Radiolunate Angle Research Articles

Clinical, radiological and dynamic CT results of scapholunate intercarpal ligamentoplasty for scapholunate dissociation

A clinical, radiological and four-dimensional computed tomography (4DCT) assessment of the outcomes of scapholunate intercarpal ligamentoplasty (SLICL) was done with a minimum follow-up of 2 years. Twenty-nine patients (23 men and 6 women) with a mean age of 40 years (22–57) who had chronic scapholunate dissociation were treated with the SLICL procedure. There were 18 cases of dynamic instability and 11 of static instability. The patients were evaluated with a mean follow-up of 61 months (24–94). SLICL significantly reduced pain and increased grip strength and wrist function. On radiographs, the mean static and dynamic scapholunate gaps as well as the scapholunate and radiolunate angles improved significantly. The dorsal scaphoid displacement was always corrected. 4DCT after surgery provided a more precise analysis of the SLICL’s effectiveness at restoring intracarpal alignment. Correction of the DISI deformity and dorsal scaphoid displacement was confirmed. SLICL restored a normal variation in the scapholunate gap (range value) during radioulnar deviation movement without systematically reducing the distance between the bones (mean and maximum values) which remained pathological in wrists with static instability but not in those with dynamic instability. At the final follow-up, no patients had signs of osteoarthritis due to ScaphoLunate Advanced Collapse. Level of evidenceIII.

Distal Radioulnar Joint Orientation and Lunate Morphology as Protective Factors of Symptomatic Idiopathic Ulnar Impaction Syndrome in Ulnar-Positive Variant Patients

Abstract Background Ulnar-positive variance is widely recognized as a risk factor for idiopathic ulnar impaction syndrome (UIS). However, not all patients with ulnar-positive variance progress to symptomatic UIS. Other factors, such as the shape of the lunate or the distal radioulnar joint (DRUJ), may also play a role. This study aims to elucidate the relationship between the shape of the lunate and the structure of the DRUJ and idiopathic UIS. Patients and Methods A cohort of 40 cases diagnosed with idiopathic UIS (UIS group) and 87 control subjects with ulnar-positive variance but without symptoms were compared. Lunate shape was assessed by measuring the lunate type and radiolunate angle (RLA), whereas DRUJ morphology was evaluated using the sigmoid notch angle, DRUJ subluxation ratio, and DRUJ inclination. Independent t-tests were conducted to analyze differences in radiographic metrics between the two groups, and logistic regression analyses were used to examine risk factors for idiopathic UIS. Receiver operating characteristic curves were utilized to determine the cutoff values for statistically significant variables. Results Significant differences were observed between the two groups in terms of RLA, DRUJ subluxation ratio, and DRUJ inclination (p < 0.05). Logistic multiple regression analysis revealed a negative correlation between idiopathic UIS occurrence and both RLA (odds ratio [OR]: 0.92; 95% confidence interval [CI]: 0.87–0.96; p < 0.001) and the DRUJ subluxation ratio (OR: 0.01; 95% CI: 0–0.07; p = 0.002). Conversely, a positive correlation was found between UIS occurrence and DRUJ inclination (OR: 1.06; 95% CI: 1.01–1.12; p = 0.021). Conclusion In patients with ulnar-positive variance, the incidence of symptomatic UIS decreases when the lunate extends more relative to the radius and when the DRUJ subluxation ratio increases or DRUJ inclination decreases. Level of Evidence Level III, case–control study.

Evaluating inter- and intraobserver reliability in radiographic determination of wrist alignment following scaphoid excision and four-corner arthrodesis

BackgroundFour-corner arthrodesis is commonly performed for advanced collapse patterns of wrist arthritis. Reduction of the capitolunate (CL) angle during four-corner fusion is crucial to allow for the greatest radiocarpal joint arc of motion. Previous studies demonstrate variable inter- and intraobserver reliability of measuring the CL angle. However, in a four-corner fusion, hardware implementation and scaphoid excision can complicate carpal alignment measurements. The purpose of this study is to investigate inter- and intraobserver reliability of measuring carpal alignment parameters following scaphoid excision and four-corner arthrodesis. MethodsThree fellowship-trained orthopaedic hand surgeons evaluated 30 posteroanterior and lateral radiographs of wrists after scaphoid excision and four-corner fusion. Radiographic evaluation included analysis of the radiolunate angle (RL), CL angle, lunate posture, carpal height, carpal height ratio, hardware impingement, and arthrodesis technique. Intraclass correlation coefficients (ICCs) and kappa values were used to evaluate reliability of radiographic measurements. ResultsRL and CL angles demonstrated very good inter- (ICCs: 0.657 and 0.693, respectively) and intraobserver agreement (ICCs: 0.576 to 0.924 and 0.596 to 0.811, respectively). Hardware impingement metrics by dorsal prominence and radiocarpal prominence had excellent interobserver reliability of 0.821 and 0.803, respectively. ICC values for arthrodesis technique were equal to 1.00. The inter- and intraobserver ICC values for the number of screws/staples used were in excellent agreement ranging from 0.910 to 1.000. ConclusionsOur study demonstrated favorable intra- and interobserver reliability at assessing carpal alignment following scaphoid excision and four-corner arthrodesis and these metrics potentially could be used in future research to evaluate long-term surgical outcomes. Level of evidenceLevel III, retrospective cohort study.

Evaluation of chronic perilunate dislocations: A comparative study of single-stage, two-stage ORIF, and salvage procedures

ObjectiveThis study aims to evaluate the outcomes of open reduction and internal fixation (ORIF) for chronic perilunate dislocations using single-stage, two-stage, and salvage procedures. The study also compares these approaches with each other and with results from existing literature. MethodsA total of 15 patients with chronic perilunate injuries from 2013 to 2019 were included in the study. Pre-operative and post-operative assessments were conducted using plain radiographs, with CT scans performed selectively for detailed morphology and fracture pattern analysis. Among the patients, 13 underwent ORIF, while 2 underwent salvage procedures. Among the ORIF cases, single-stage procedures were performed in 4 patients, and two-stage procedures in 9 patients. External fixators, including unilateral uniplanar external fixators (UUEF) and bilateral uniplanar external fixators (BUEF), were applied in 5 and 4 patients, respectively. Our methodology of treating chronic perilunate injuries has evolved over the years. We started with single stage ORIF then graduated to a two staged procedure initially using a external fixator as a carpal distractor applied only on the radial side and finally settling down with bilateral carpal distraction using external fixators both on the radial and ulnar sides. ResultsAmong the 15 patients, 3 were lost to follow-up. Of these, one underwent four-corner fusion, while the remaining two had UUEF. The mean time interval between injury and surgery was 3.60 months. The post-operative mean scapholunate angle measured 52.46°, with a negative radio-lunate angle (indicating flexion) observed in two patients, while others showed a positive angle (indicating extension). Two cases exhibited nonunion and avascular necrosis (AVN) of the scaphoid, while one case presented with lunate AVN. Mid-carpal and radio-carpal arthritis was observed in 4 and 2 patients, respectively. Functional outcomes were evaluated using Mayo's wrist score categorized as good for two-stage BUEF cases and satisfactory for UUEF and single-stage procedures. ConclusionStaged reduction utilizing the BUEF followed by open reduction has demonstrated superior outcomes when compared to UUEF, single-stage open reduction and salvage procedures. Level of evidence: 4

Three-corner arthrodesis for scapholunate and scaphoid nonunion advanced collapsed wrists: outcomes at long term follow-ups

ObjectivesThis study aimed to assess clinical, functional and radiological outcomes after three-corner arthrodesis in patients suffering from symptomatic scapholunate or scaphoid non-union advanced collapsed wrists. We hypothesised that three-corner arthrodesis provided satisfactory clinical and radiological results in the long term. Material and methodsThis was a retrospective study of 13 patients (14 wrists) who underwent a three-corner arthrodesis between March 2004 and January 2019 with a mean follow-up of 6,7 years. Clinical assessment consisted of wrist motion, grip strength, pain and functional scores (Quick-DASH, PRWE, MWS). All complications and surgical revisions were investigated. Radiographic assessment searched for union, evaluated carpal height and ulnar translation, lunate tilt and occurrence of radio-lunate arthritis. ResultsAt the last follow-up Quick-DASH and PRWE scores were 24,87(± 17.2) and 47.4 (± 26.9) respectively and were significantly improved. Wrist motion was 35°, 32°, 10° et 24° of flexion, extension, radial and ulnar deviation respectively. Union was obtained for 13 (92,9%) wrists. The mean radiolunate angle was 11° (-17°-34°). Three patients needed reintervention, which 2 consisted of total wrist arthrodesis due to persisting pain. Mild signs of radio-lunate arthritis were found in three patients. ConclusionThree-corner arthrodesis seemed to provide satisfactory long-term functional outcomes. The union rate was high and even patients with signs of radio-lunate arthritis still had improved outcomes at the last follow-up. It could be a part of surgical options in wrists with radio- and midcarpal arthritis, among other procedures.

A comparative study of volar locking-plate fixation with corticocancellous and pure cancellous bone grafts for scaphoid nonunion with dorsal intercalated segmental instability secondary to scaphoid humpback deformity

IntroductionBone grafts for scaphoid nonunion with deformity include cortcicocancellous or pure cancellous bone grafts. This study compared the outcomes between two types of bone grafts when employing a volar locking-plate in patients with scaphoid nonunion with dorsal intercalated segmental instability (DISI). Patients and MethodsThis retrospective study included 34 patients with scaphoid nonunion and DISI due to humpback deformity treated between March 2017 and January 2022. Two types of bone grafts were obtained from iliac crest. Twenty of the corticocancellous (CC) group underwent a wedge-shaped graft, while 14 patients of the pure cancellous (C-only) group received graft chips. In both groups, a 1.5-mm anatomically pre-contoured locking plate was used for fixation. Radiographic evaluations included the union rate and carpal alignment including scapholunate angle (SLA), radiolunate angle (RLA), intrascaphoid angle (ISA) and scaphoid height to length ratio (HLR). Clinical assessments encompassed wrist range-of-motion, grip strength, and patient-reported outcomes. ResultsNineteen of the 20 patients in the CC group and 12 of the 14 patients in the C-only group respectively, achieving osseous union. The mean follow-up period in CC group was 14.7 (range, 12 ∼ 24) months and that in C-only group was 12.6 (range, 12 ∼ 15) months. Postoperatively, there were no significant intergroup differences of radiographic parameters including SLA (CC; 49.9° ± 6.7° vs. C-only; 48.9° ± 3.5°, P = 0.676), RLA (1.7° ± 6.4° vs. 2.4° ± 3.3°, P = 0.74), ISA (36° ± 7.5° vs. 36.6° ± 12.2°, P = 0.881), and HLR (0.54 ± 0.09 vs. 0.53 ± 0.05, P = 0.587). Clinical outcomes, including the flexion–extension arc (137° ± 30° vs. 158° ± 33°, P = 0.122), grip strength (93.4 % ± 15.4% vs. 99.5 % ± 16.7 %, P = 0.39), Quick Disabilities of the Arm, Shoulder, and Hand scores (11.2 ± 8.3 vs. 12.5 ± 7.7, P = 0.74) and Mayo Wrist Scores (81.2 ± 13.1 vs. 89 ± 11.4, P = 0.242) also showed no significant intergroup differences. ConclusionsVolar locking-plate fixation with pure cancellous bone grafts achieved outcomes comparable to those achieved with corticocancellous bone grafts in scaphoid nonunion with deformity, possibly due to the biomechanical advantages of the volar plate to provide structural supports.

Distal Scaphoid Excision for Chronic and Nonchronic Scaphoid Fracture Nonunion

PurposeThe indications for distal scaphoid excision are limited to localized wrist arthritis surrounding the scaphoid as a result of scaphoid nonunion advanced collapse or scapho-trapezio-trapezoid (STT) joint arthritis. The procedure historically has led to relief of symptoms and improvement in strength. Our aim was to examine the outcomes of this procedure in patients with scaphoid fracture nonunion. MethodsThis is a single-center retrospective case series of 12 consecutive patients who underwent distal scaphoid excision after scaphoid fracture nonunion. Patients were divided into two groups based on nonunion chronicity: chronic (more than a year) and non-chronic (less than a year). Clinical and radiographic data were examined using descriptive statistics. ResultsOur cohort consisted of 12 patients, 10 men (83%) and 2 women (17%), with a mean age 37.6±13.6 years. Eight patients had a chronic scaphoid fracture nonunion (6 had a neglected scaphoid fracture and 2 had a nonunion after scaphoid open reduction and internal fixation (ORIF) with bone graft) and 4 patients had non-chronic fracture non-union (2 had failed cast treatment and 2 had nonunion after scaphoid ORIF with bone graft). Pre-operatively, all patients complained of pain and 4 had numbness (all in chronic group). After an average 21 weeks post-operatively, 7 patients (58%) reported continued pain. Two patients reported ulnar side pain, one underwent arthroscopic synovectomy. All patients who started with normal radiolunate angle continued to have normal angle, whereas patients who had DISI prior to surgery persisted after surgery except for a patient who underwent midcarpal fusion and had their radiolunate angle corrected. ConclusionsDistal scaphoid excision is an effective procedure for carefully selected patients with periscaphoid wrist arthrosis. Patients with recent scaphoid fracture that failed treatment may also be treated with distal scaphoid resection.

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.

One-Year Outcomes of the Anatomical Front and Back Reconstruction for Scapholunate Dissociation

Anatomical front and back (ANAFAB) reconstruction addresses the critical volar and dorsal ligaments associated with scapholunate dissociation. We hypothesized that patients with symptomatic, chronic, late-stage scapholunate dissociation would demonstrate improvements in all radiographic parameters and patient-reported outcomes (PROMs) after ANAFAB reconstruction. From 2018 to 2021, 21 ANAFAB reconstructions performed by a single surgeon were followed prospectively, with 20 patients having a minimum follow-up of 12 months. In total, 17 men and four women were included, with an average age of 49 years. Three patients had modified Garcia-Elias stage 3 disease, eight stage 4, seven stage 5, and three stage 7. ANAFAB reconstruction of intrinsic and extrinsic ligament stabilizers was performed using a hybrid synthetic tape/tendon graft in a transosseous reconstruction. Pre- and postoperative radiographic parameters, grip, pinch strength, the Patient-Rated Wrist Evaluation, PROMIS Upper Extremity Function, and PROMIS Pain Interference outcome measures were compared. Mean follow-up was 17.9 months (range: 12-38). Radiographic parameters were improved at follow-up, including the following: scapholunate angle (mean 75.3° preoperatively to 69.2°), scapholunate gap (5.9-4.2 mm), dorsal scaphoid translation (1.2-0.2 mm), and radiolunate angle (13.5° to 1.8°). Mean Patient-Rated Wrist Evaluation scores for pain and function decreased from 40.6 before surgery to 10.4. We were unable to detect a significant difference in grip or pinch strength or radioscaphoid angle with the numbers tested. There were two minor complications, and two complications required re-operations, one patient who was converted to a proximal row carpectomy for failure of fixation, and one who required tenolysis/arthrolysis for arthrofibrosis. At 17.9-month average follow-up, radiographic and patient-reported outcome parameters improved after reconstruction of the critical dorsal and volar ligament stabilizers of the proximal carpal row with the ANAFAB technique. Therapeutic study IV.

Comparison of corticocancellous bone graft from the anterolateral metaphysis of the distal radius versus iliac crest for the treatment of unstable scaphoid nonunion with humpback deformity

BackgroundCorticocancellous bone grafting from the iliac crest is acceptable treatment for unstable scaphoid nonunion with a viable proximal pole. However, harvesting graft from the iliac crest is associated with donor site morbidity and the requirement of general anesthesia. Thus, bone grafting from the anterolateral metaphysis of the distal radius (DR) can be a treatment option. However, no study has compared the clinical effect between the two grafting techniques.MethodsFrom 2014 to 2019, patients with unstable scaphoid nonunion with humpback deformity underwent corticocancellous bone grafting from the anterolateral metaphysis of the DR (group DR) or iliac crest (group IC). Humpback deformity was determined by evaluating the scapholunate angle (SLA) ≥ 60°, intrascaphoid angle (ISA) ≥ 45°, and radiolunate angle (RLA) ≥ 15° from preoperative radiographs and computed tomography scans. The SLA, ISA, and RLA served to gauge carpal alignment. The operative time, grip strength, active range of motion (ROM), the Modified Mayo Wrist score (MMWS), and Disabilities of Arm, Shoulder, and Hand (DASH) score were assessed postoperatively.ResultsThirty-eight patients qualified for the study (group DR, 15; group IC, 23). Union rates did not differ by patient subset (group DR, 100%; group IC, 95.7%; P = .827), and grip strength, ROM, MWS, and DASH score were similar between groups at the last follow-up. The operative time (minutes) was significantly shorter in group DR (median, 98; quartiles, 80, 114) than in group IC (median, 125; quartiles, 105, 150, P < .001). The ISA, RLA, and SLA improved postoperatively in both groups (P < 0.001). The degree of restoring carpal alignment, as evaluated by SLA, showed superior correction capability in group DR (median, 25.3% quartiles, 21.1, 35.3, P < 0.05). Donor site complications were not significantly different between the groups.ConclusionsCorticocancellous bone graft from the anterolateral metaphysis of the DR for unstable scaphoid nonunion is associated with a shorter operation time and comparable results with that from the iliac crest in regard to union, restoration of carpal alignment, and wrist function.Level of EvidenceLevel III.

Dorsal Scapholunate Ligament Complex Reconstruction Using Suture Tape-Augmented Autologous Free Tendon Graft for Chronic Scapholunate Dissociation.

The treatment of chronic scapholunate dissociation (SLD) can be challenging due to several factors such as poor quality of ligament, malalignment of the carpus, limited surgical options, and risk of recurrent instability. Various surgical techniques have been developed, but there is ongoing debate regarding the optimal surgical technique. This study aimed to report the clinical and radiological outcomes after dorsal scapholunate (SL) ligament complex reconstruction using suture tape-augmented autologous tendon graft. The study included patients with Garcia-Elias stage 3-4 chronic SLD, SL advanced collapse (SLAC) stage 1, and a follow-up period exceeding 1 year. Pre- and postoperative SL gap, SL angle (SLA), radiolunate angle (RLA), and dorsal scaphoid translation (DST) were measured, and wrist active range of motion, Modified Mayo Wrist Score (MMWS), and visual analog scale (VAS) were evaluated. Nine patients were included in this study with a mean follow-up period of 17 months (range, 15-31 months). All patients were male, with a mean age of 49 years (range, 30-62 years). Eight patients were classified as Garcia-Elias stage 4, while one was classified as SLAC 1. The median (range) of preoperative, immediate postoperative, and final follow-up measurements for SL gap, SLA, RLA, and DST were 5.4 mm (4.5-5.9), 2.1 mm (1.8-2.5), and 2.5 mm (2.0-2.8) (p = 0.008); 76° (69°-88°), 50° (32°-56°), and 54° (50°-64°) (p = 0.008); 22° (11.5°-33°), 2.8° (0.5°-3.8°), and 3.8° (2.2°-5.6°) (p = 0.008); and 2.8 mm (2.0-3.4), 0.8 mm (0.1-1.2), and 1.0 mm (0.1-2.0) (p = 0.008), respectively. Immediately after surgery, all radiological measurements showed significant improvement, which persisted up to 15 months postoperatively. The preoperative and final follow-up measurements of active flexion, extension, radial deviation, and ulnar deviation of the wrist showed significant improvement. The median preoperative and final follow-up values of MMWS were 51.1 (range, 40-60) and 88.3 (range, 85-95) (p = 0.007), respectively, and those of VAS were 7 (range, 6-8) and 2 (range, 1-3) (p = 0.007), respectively. Dorsal SL ligament complex reconstruction using suture tape-augmented autologous free tendon graft could be regarded as a feasible and straightforward technique for addressing irreparable chronic SLD.

Does correction of carpal malalignment influence the union rate of scaphoid nonunion surgery?

IV.

Biomechanical Comparisons of Different Reconstructive Techniques for Scapholunate Dissociation: A Cadaveric Study.

There are many techniques for the treatment of chronic scapholunate dissociation. The three-ligament tenodesis (3LT) is used most widely, but reconstruction of the dorsal ligament alone may not provide sufficient stability. The Mark-Henry technique (MHT) compensates for the insufficient stability of 3LT by additional reconstruction of the volar ligament, but the procedure is complex. The SwiveLock technique (SWT), a recently introduced method, provides stability by using autologous tendons with synthetic tapes, but lacks long-term clinical results. To perform biomechanical comparisons of different reconstructive techniques for scapholunate dissociation using a controlled laboratory cadaveric model. Eleven fresh-frozen upper-extremity cadaveric specimens were prepared. The scapholunate distance, scaphoid rotation, and lunate rotation of the specimens were measured during continuous flexion-extension and ulnar-radial deviation movements. The data were collected using a wrist simulator with a linear guide rail system (tendon load/motion-controlled system) and a motion capture system. Results were compared in five conditions: (1) intact, (2) scapholunate dissociation, (3) SWT, (4) 3LT, and (5) MHT. Paired t-test was employed to compare the biomechanical characteristics of intact wrists to those of scapholunate dissociated wrists, and to those of wrists after each of the three reconstruction methods. SWT and MHT were effective solutions for reducing the widening in scapholunate distance. According to the radioscaphoid angle, all three reconstruction techniques were effective in addressing the flexion deformity of the scaphoid. According to the radiolunate angle, only SWT was effective in addressing the extension deformity of the lunate. In terms of scapholunate angle, only the results after SWT did not differ from those of the intact wrist. The SWT technique most effectively improved distraction intensity and rotational strength for the treatment of scapholunate dissociation. Taking into account the technical complexity of 3LT and MHT, SWT may be a more efficient technique to reduce operating time and minimize complications due to multiple incisions, transosseous tunnels, and complicated shuttling.

Anatomical front and back reconstruction sustains radiographic alignment: a comparison to three-ligament tenodesis.

Multiple techniques exist to reconstruct the scapholunate interosseous ligament, though none have demonstrated superiority. This study compares 1-year radiographic outcomes of the three-ligament tenodesis and the anatomical front and back reconstruction. All patients who underwent reconstruction of their scapholunate interosseous ligament at one institution with either anatomical front and back reconstruction or three-ligament tenodesis between 2011 and 2020 were retrospectively reviewed. At 52-week follow-up, anatomical front and back reconstruction maintained a statistically significant improvement in scapholunate gap, corrected radiolunate angle and dorsal scaphoid translation, while three-ligament tenodesis demonstrated no sustained improvement in any parameter. The improvement in dorsal scaphoid translation was significantly greater for patients undergoing anatomical front and back reconstruction compared with three-ligament tenodesis at the 16-weeks postoperative timepoint (-1.0 mm, -0.3 mm). Anatomical front and back reconstruction demonstrates sustained improvement in radiographic outcomes at 1 year when compared with three-ligament tenodesis. By addressing both volar and dorsal critical ligament restraints, adoption of anatomical front and back reconstruction for advanced stage scapholunate interosseous ligament injuries should be considered.Level of evidence: IV.

Carpal Joint Malalignment With Distal Radius Malunion and Factors in Correction After Distal Radius Osteotomy

There is a paucity of data regarding recommendations on when to correct for distal radius malunions and if the initial severity of the radiographic outcomes is correlated with the ability to correct to baseline. We evaluated the effects of distal radius corrective osteotomy on preoperative carpal joint malalignment resulting from distal radius malunions, correlated injury severity and osteotomy timing to radiographic outcomes, and developed a straightforward classification system for predicting radiocarpal and midcarpal maladaptive patterns. A retrospective review included 26 patients (27 wrists) who reported initial closed treatment for a distal radius fracture and who subsequently underwent a corrective osteotomy for malunion. Data included patient demographics, range of motion, preoperative fracture deformity, fracture deformity correction, and preoperative and postoperative radiographic measurements of the radiocarpal and midcarpal alignment patterns. Of 27 dorsally angulated malunions, 16 were classified as type 1 midcarpal adaptation and 11 as type 2 radiocarpal adaptation. The midcarpal group showed significant improvements in distal radius and carpal alignment parameters after surgery, except for the ulnar variance. The radiocarpal group showed significant improvements in distal radius and carpal alignment parameters, except for the radiolunate angle, radioscaphoid angle, and capitolunate angle. The radiocarpal group exhibited an overall decrease in range of motion compared with that of the midcarpal group. Severity of the fracture and time taken from injury to corrective osteotomy correlated with the ability to correct carpal radiographic parameters in dorsally angulated malunions of the distal radius, especially beyond 40 weeks. The severity of the initial fracture and time taken from injury to corrective osteotomy correlate with the ability to correct radiographic parameters in dorsally angulated malunions of the distal radius. Early correction of distal radius malunions is recommended, especially in radiocarpal malalignment patterns. A useful analysis for predicting midcarpal and radiocarpal adaptation patterns is the direct measurement of the distal articular surface of the radius to the lunate, termed the relative-radiolunate angle. Therapeutic IV.

Long-term Results of the Treatment of Scapholunate Instability with Dynamic Extensor Carpi Radialis Brevis Tenodesis

Background: Scapholunate dissociation is the most common form of carpal instability. This retrospective case series aimed to assess long-term results obtained by treating scapholunate instability with dynamic tenodesis using the entire extensor carpi radialis brevis tendon, which is detached from the base of the third metacarpal, rerouted in the third extensor compartment, and fixed at the distal portion of the scaphoid to maintain reduced rotatory subluxation. Methods: Nine patients with scapholunate instability were treated. We reviewed eight patients with a mean follow-up of 12 years. One subgroup of four patients was affected by static scapholunate instability, and the other by dynamic scapholunate instability. Disability of the Arm, Shoulder, and Hand score, Patient Rated Wrist Evaluation score, modified Mayo score, and radiographs were used to determine functional and anatomical outcomes. Results: Excellent functional results did not correlate with radiological outcome in patients with static scapholunate instability. In this subgroup, scapholunate angle and gap and radiolunate angle improved in average but remained in the pathologic range. In only one of these patients, osteoarthritis was observed. In the subgroup of patients affected by dynamic instability, very good functional outcomes correlate with radiological results, except in one patient who developed arthritic changes. Conclusions: Dynamic tethering of the scaphoid with the extensor carpi radialis brevis tendon might be indicated in the treatment not only in patients affected by dynamic scapholunate instability but also in patients with static instability. Prospective studies with a larger number of patients are required to evaluate this method.

The effect of intercarpal arthrodeses on wrist kinematics during radial and ulnar deviation: a cadaveric study using four-dimensional CT.

In this cadaveric study, we report quantitative dynamic four-dimensional CT evaluation of the effect on wrist kinematics of three intercarpal arthrodeses during radial and ulnar deviation. In five wrists, we successively performed scaphocapitate, four-corner and two-corner fusions. Four-dimensional CT examinations were performed prior to dissection and after each arthrodesis. The lunocapitate gap, posterior lunocapitate angle, radiolunate radial gap, radiolunate ulnar gap and radiolunate angle were assessed. After scaphocapitate arthrodesis, in radial deviation, we noted midcarpal diastasis and dorsal displacement of the capitate. In ulnar deviation, there was correction of that incongruence. After four-corner and two-corner fusions, in radial deviation, we noted radial radiolunate impingement and ulnar radiolunate incongruence. In ulnar deviation, after two-corner fusion, ulnar radiolunate impingement and radial radiolunate incongruence were present contrary to four-corner fusion. Our findings confirm that the constant radiocarpal and midcarpal congruence during radioulnar deviation in normal wrists is no longer possible with intercarpal kinematic modifications after these arthrodeses.

Scaphoid Length Loss Following Nonunion Is Associated with Dorsal Intercalated Segment Instability.

Background Dorsal intercalated segment instability (DISI) in scaphoid nonunions is frequently attributed to fracture location relative to ligamentous attachments onto the scaphoid apex. We hypothesize scaphoid length loss to have a stronger correlation with DISI deformity than fracture location in patients with scaphoid nonunion. Questions/Purposes To investigate the correlation between (1) scaphoid length loss, (2) fracture location relative to the scaphoid apex, and (3) type of nonunion (Herbert classification) and DISI deformity in skeletally mature patients with scaphoid nonunion. Patients and Methods Twenty-seven cases of computed tomography (CT)-confirmed scaphoid nonunion (>6 months) were retrospectively included. Our primary outcome was the degree of DISI as measured by the radiolunate (RL) angle on CT. Scaphoid length loss was expressed as height-to-length (H/L) ratio. Fracture location was classified as proximal or distal to the scaphoid apex. Nonunions were classified as fibrous unions (type D1) or pseudoarthrosis (type D2). The correlation between RL angle, H/L ratio, fracture location, and nonunion type was evaluated. Results H/L ratio was the only factor associated with the degree of DISI as measured by RL angle. As scaphoid length loss increased (increasing H/L ratio), the RL angle increased. There was no significant difference in RL angle between fractures located proximal (30 degrees) or distal (28 degrees) to the scaphoid apex, or type D1 (31 degrees) versus type D2 (28 degrees) nonunions. There was no correlation between patient age, sex, or wrist side affected and RL angle. Conclusions Scaphoid length loss, rather than fracture location, is correlated to the degree of DISI deformity in patients with scaphoid nonunion. This highlights the importance of restoring scaphoid height when planning scaphoid nonunion reconstruction. Level of Evidence Level III, diagnostic study.

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.

Clinical Outcomes of Arthroscopic-Assisted Volar Scapholunate Capsulodesis: A Case Series.

Purpose We have previously described arthroscopic-assisted volar scapholunate (SL) capsulodesis as an alternative technique for addressing volar SL interosseous ligament (SLIL) injuries. In this article, we report the outcomes of this procedure in a cohort of patients. Methods Postoperative outcomes including range of motion, grip strength, visual analog scale (VAS) pain score, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), and Mayo Wrist Score were assessed through a prospective review of six patients in a single center who underwent this procedure. Results Six patients (four male and two female) with a mean age of 43 ± 14 years were evaluated in the study. The mean duration of follow-up was 41 ± 17 weeks. Postoperative outcomes noted a reduction in VAS pain score from 8 before surgery to 0.7 postoperatively ( p = 0.00004) and improvement in Mayo Wrist Score (42 preoperatively to 80 postoperatively; p = 0.001), grip strength (86% of contralateral side; p = 0.20), and flexion arc (81% of contralateral side; p = 0.08). QuickDASH was 20 ± 8 and Patient-Rated Wrist Evaluation score was 13 ± 2 at the last clinical follow-up. There was an improvement in SL gap ( p = 0.03), SL angle ( p = 0.11), and radiolunate angle ( p = 0.15) measurements postoperatively. Conclusions The described arthroscopic-assisted volar SL capsulodesis in this study presents an alternative method to address volar SLIL pathology with positive short-term clinical outcomes. Clinical Relevance Arthroscopic-assisted volar SL capsulodesis may be considered in the treatment algorithm for volar SLIL injuries.