Nonunion Advanced Collapse Wrist Research Articles

Lunate Shift Index (LSI): A New Parameter for the Evaluation of Residual Ulnar Side Wrist Pain in Patients with Wrist Osteoarthritis Undergoing Three-Corners Arthrodesis vs. Four-Corners Arthrodesis-A Retrospective Comparative Study with Minimum 2Years of Follow-up.

Both scaphoid non-union advanced collapse wrist (SNAC) and scapho-lunate advanced collapse wrist (SLAC) at stage II-III are common indications for limited wrist fusions including four-corners fusion (4CF) and three-corners fusion (3CF). The aim of this study was to assess the clinical and radiological outcomes in patients undergoing 3CF vs. 4CF. A new radiological index called Lunate Shift Index (LSI) was devised to evaluate the importance of the lunate displacement relative to the radiolunate joint. Twenty-eight patients undergoing 3CF and 40 patients undergoing 4CF were clinically evaluated. The radiolunate angle, the carpal height, and the LSI were recorded radiographically. The LSI corresponds to the ratio between the distance from the lunate centre to the middle of the intermediate column and the length of the intermediate column of the distal radius. A statistically significant correlation was observed between LSI and clinical outcomes. The lunate displacement was associated with an increased incidence of wrist ulnar pain.No statistically significant differences were observed between 3 and 4CF in all parameters compared. The osteoarthritis of piso-triquetral joint has been identified as the cause of wrist ulnar pain in patients undergoing 4CF. The lunate correct positioning allows to maintain the carpal height and to increase the contact area at the level of the radiolunate joint. A good reduction of the lunate could be obtained with the 3CF compared to 4CF. This study showed how proper realignment of the lunate following midcarpal arthrodesis correlates with a better clinical outcome. Level III, Retrospective comparative study.

Four-Corner Fusion Versus Proximal Row Carpectomy for Scapholunate Advanced Collapse and Scaphoid Nonunion Advanced Collapse Wrist: A Systematic Review and Meta-Analysis

Although proximal row carpectomy (PRC) has increasingly been shown to have superior features to four-corner fusion (4CF), individual surgeons may remain convinced of the superiority of one procedure based on personal experience and individual biases. Hence, we sought to perform an updated meta-analysis with some of the largest studies to date to compare outcomes and complications between these procedures in the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists. A systematic review and meta-analysis was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, Embase, Web of Science, and Cochrane were queried for articles on PRC and 4CF performed for scapholunate advanced collapse and scaphoid nonunion advanced collapse wrist. Primary outcomes included wrist range of motion; grip strength; outcome measures, including Disabilities of Arm, Shoulder, and Hand and Quick Disabilities of Arm, Shoulder, and Hand scores, Patient-Rated Wrist and Hand Evaluation, and visual analog scale pain scores; and surgical complications. Sixty-one studies reported on 3,174 wrists, of which 54% were treated with PRC and 46% were treated with 4CF. The weighted mean follow-up was 61 months (range, 12-216 months). Meta-analysis comparing PRC and 4CF demonstrated that PRC had significantly greater postoperative extension; ulnar deviation; postoperative improvement in extension, flexion, ulnar deviation; and visual analog scale score. No comparisons showed significant differences in grip strength. The percentage of wrists requiring arthrodesis was 5.2% for PRC and 11% for 4CF. There was an 8.9% (57/640 wrists) 4CF nonunion rate and 2.2% (17/789) hardware removal rate after 4CF. In the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists, PRC results in better outcomes and a lower complication rate compared to 4CF. Therapeutic IV.

Two-, Three-, or Four-Corner Arthrodesis for Midcarpal Osteoarthritis: A Systematic Review and Meta-Analysis

Several limited midcarpal arthrodeses have been used in the treatment of midcarpal osteoarthritis as part of scapholunate advanced collapse and scaphoid nonunion advanced collapse. There is no consensus on whether two-carpal arthrodesis (2CA), three-carpal arthrodesis (3CA), bicolumnar arthrodesis, or four-carpal arthrodesis (FCA) results in the best outcomes. The objective of this study was to determine whether there is a difference in outcomes in patients undergoing FCA, 3CA, 2CA, or bicolumnar arthrodesis for midcarpal osteoarthritis. A systematic review and meta-analysis were performed in multiple databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting the four surgical techniques were included. The primary outcomes were postoperative visual analog scale pain score, the Disabilities of the Arm, Shoulder, and Hand score, and the Mayo Wrist Score. The secondary outcomes were active range of motion, grip strength, and reported complications. Of 2,270 eligible studies, 80 articles were selected, including a total of 2,166 wrists. The visual analog scale pain scores for both the 2CA and FCA groups reached an adequate pain reduction based on the Patient Acceptable Symptom Scale. The Disabilities of the Arm, Shoulder, and Hand score was also comparable between these two groups. The 2CA group also showed a significantly better active range of motion than the FCA group for both flexion-extension and radioulnar deviation arc. The incidence of nonunion was 6.9% in the FCA group compared with 10.0% in the 2CA group. Although the 2CA procedure has a theoretical advantage over the FCA method, the analysis of data showed that generally, these techniques have similar outcomes and complications. Therefore, both (2CA and FCA) are good options for midcarpal osteoarthritis in scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists. Therapeutic IV.

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.

Routinely-Collected Outcomes of Proximal Row Carpectomy

To describe patient-reported pain and function 12 months after proximal row carpectomy (PRC). Secondary outcomes included return to work, grip strength, range of wrist motion, satisfaction with treatment results, and complications. This cohort study was part of the British Society for Surgery of the Hand Studyathon 2021, using ongoing routinely-collected data of 304 eligible patients who underwent PRC (73% scapholunate advanced collapse, 11% scaphoid nonunion advanced collapse wrist; 11% Kienböck, 5% other indications) from Xpert Clinics, the Netherlands between 2012-2020. The primary outcome was the Patient Rated Wrist/Hand Evaluation total score (range, 0-100, lower scores indicate better performance). Of the 304 patients, the primary outcome was available in 217 patients. The total Patient Rated Wrist/Hand Evaluation score improved from 60 (95% confidence interval [CI], 57-63) to 38 (95% CI, 35-41) at 3 months, and 26 (95% CI, 23-29) at 12 months. The pain and function subscales improved by 18 (95% CI, 17-20) and 16 (95% CI, 14-18) points, respectively. At 12 months, 82% had returned to work at a median time of 12 (95% CI, 9-14) weeks following PRC. Grip strength did not improve. Wrist flexion and extension demonstrated a clinically irrelevant decrease. Satisfaction with treatment result was excellent in 27% of patients, good in 42%, fair in 20%, moderate in 6%, and poor in 5%. Complications occurred in 11% of patients, and conversion to wrist arthroplasty occurred in 2 patients. A clinically relevant improvement in patient-reported pain and function was observed at 3 months after PRC, with continued improvement to 12 months. These data can be used for shared-decision making and expectation management. Therapeutic IV.

Lateral Approach for Scaphoid Excision and Capitolunate Arthrodesis in the Treatment of Scapholunate Advanced Collapse and Scaphoid Nonunion Advanced Collapse Wrists: A Case Series.

The dorsal approach is commonly used in open wrist arthrodesis. However, the extensor compartments and the dorsal wrist capsule need to be opened. We propose and evaluate a lateral approach using a small incision over the scaphoid anatomical snuffbox, which could be more straightforward for performing scaphoid excision and capitolunate arthrodesis in the treatment of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC). Between 2016 and 2021, 10 patients were enrolled retrospectively and underwent the lateral approach for scaphoid excision and capitolunate arthrodesis. We presented the radiographic outcomes, including fusion status, capitolunate angle, and carpal height ratio. The functional outcomes of wrist range of motion, grip strength, visual analog scale (VAS) score for pain, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, and Mayo wrist score were evaluated. The data obtained were analyzed and presented as the mean and standard deviation (SD). All 10 patients achieved solid bone fusion, and the mean follow-up period was 20.4 (range 12-38; SD 10.1) months. Postoperatively, the mean capitolunate angle and carpal height ratio improved from 18.1° (range 8-34°; SD 8.6°) to 2.9° (range 0-5°; SD 1.9°) and 0.45 (range 0.40-0.49; SD 0.03)% to 0.50 (range 0.46-0.54; SD 0.02)%, respectively. The average preoperative and final follow-up functional results were as follows: flexion-extension arc of 76.5° (range 50-110°; SD 20.0°) and 74.0° (range 65-90°; SD 9.1°); VAS pain score of 5.8 (range 4-7; SD 1.0) and 0.9 (range 0-2; SD 0.6); QuickDASH score of 55.9 (range 40.9-79.5; SD 11.4) and 26.1 (range 18.2-36.4; SD 6.0); and Mayo wrist score of 46.5 (range 25-60; SD 13.8) and 72.5 (range 70-80; SD 3.5), respectively. The lateral approach for scaphoid excision and capitolunate arthrodesis in treating SLAC and SNAC can provide a straightforward way for performance. This approach does not require disruption of the dorsal wrist capsule and extensor retinaculum. Bony healing can be achieved, and functional outcomes can be improved.

Relationship Between Preoperative and Postoperative Motion After Four-Corner Wrist Fusion for Osteoarthritis: Clustering and Regression Analyses

Four-corner fusion (4CF) is a surgical option for refractory scapholunate advanced collapse and scaphoid nonunion advanced collapse wrist arthritis. Preoperative range of motion (ROM) predicts outcomes in many orthopedic procedures. This study investigates ROM in a cohort of 4CF patients to examine the relationship between preoperative and postoperative motion and identifies different clinical patterns. We performed a retrospective review of 4CF patients. Patients with a history of inflammatory arthritis and radiographic characteristics of inflammation were excluded. Demographics, prior wrist surgery history, and ROM data were collected at preoperative and postoperative intervals after cast removal at 8 weeks, 3 months, and 8 months. Regression analysis compared the motion before and after 4CF. Subsequent cluster analysis to reduce confounding compared postoperative motion differences in the top 20% to the bottom 20% of patients by preoperative motion. We included 148 patients; 27 had prior surgery on the ipsilateral wrist. Preoperative arc averaged 86° ± 28° (flexion 46° ± 17°, extension 40° ± 15°); 8-week arc 43° ± 19° (flexion 19° ± 12°, extension 24° ± 12°); 3-month arc 62° ± 17° (flexion 30° ± 12°, extension 32° ± 11°); and 8-month arc 74° ± 17° (flexion 36° ± 11°, extension 37° ± 12°). Preoperative and final arcs were (r= 0.39). Clustering by the preoperative arc, the top 20% (mean 124° ± 15°) achieved a mean final arc of 81° ± 16°, while the bottom 20% (mean 47° ± 16°) achieved a mean final arc of 65° ± 19°. Intercluster differences were statistically significant. The bottom 20% gained motion postoperatively. Most patients in the middle 60% did not differ significantly in postoperative motion. Although wrist motion following 4CF correlates positively with preoperative motion, most patients do not differ significantly in postoperative motion. Patients with substantial preoperative motion deficits gain motion after 4CF. This information is important when counseling patients, determining the timing of surgical intervention, and managing expectations related to motion outcomes. Prognostic II.

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.

Four-corner fusion method using a bioabsorbable plate for scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists: a case series study

BackgroundScaphoid excision and four-corner arthrodesis is an acceptable salvage procedure for the treatment of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrists, since first popularized in the 1980s. We investigated the potential application of novel bioabsorbable plates and screws made of un-sintered hydroxyapatite/poly-L-lactide composite for the treatment of metacarpal fractures. We used this material for the fixation of four-corner fusions for SLAC or SNAC wrists commencing from April 2009. The purpose of this study was to clarify the controversy in the literature regarding the use of these plates.MethodsThe surgical procedures and clinical outcomes of four-corner fusions using a bioabsorbable (poly-L-lactic acid and hydroxyapatite) plate were reported. Ten patients (mean age, 59.2 years) with SLAC or SNAC wrists underwent fusions between April 2009 and June 2016. The primary diseases were scapholunate ligament injury, Preiser disease, and scaphoid pseudarthrosis. The mean postoperative follow-up period was 45.9 months (range, 12–86).ResultsIn all patients, bone union was achieved without dislocation or pain. The mean wrist flexion and extension arc improved from 78.5 degrees before surgery to 90.5 degrees after surgery. Mean grip strength improved from 51 to 69% after surgery, and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score improved from 53.5 to 14.3. No complications such as infection, avascular swelling, or tendon adhesion were observed. This implant requires no removal of internal fixation devices, produces stable outcomes, and is an effective fusion technique.ConclusionsWe summarized the outcomes of four-corner arthrodesis using bioabsorbable plates. Satisfactory clinical results were shown, with no obvious complications. This novel plate also serves as a good alternative for patients who are allergic to metals. Furthermore, bioabsorbable plates are advantageous as they do not require removal.

Capitolunate Arthrodesis: A Systematic Review

To compile and review the indications, outcomes, and complications of capitolunate arthrodesis (CLA). We performed a literature search identifying 33 articles, 6 of which met inclusion criteria, including 80 patients. Included publications contained the results of CLA with minimum 12-month follow-up between 2000 and 2018. Data were pooled and analyzed focusing on the primary outcomes of union and complications. Average age of patients was 48 years (range, 22-86 years), median follow-up was 34 months (range, 12-198 months), and most common indication was scaphoid nonunion advanced collapse (59%). Nearly half underwent a concomitant triquetrum excision (49%). Most patients were pain-free (78%) and returned to work (92%). Grip strength and visual analog pain scale both improved after CLA. Whereas 96% fused within a reported 42 to 210 days (median, 70 days), 11% of patients had complications including nonunion (3.8%) and loose hardware (6.3%). The reoperation rate was 14%, including wrist arthrodeses and wrist arthroplasty. Capitolunate arthrodesis is a feasible option for scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists with complications similar to those encountered in 4-corner arthrodesis. Therapeutic IV.

Imaging of the wrist

• MR or CT is advocated in the assessment of radiographically occult fractures. • The intrinsic ligaments of the wrist are better visualized at 3.0-T MRI than at 1.5-T MRI; however, MR or multidetector CT arthrography is the most sensitive at detecting intrinsic ligament and triangular fibrocartilage complex (TFCC) tears. • MR is more sensitive at detecting scapholunate ligament tears than lunotriquetral ligament tears. • TFCC tears can be divided into traumatic or degenerative tears, the latter being related to ulnar impaction syndrome. • Chronic wrist pain as a result of trauma may be secondary to scaphoid avascular necrosis, malunion, non-union, scapholunate advanced collapse and scaphoid non-union advanced collapse wrist or chronic regional pain syndrome. • Specific ulnar-sided wrist pain has its own unique causes that are optimally imaged with MR. • Doppler ultrasound and dynamic-enhanced MRI are the most sensitive imaging tools for diagnosing and monitoring synovitis in inflammatory arthropathies. • Most masses in the wrist and hand are benign and have typical imaging appearances. This article details the current imaging modalities utilized in the assessment of wrist pathology, with particular emphasis on recent developments and difficult areas. A stepwise approach for the assessment of wrist pathology in the context of clinical presentation will be discussed. The radiologist's role in the evaluation of wrist pain continues to evolve with the growing development of new techniques in order to evaluate with greater sensitivity the disorders affecting the complex joint and ligamentous structures of the wrist. The imaging strategy for wrist pathology begins with radiographs, with the use of further imaging such as ultrasound, CT, MRI and arthrography techniques if the diagnosis remains unclear.

Four-corner arthrodesis using distal radius bone grafting

Purpose The aim of the study was to review the clinical and radiographic results of four-corner arthrodesis for stages 2 and 3 scapholunate advanced collapse and scaphoid nonunion advanced collapse wrist using 3 Kirschner-wires (3K-wires) and bone graft from distal end of the radius. Patients and methods Twenty patients (scaphoid nonunion advanced collapse, n = 14; scapholunate dissociation, n = 6) underwent four-corner arthrodesis using 3K-wires and distal end radius bone graft and were evaluated for radiographic and clinical success using standard posteroanterior and lateral wrist radiographs and according to modified Mayo Wrist Scoring Chart at 6 and 12 months after surgery. Wrist pains, range of the wrist motion, and grip strength were evaluated at final follow-up. A total of 12 men and eight women were included and their average age at surgery was 38 years. In all, 14 wrists were right and six were left. Results Radiographic film assessment revealed union in all cases after an average period of 7 weeks, a well-preserved radiolunate articular interval at all stages of follow-up examination. Pain classification scores showed that 10 patients were pain free, nine patients complained slight pain with vigorous activities, and only one patient complained moderate pain with vigorous activities. The mean flexion improved from 42 to 70% of the normal side. The mean extension improved from 29 to 65% of the normal side. The mean ulnar deviation improved from 28 to 43% of the normal side. The mean radial deviation improved from 30 to 45% of the normal side. Grip strength significantly improved from 28% of opposite side preoperatively to 61% postoperatively. Complications occurred in three cases, radial impingement in one patient, ulnar neuritis in one patient, and superficial infection in one patient. Conclusion We have shown that four-corner arthrodesis using K-wires effectively achieves union, provides satisfactory pain relief, restores grip strength, allows return to original job, and preserves functional motion.

Four-Corner Fusion and Scaphoid Excision Using Headless Compression Screws for SLAC and SNAC Wrist Deformities

Scapholunate advanced collapse and scaphoid nonunion advanced collapse wrist deformities are the most common causes of traumatic arthritis of the wrist. Four-corner fusion and scaphoid excision has proven to be an effective procedure for relieving pain and preserving range of motion in the wrist joint. Several methods for providing fixation of the midcarpal joint during fusion have been used, including K-wires, staples, and the Spider plate. K-wire fixation has proven effective, but requires a period of cast immobilization to protect the fusion mass. The Spider plate was promising, but has not been without complications. The development and improvements in cannulated headless compression screws has resulted in increased indications for their use, including fixation for 4-corner fusion. We review the technique and tips developed by the senior author over the last several years using headless compression screws for fixation of the midcarpal joint. Acutrak 2 Standard implants were used. This technique has allowed for early range of motion with reliable fusion rates.

Scapholunate Advanced Collapse and Scaphoid Nonunion Advanced Collapse Arthritis—Update on Evaluation and Treatment

Scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse are common patterns of wrist arthritis. Scaphoid nonunion advanced collapse is caused by trauma, whereas SLAC wrist may also result from chronic pseudogout and can appear bilaterally without a clear history of injury. Surgical treatment for SLAC wrist includes 4-corner arthrodesis, capitolunate arthrodesis, complete wrist arthrodesis, proximal row carpectomy (PRC), denervation, and radial styloidectomy. Scaphoid nonunion advanced collapse wrist has the additional surgical option of excision of the distal ununited scaphoid fragment. Controversy persists over the relative merits of PRC versus 4-corner arthrodesis and whether PRC may be performed in the setting of capitate arthritis.

A New Volar Vascularization Technique Using the Superficial Palmar Branch of the Radial Artery for the Collapsed Scaphoid Nonunion

Achieving union to prevent scaphoid nonunion advanced collapse wrist in the scaphoid nonunion is a challenging clinical problem. Much of the difficulty relates to the tenuous blood supply to the scaphoid. One unsolved reconstructive problem is the collapsed scaphoid that requires an intercalated wedge graft with proximal pole avascular necrosis. We offer a simple technique that only requires preservation of the superficial palmar branch of the radial artery that is typically ligated during the volar approach to the scaphoid. This technique can also be used during any open volar approach to the scaphoid to increase vascularity and healing.