extant hominids and fossil hominins with implications for midcarpal joint loading and the dart-thrower's motion.

This research examines whether the distribution of trabecular bone in the proximal capitates of extant hominids, as well as several fossil hominin taxa, is associated with the oblique path of the midcarpal joint known as the dart-thrower's motion (DTM). We analyzed proximal capitates from extant (Pongo n = 12; Gorilla n = 11; Pan n = 10; fossil and recent Homo sapiens n = 29) and extinct (Australopithecus sediba n = 2; Homo naledi n = 1; Homo floresiensis n = 2; Neandertals n = 3) hominids using a new canonical holistic morphometric analysis, which quantifies and visualizes the distribution of trabecular bone using relative bone volume as a fraction of total volume (rBV/TV). Homo sapiens and Neandertals had a continuous band of high rBV/TV that extended across the scaphoid, lunate, and hamate subarticular regions, but other fossil hominins and extant great apes did not. A. sediba expressed a distinct combination of human-like and Pan-like rBV/TV distribution. Both H. floresiensis and H. naledi had high rBV/TV on the ulnar-side of the capitate but low rBV/TV on the radial-side. The proximal capitates of H. sapiens and Neandertals share a distinctive distribution of trabecular bone that suggests that these two species of Homo regularly load(ed) their midcarpal joints along the full extent of the oblique path of the DTM. The observed pattern in A. sediba suggests that human-like stress at the capito-scaphoid articular surface was combined with Pan-like wrist postures, whereas the patterns in H. floresiensis and H. naledi suggest their midcarpal joints were loaded differently from that of H. sapiens and Neandertals.

Treatment of scaphoid nonunion by arthroscopic cancellous bone grafting

IntroductionIn order to avoid Scaphoid Nonunion Advanced Collapse (SNAC) type osteoarthritis, which progressively affects the radial and midcarpal joints, several vascularized and non-vascularized grafting techniques have been described. Over the past decade, there has been growing interest in arthroscopic cancellous bone grafts for scaphoid nonunion. The aim of this novel prospective study was to assess the healing rate of scaphoid grafts under arthroscopy, and the prognostic factors for healing. Material and methodsThis prospective study was carried out across 10 centers between September 2019 and April 2021, in patients aged 16 to 65. Scaphoid nonunion grafting was performed arthroscopically. Union was assessed on CT scans and displacement correction angles were measured preoperatively and then at 3 and 6months. We assessed mobility, Jamar wrist strength, functional results as per the Patient Related Wrist Score (PRWE) and the Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH) score. Risk factors for nonunion were assessed. ResultsWe included 77 patients with a mean age of 24years (18 to 55years) with a mean time between trauma and treatment of nonunion of 34.8months (6 to 180months). The population was represented by 46 manual workers and 20 were smokers. In 42 cases, the nonunion was proximal, in Schernberg zone I or II. At the last follow-up of 12.9months on average (Standard Deviation: 8.7months), union was achieved in 72 patients (93.5%). The average duration of union was 3.4months (Standard Deviation 1.6). Among the 5 patients who did not heal, grafting was performed in addition to the fixation. We did not identify any contributory factors for nonunion. ConclusionThis study demonstrated the effectiveness of arthroscopic treatment of scaphoid nonunion with a union rate at least equivalent to pedicled vascularized grafts. Smoking and delayed treatment were no longer considered unfavorable prognostic factors in the context of arthroscopic treatment. Level of evidenceIII.

Treatment of Early Undifferentiated Chronic Monoarthritis of the Wrist by Arthroscopic Wrist Synovectomy Combined with Partial Denervation.

Undifferentiated chronic monosecarthritis (UCMA) is a group of inflammatory joint diseases that has the potential to progress to other diseases and can seriously affect patients' quality of life. There is yet no unified consensus regarding treatment of UCMA. This study aimed to investigate the efficacy of arthroscopic synovectomy combined with partial wrist denervation in treating Larsen 1-3 UCMA. In this case series, we reviewed 14 patients with UCMA treated by arthroscopic synovectomy combined with partial denervation from February 2017 to June 2020. The mean duration of symptoms was 17.4 months (range, 4-60 months), and the mean follow-up was 13.3 months (range, 6-23 months). The anterior and posterior interosseous nerves were severed at the distal forearm, and the radiocarpal, midcarpal, and distal radial ulnar joint synovial membranes were arthroscopically resected at the wrist. The clinical evaluation indices included the visual analogue scale score (VAS) for pain, grip strength, range of (active) motion of the wrist, total active motion, and Mayo wrist score. Larsen's scoring method was used as the imaging evaluation index. At the last follow-up, significant clinical improvements were observed in the visual analogue scale (VAS) score for pain (6.0 (5.0-6.3) vs 1.0 (1.0-2.3), P = 0.001) and Mayo wrist score (42.1 ± 9.7 vs 61.8 ± 12.3, P < 0.0001). No significant changes were found in grip strength (15.9 ± 4.5 vs 16.6 ± 4.7, P = 0.230) or the flexion-extension arc (58.9 ± 39.0 vs 64.3 ± 36.5, P = 0.317), although the mean and median did show positive changes. Among the three patients who showed progress in imaging, there was no significant difference in their pain and functional scores compared to those who did not progress. One patient underwent total wrist fusion 17 months after the operation. Arthroscopic wrist synovectomy combined with partial wrist denervation can provide sustained pain relief and functional recovery for patients with Larsen 1-3 UCMA.

Volar spanning plate fixation for a distal radius fracture

A comminuted distal radial fracture is sometimes so fragmented that it is impossible to treat it with fixation using a plate and screws. In this case, we can perform a bridging fracture and joints with an external fixator or a dorsal spanning plate. Unfortunately, both methods completely immobilize the wrist until the implants are removed. In the article is presented an alternative method of bridge fixation. After fracture bridging with a volar spanning plate, the patient immediately has the possibility of dorsal and volar flexion of approximately 30 degrees in each direction. The study group consists of 6 patients treated surgically with a volar spanning plate after an unsuccessful attempt of stable fixation with a volar plate. 5 patients suffered from a distal radius fracture in the AO classification type C3, and one man with an inveterate dorsal dislocation of the wrist and fracture of the radial styloid process type B1. The volar spanning plate was fixed distally in the scaphoid and lunar, and proximally in the shaft of the radius. All patients achieved bone union. There was no destabilization or any damage of the implant. The average dorsal flexion was 48°, and the palmar flexion was 45°. All patients obtained a satisfactory result according to the Mayo scale, without pain. The volar spanning plate may be indicated when intraoperative fixation by a volar plate turns out to be too optimistic. Compared to the external fixator or the dorsal spanning plate, the volar spanning plate does not distract the midcarpal and carpometacarpal joints. What is more, immediately after the operation, the possibility of dorsal and palmar flexion are approximately 30 degrees in each direction, which improves the quality of life in the first weeks of treatment. After removing the implant, there is still a chance to improve the range of motion of the wrist.

The Effect of 3rd Carpometacarpal Arthrodesis in the Outcomes of Total Wrist Fusion Using Modern Plate Technology.

Background The inclusion of the third carpometacarpal (CMC) joint in the fusion mass in total wrist fusion (TWF) remains controversial. Our goal was to evaluate the clinical outcomes and effects of third CMC joint arthrodesis compared with bridging the CMC joint during TWF. A retrospective chart review was performed. Outcomes assessed included hardware loosening, hardware failure, symptomatic hardware necessitating removal, and need for revision arthrodesis. Case Description/Literature Review We found that concomitant third CMC joint arthrodesis was associated with a significantly reduced rate of radiocarpal and midcarpal joint nonunion, hardware loosening, and symptomatic hardware removal when compared to bridging of the CMC joint. There was no significant difference in hardware failure rates or the need for revision arthrodesis. Clinical Relevance When using a contoured dorsal spanning plate, concomitant CMC joint arthrodesis should be considered during TWF to mitigate against hardware loosening and symptomatic hardware. Level of Evidence Level IV.

Midcarpal Instability.

Midcarpal instability (MCI) of the wrist represents multiple distinct clinical entities that all have in common abnormal force transmission across the midcarpal joint. This can be asymptomatic but can also result in painful wrist motion, a characteristic catch-up clunk, and symptoms of instability. The carpus is stabilized by numerous extrinsic and intrinsic ligaments. Dynamic joint reactive forces between the proximal and distal carpal rows help create reciprocal motion, which results in smooth, physiologic wrist mechanics. Diagnosis of MCI requires a thorough history, physical examination, and adequate imaging. MCI can be managed nonsurgically with activity modification, physical therapy, specialized orthotics, medications, and corticosteroid injections. A variety of surgical treatment options exists to treat symptomatic MCI. These include arthroscopic thermal capsulorrhaphy, ligament repair or reconstruction, radial osteotomies, and limited radiocarpal or intercarpal fusions. Capsulorrhaphy or ligament repair is favored for mild to moderate cases; osteotomies can be used for the correction of bony deformities contributing to instability, whereas partial wrist arthrodesis is indicated for severe or recurrent instability and fixed deformities.