Radioscaphoid Arthritis Research Articles

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.

Parallel K-Wire Placement Leads to Fusion and Midcarpal Settling in Scaphoid Excision Four-Corner Fusion.

Scaphoid excision 4-corner fusion is a motion-sparing procedure in patients with advanced radioscaphoid arthritis. This study introduces an alternate technique for scaphoid excision 4-corner fusion using a parallel Kirschner wire (K-wire) construct across the midcarpal joints that leads to reliable fusion rates, and good patient outcomes. This is a single-surgeon, retrospective study of patients who underwent scaphoid excision 4-corner fusion, using a parallel K-wire construct across the midcarpal joints. Once fusion was achieved, K-wires were removed. Radiographic union rate, time to union, capitolunate angle, capitolunate coverage, and amount of midcarpal settling are measured. Patient-reported outcome measures and descriptive statistics are presented. Sixty-five wrists were included in this study with a mean age of 50.1 years. One patient was lost to follow-up. All 64 wrists (100%) fused at an average of 2.6 months. The mean capitolunate angle was 7°, and capitolunate coverage was 99.2%. Fifty-two patients (81%) had adequate radiographs for measurement. Average midcarpal settling was 1.1 mm. Thirty-two patients (51%) were available for long-term follow-up at an average of 5.3 years (0.7-10.2 years), and participated in patient reported outcomes (PRO) surveys. The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 16.6, and numeric pain rating scale score was 1.8. Parallel K-wire placement across the midcarpal joints with scaphoid leads to a high rate of fusion with good patient outcomes long term. Midcarpal settling that occurs through dynamic compression around the K-wires may have contributed to bony fusion. This technique may provide an alternative approach to achieving reliable fusion across the midcarpal joints.

Limited Carpal Fusion in Kienböck's Disease: Early Results following Scaphocapitate Arthrodesis.

Background Kienböck's disease leading to progressive carpal collapse alters the wrist biomechanics leading to early arthritis and degenerative changes. Out of multiple surgical procedures present, no gold standard has been described. Scaphocapitate arthrodesis (SCA) is limited carpal fusion which shifts the loading axis toward radioscaphoid joint. This study presents the midterm clinical and radiological results of SCA in Kienböck's disease. Materials and Methods The data were reviewed from January 2016 to December 2017. Lichtman's classification used to stage the disease. Clinical variables were noted for wrist range of motion, grip strength, visual analog scale (VAS) score, quick disabilities of the arm, shoulder, and hand (quickDASH), and patient-rated wrist evaluation (PRWE) scores. Radiographs were evaluated for union, ulnar variance, carpal height ratio, radioscaphoid angle, and scapholunate angle. Results A total of 11 patients of Stage IIIA and IIIB Kienböck's disease with mean age of 24 years were included in the study with a minimum of 18 months of clinical follow-up. The procedure resulted in decreased ranges of motion but improved grip strength (26.09 ± 4.76 from 19.54 ± 4.63 kgf) and reduced pain with VAS score decreased from 7.36 ± 0.8 to 2 ± 1. Radiographic analysis showed union in all patients, reduced carpal height with a corrected radioscaphoid angle (from 62.12 to 48.3 degrees), and scapholunate angle (from 34 to 26.27 degrees). Discussion SCA has advantage of technical ease of orientation of the scaphoid and osteosynthesis of only one intercarpal joint with a large contact surface. Coupling the distal and proximal carpal rows results in significant loss of mean wrist range of motion but with improved grip strength, shifting the load away from the radiolunate joint. However, long-term studies are needed for clinical benefits and radiographic signs of radioscaphoid arthritis for the treatment of advanced-stage Kienböck's disease. Level of Evidence This is a Level IV, retrospective observational study.

The management of proximal pole scaphoid nonunion with avascular necrosis using 1, 2 intercompartmental supraretinacular arterial bone graft and radial styloidectomy: A midterm outcome study

Background: The management of proximal pole nonunions of scaphoid with avascular necrosis remains the most controversial of all scaphoid fracture nonunions. Various types of vascularised bone grafts have been used to hasten union. We studied the union rate, clinical and functional outcome of 1, 2 intercompartmental supraretinacular arterial bone graft (1, 2 ICSRA) and radial styloidectomy for proximal pole scaphoid nonunion with avascular necrosis. Methods: We retrospectively analysed the four year outcome of vascularised distal radius bone graft (1, 2 ICSRA) and radial styloidectomy in 20 patients treated at our institution for proximal pole scaphoid nonunion with avascular necrosis between 2010 and 2014. Majority of cases (10) presented as failure of adequate immobilization. The average time to surgery from trauma was 14 months and mean duration of follow up was 30 months. Twelve (12) cases had features of early radioscaphoid arthritis. Nonunion and avascular necrosis were confirmed in all cases with radiographs and MRI scan. We followed the technique described by Zaidemberg et al for harvesting the vascualrised bone grafting from the distal radius. Results: Majority of the cases (80%) united by 20 weeks. There was significant improvement in the grip strength and pain postoperatively. Wrist flexion-extension and radial-ulnar deviation arcs improved but was not statistically significant. The Mayo Wrist Score showed 75 percent of patients had an excellent or good outcome. The scapholunate angle also improved from 62.5 deg to 46.5 deg postoperatively. Radiographic union was achieved in sixteen cases (80%) by 20 weeks. Three cases (15%) went for delayed union and achieved bony healing by thirty weeks. One case (5%) developed pintract infecton and progressed to radioscaphoid arthritis. Conclusions: Our study highlights the efficacy of 1,2 ICSRA vascualrised distal radius bone grafting in proximal pole scaphoid nonunions with avascualr necrosis in achieving good union rate with acceptable clinical and functional outcome in this difficult problem. This procedure can be done under regional block without the need for microsurgical set up and costly implants. Vascularised distal radius grafts with radial styloidectiomy is a promising solution for scaphoid proximal nonunions with avascular and early radioscaphoid arthritic changes.

Classifications in Brief: Watson and Ballet Classification of Scapholunate Advanced Collapse Wrist Arthritis.

Classifications in Brief: Watson and Ballet Classification of Scapholunate Advanced Collapse Wrist Arthritis.

Effect of Push-Up Position on Wrist Joint Pressures in the Intact Wrist and Following Scapholunate Interosseous Ligament Sectioning.

To determine the contact pressures between the scaphoid and lunate and the distal radius during 2 wrist push-up positions before and following scapholunate interosseous ligament (SLIL) sectioning. Eight fresh cadaveric wrists were tested in a neutral flexion-extension (knuckle) push-up position and in an extended push-up position. Pressure measurements were acquired as each wrist was loaded with the wrist in extension and with the wrist in a neutral position. Data were acquired with the SLIL intact and following sectioning of its dorsal, volar, and proximal components. The wrist was disarticulated and a map drawn on each sensor to identify each joint fossa. A push-up performed with the wrist in extension caused a significantly greater peak pressure in the radioscaphoid fossa but not in the radiolunate fossa. Moving the wrist into extension caused a significant dorsal movement of the pressure centroid an average of 2.9 mm in the radiolunate fossa and an average of 5.7 mm in the radioscaphoid fossa. Sectioning the SLIL caused the centroid of pressure in the radioscaphoid fossa to significantly move an average 1.4 mm radially. A push-up with the wrist in extension causes a significant increase in the pressure in the radioscaphoid fossa but not in the radiolunate. This finding may help explain why degenerative arthritis first develops in the radioscaphoid fossa before involving the radiolunate fossa. As expected, gapping that occurs with SLIL injury was observed here as a radial translation of the scaphoid and not as a movement of the lunate. The new location of scaphoid contact may be an additional reason for the development of radioscaphoid arthritis occurring before radiolunate arthritis. This study provides a possible explanation as to why degenerative arthritis may first occur in the radioscaphoid fossa.

Scaphocapitate Fusion in Advanced Kienböck’s Disease

Objective: The treatment goal in Kienböck’s disease is to preserve the integrity and allow revascularization of the lunate and preserve wrist motion while relieving patients’ symptoms. In stage 3 Kienböck’s disease, the lunate is often unsalvageable due to comminution and subsequent collapse. Scaphocapitate (SC) fusion aims at decompressing the lunate while restoring carpal height and maintaining wrist motion. Materials and Methods: We retrospectively reviewed patients with a minimal 1-year follow-up who underwent SC fusion in stage 3A and 3B Kienböck’s disease. Eleven patients were reviewed clinically and radiologically. Pain, Disabilities of Arm, Shoulder and Hand (DASH) and Patient-Rated Wrist Evaluation (PRWE) scores, satisfaction, wrist range of motion, and grip strength were assessed independently. Preoperative and last follow-up standard films were compared for Lichtman stage, radiocarpal or midcarpal osteoarthritis, scapholunate and radioscaphoid angles, the Stahl index, carpal height, ulnar carpal deviation, and ulnar variance. Results: In all, 7 male and 4 female patients were reviewed. The average follow-up was 4.85 years (1-10.55 years). The average age at the time of surgery was 30.1 years (18.5-36 years). Six patients had a radial shortening at the same time and 2 others had 2 and 23 years prior to SC fusion. The lunate was not explored and always left in place. Preoperative pain was 8 (6-10) and was described as constant by all patients. Visual analogue scale (VAS) significantly decreased after surgery to 1.09 (0-2; P < .0001). Wrist range of motion was mildly but not significantly ( P = .45) improved at follow-up. Preoperative wrist flexion was 35.5° (20°-50°) and wrist extension was 35° (20°-70°). Postoperative wrist flexion was 42.7° (10°-95°) and wrist extension was 41.4° (30°-70°). Wrist range of motion was significantly decreased in comparison with the unaffected wrist. Pronosupination was comparable with the unaffected ( P = .01) side. Grip strength was significantly decreased ( P = .027) with 25.8 kg in comparison with the unaffected side with 34.5 kg. Nine lunates were stage 3B, and 2 were stage 3A. Radiographically, all SC fusions united. Ulnar variance was −1 mm on average. Three stage 3B patients improved to stage 3A on follow-up films. Four patients with more than 4-year follow-up had radiographic dorsal radioscaphoid and radial styloid osteophyte suggesting impingement but was not clinically symptomatic. The carpal height decrease from 1.47 to 1.2 was not statistically significant ( P = .09). Ulnar carpal deviation and Stahl index were unchanged. The radioscaphoid and scapholunate angles were restored to a normal range. Functional outcome was good: Average DASH was 30.45 and PRWE was 23.8. Nine patients thought their wrist was very good or good, and 2 thought that it was fair. Nine out of 11 patients were employed and remained so at follow-up. Two patients changed jobs to less demanding positions. Conclusion: SC fusion is a treatment option for advanced Kienböck’s disease. Pain relief is significant. Wrist range of motion remains similar to the preoperative range. Carpal collapse does not progress and keeping the lunate avoids ulnar translation. However, radiological progression of radioscaphoid arthritis may occur.

Rib cartilage grafting in upper limb surgery: an overview.

Introduction: Used routinely in maxillofacial reconstructive surgery, the chondrocostal graft is also used in hand surgery. The purpose of this overview was to analyze at long follow-up the radiological and histological evolution of this autograft, in the hand and wrist surgery. Materials and methods: Since 1992, 144 patients have benefitted from a chondrocostal autograft: 116 osteoarthritis of the thumb carpometacarpal joint, 18 radioscaphoid arthritis, six articular malunions of the distal radius, four kienbock, and four traumatic loss of cartilage of the PIP joint. Magnetic Resonance Imaging (MRI) was performed in 19 patients and histological study in 12 patients with a mean follow-up of 68 months (4–159). Results: Whatever the indication, the reconstruction by a chondrocostal or ostochondrocostal graft has allowed us to obtain satisfactory clinical results at long follow-up. The main question was the viability of the graft. The radiological study has shown the non-wear of the graft and a certain degree of ossification. The MRI confirmed a very small degree of osseous metaplasia but its viability. The biopsies showed a neo-vascularization of the cartilage. Conclusion: Despite the strong mechanical strain in the hand and wrist, the chondrocostal graft is a biological arthroplasty, trustworthy and secure at long time even if it can cause infrequent complications inherent to this type of surgery. Despite the inevitable histological modification, the cartilage remains alive and is of satisfactory quality at long term follow-up and fulfilling the requirements for interposition and reconstruction of an articular surface.

Reduction and Association of the Scaphoid and Lunate Procedure: Short-Term Clinical and Radiographic Outcomes

To evaluate the success of reduction and association of the scaphoid and lunate with a fibrous union in an effort to evaluate the technique's validity and reproducibility. A retrospective review was performed on 7 patients (8 wrists) with an average follow-up of 38 months. Static and grip radiographs were examined in the preoperative, immediate postoperative, and final follow-up settings to evaluate scapholunate (SL) diastasis, SL angle, hardware position, and complications. At final follow-up, grip strength and wrist range of motion were recorded, and patients completed the Disabilities of the Arm, Shoulder, and Hand and the Patient-Rated Wrist Evaluation outcome questionnaires. Radiographic success, defined by maintenance of corrected SL diastasis, absence of dorsal intercalated segmental instability, and no progression of SL advanced collapse was achieved in 3 of the 8 wrists. One wrist developed radioscaphoid arthritis. No patients required a salvage procedure. Despite the loss of reduction that occurred in all patients, the patients' disability remained minimal as detected by the scores on the outcome measures. The procedure was ineffective in providing stability about the SL interval. With a majority of patients experiencing early radiographic failure of the procedure in the short term, our experience suggests that the reduction and association of the scaphoid and lunate procedure should be abandoned despite the relatively low outcomes measures scores, which may be reflective of the short follow-up duration for this series. Therapeutic IV.

Scaphocapitate arthrodesis for treatment of late stage Kienböck disease

Symptomatic lunate collapse owing to Kienböck disease is difficult to treat. To define the potential role of scaphocapitate arthrodesis, we reviewed ten patients who underwent scaphocapitate arthrodesis for stage IIIB-IV Kienböck disease at a mean follow-up of 8.75 years (range 1.3-18.6). Clinical variables included ranges of motion, grip strength, pain, return to work, and QuickDASH (disabilities of the arm, shoulder and hand) scores. Radiographs were evaluated for union, carpal height, alignment, ulnar translation, and radiocarpal arthritis. The procedure resulted in functional ranges of motion and good grip strengths. Pain was substantially reduced. The mean QuickDASH score was 27 (range 9.1-56.3). Radiographic analysis showed union in nine patients, maintenance of carpal height with a corrected radioscaphoid angle, and no evidence of ulnar translation. The long-term clinical benefits of scaphocapitate arthrodesis for treatment of collapsed Kienböck disease are demonstrated. However, radiographic signs of radioscaphoid arthritis were often observed in patients with follow-up greater than 10 years.

Joint Space Height Correlates with Arthroscopic Grading of Wrist Arthritis

Osteoarthritis of the radiocarpal joints is commonly encountered by hand surgeons. To date, there is no well-defined method of radiographically grading osteoarthritis of the wrist. Preoperative radiographs of 48 patients undergoing wrist arthroscopy were evaluated retrospectively. Images were graded subjectively by five surgeons based on overall severity of arthritis, osteophytes, subchondral cysts, and subchondral sclerosis. The joint space height (JSH) ratio was calculated by measuring the space of the mid-radioscaphoid and mid-radiolunate joints and dividing each by the height of the capitate. Arthroscopic grading of arthritis was obtained from operative records and compared to subjective and objective grades. ANOVA testing evaluated for statistical significance with p < 0.05. Inter-rater and intra-rater reliability was determined using Pearson's correlation analysis and Cohen's kappa coefficient. Objective measurement using the JSH ratio demonstrated a significant decrease as arthroscopic arthritis grade increased for both radioscaphoid and radiolunate joints. Subjective grading of radioscaphoid and radiolunate joints was able to detect moderate/severe, but not mild arthritis. Subjective grading underestimated the degree of arthritis, particularly in the radiolunate joint. Inter-rater reliability was better for objective compared to subjective grading. Subjective grading of wrist arthritis can detect moderate/severe radiocarpal arthritis but poorly evaluates early arthritis and underestimates severity. Objective grading using the JSH ratio accurately grades radioscaphoid arthritis and detects early radiolunate arthritis. The JSH ratio more accurately assesses radiocarpal arthritis compared with subjective grading. As there currently is no accepted method to radiographically grade wrist arthritis, the JSH ratio represents a promising option.

Scaphotrapeziotrapezoid Arthrodesis and Lunate Excision for Advanced Kienböck Disease

To analyze the outcomes of lunate excision combined with scaphotrapeziotrapezoid arthrodesis for the treatment of advanced Kienböck disease. Sixteen patients with Lichtman stage IIIB Kienböck disease were treated with scaphotrapeziotrapezoid arthrodesis and lunate excision and were followed for a mean of 67 months (range, 49 to 108 mo). The indications for lunate excision included pain and limited motion associated with a collapsed lunate. Clinical evaluation included range of motion, grip strength, and modified Mayo wrist score. Based on plain radiographs, the carpal height ratio, ulnar carpal distance ratio, scaphoid translation ratio, and radioscaphoid angle were measured and any presence of degenerative changes was assessed. To investigate the effects of lunate excision on the radiologic results, we compared 12 patients with stage IIIB Kienböck disease who had only scaphotrapeziotrapezoid arthrodesis as the control group. Range of motion tended to be preserved, with a trend toward an increase in extension after surgery. Grip strength and modified Mayo score improved significantly. Fourteen patients with lunate excision demonstrated radiographic ulnar translation of the scaphoid beyond the scapholunate ridge, and radioscaphoid arthritis was observed in 4 patients. Compared to initial postoperative radiographs, the scaphoid translation ratio was significantly decreased, but neither ulnar carpal distance ratio nor radioscaphoid angle showed significant differences. In the control group, neither ulnar translation of the scaphoid nor significant changes of radiologic parameters was found between initial postoperative and final radiographs. Scaphotrapeziotrapezoid arthrodesis with lunate excision for advanced Kienböck disease provided favorable clinical results in terms of pain relief and functional improvement. With the absence of the lunate, however, the scaphoid had a tendency to shift toward the lunate fossa. This study suggests the risk of early development of radioscaphoid arthritis as a negative effect of lunate excision.

Scaphocapitolunate Arthrodesis and Radial Styloidectomy for Posttraumatic Degenerative Wrist Disease

Long-standing scaphoid nonunion, scaphoid malunion, and chronic scapholunate dissociation result in malalignment of the carpal bones, progressive carpal collapse, instability, and osteoarthritis of the wrist. The most commonly used procedures to treat scaphoid nonunion advanced collapse (SNAC) and scapholunate advanced collapse (SLAC) wrists are the four-corner fusion (4CF) and the proximal row carpectomy (PRC). The purpose of this study was to evaluate the clinical outcome of a different treatment modality: radial styloidectomy and scaphocapitolunate (SCL) arthrodesis. This treatment option is chosen in an effort to maintain the joint contact surface and load transmission across the radiocarpal joint. We conducted a retrospective review of 20 patients (average age 62 years, range: 27 to 75 years) treated from 1994 to 2010. Seven patients were treated for SNAC, 12 patients for SLAC wrists, and 1 for degenerative joint disease following a transscapho-transcapitate perilunar dislocation. Sixteen patients had Herbert screw fixation, and four had Spider plate fixation. All patients had autologous bone graft used for the arthrodesis. The mean follow-up was 4.6 years (range: 2 to 9.6 years). Patients were evaluated clinically and radiographically. Nineteen of 20 arthrodeses healed on an average of 9.6 weeks. One patient was reoperated 8 months after the initial operation with salvage of the SCL arthrodesis with a spider plate with an adequate result. The mean active flexion-extension arc was 70 degrees and the radioulnar deviation arc was 23 degrees. Pain decreased in all patients, 13 of whom were pain free postoperatively. The average postoperative disabilities of arm, shoulder, and hand score was 24. Radiographically, neither radiolunate nor radioscaphoid arthritis was noted on follow-up. SCL arthrodesis with radial styloidectomy resulted in an adequate residual range of motion and pain relief. This method preserves the normal ulnar sided joints of the carpus and maintains a more physiologic joint surface for radiocarpal load sharing.

A modified matti-russe technique for the treatment of scaphoid waist non-union and pseudarthrosis

SummaryBackgroundThe aim of this study was to analyze the long-term results of a modified Matti-Russe technique for the treatment of scaphoid non-union and pseudarthrosis. The modification was based on the use of bone graft taken from the ipsilateral distal radius, rather than from the iliac crest, as originally described.Material/MethodsBetween 1987 and 2000, 23 consequent male patients with scaphoid waist non-union or pseudarthrosis underwent surgery by a modified Matti-Russe technique. During the 5-year follow-up, patient evaluation was based on radiological findings and the Green & O’Brien scoring system.ResultsAnatomy was restored and healing of the non-union was achieved in 21 (91.3%) patients. The other 2 patients failed to achieve union and underwent the same operation a second time, which was successful. According to the Green & O’Brien scoring system, 82.6% (19/23) of patients showed excellent results and 17.4% (4/23) showed good results at 2-year follow-up. At 5-year follow-up, 73.9% of patients (19/23) had excellent results and 26.0% (4/23) had good results. No early postoperative complications developed. Two patients demonstrated mild radiological radio-scaphoid arthritis at 2.5 years postoperatively. All patients returned to previous levels of activity.ConclusionsThe standard Matti-Russe technique is an old but reliable and inexpensive method for the treatment of long-standing or neglected scaphoid non-unions or pseudarthroses. The modification of this established method, based on use of the distal radius as a donor site, reduces operative time, can be performed through a single approach, does not show donor site morbidity, and allows the use of regional anaesthesia.

CLOSED RADIAL WEDGE OSTEOTOMY FOR PREISER'S DISEASE: A REPORT OF FOUR CASES

To investigate the clinical outcome of closed radial wedge osteotomy (CRWO) for Preiser's disease. CRWO was performed for four patients with Preiser's disease between 2000 and 2005. All patients were diagnosed by X-ray and magnetic resonance imaging (MRI) scans. Separation gaps in the radioscaphoid joint were observed to evaluate the decompression in the area. Clinical evaluation was performed using Cooney's scoring system. Although wrist pain persisted in patients with radioscaphoid arthritis change, marked mitigation of wrist pain was confirmed in three patients. The average clinical score was 66, with good in one, fair in two, and poor in one. Restriction of wrist movement by CRWO caused lower clinical scores. No patients had wrist arthrodesis at the last follow-up evaluation. Short-term observation showed disappointing clinical results; however, for relief of wrist pain, this method is a potential surgical procedure for Preiser's disease under limited conditions.

Scapholunate Dissociation With Radiolunate Arthritis Without Radioscaphoid Arthritis

Watson and Ballet introduced the concept of a direct association between scapholunate (SL) dissociation and radioscaphoid (RS) arthritis with preservation of the radiolunate (RL) articulation in 1984. This principle has served as the anatomic, biomechanical, and pathophysiological basis for reconstructive surgery in the carpus. Recently, we have noted cases of concurrent SL dissociation and RL arthritis without RS arthritis, which is contrary to the accepted concept of wrist arthritis due to SL advanced collapse. The purpose of this study was to determine whether Watson and Ballet's thesis that SL dissociation results in RS joint degeneration with sparing of the RL joint can be confirmed, or whether another joint degeneration pattern can be associated with SL dissociation. The 3 authors independently reviewed 897 radiographs of the wrist in 691 male patients (206 bilateral and 485 unilateral) with diagnosis codes of wrist osteoarthritis (715.13), wrist instability (718.83), and wrist sprain (842.00). Posterior-anterior, oblique, and lateral views were available for all wrists. Elements assessed were RS joint, RL joint, SL joint, midcarpal joint, ulnar variance, ulnolunate joint, SL angle, and lunocapitate angle. There were 146 wrists with radiographic SL dissociation. Nine wrists in 6 patients had radiographic SL dissociation and RL arthritis but no RS arthritis. An additional 6 wrists in 6 patients had radiographic RL arthritis but no SL dissociation or RS arthritis; however, 5 of these did have an SL angle of 60 degrees or greater. Our results show that RL arthritis can occur in association with SL dissociation, and that the generally held view that the RL articulation is spared in SL advance collapse is not universally true. Consequently, it is our recommendation that both the RL and RS joints should be carefully evaluated for degenerative changes when planning treatment for patients with SL dissociation, because it should not be assumed that the RL joint has been spared.

High Fusion Rates with Circular Plate Fixation for Four-corner Arthrodesis of the Wrist

Scaphoid excision and four-corner fusion is commonly performed to reconstruct advanced scapholunate collapse and scaphoid nonunion with collapse. Metallic plates were introduced for achieving fixation of the four carpal bones. Although the developer reported high rates of fusion, several other early reports of circular plate fixation suggest higher complication rates and inferior outcomes compared with traditional fixation techniques. To clarify the controversy in the literature we determined the fusion rates, complications, and functional outcomes of patients having circular plate fixation for four-corner fusion. We retrospectively reviewed 15 patients treated for radioscaphoid arthritis with four-corner fusion using circular plate fixation. The minimum followup was 11 months (mean, 22 months; range, 11-39 months). Radiographic union was achieved by all 15 patients. There was only one postoperative complication. ROM was 71% and grip strength was 78% of the opposite normal side. Our results compare favorably with those using traditional fixation techniques. ROM measurements seem superior to those reported in the literature. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Outcome After Vascularized Bone Grafting of Scaphoid Nonunions With Avascular Necrosis

Vascularized bone grafting has been proposed as a treatment for scaphoid nonunions with avascular necrosis of the proximal pole. The purpose of this investigation is to report the results of vascularized bone graft and internal fixation for established scaphoid nonunions with proximal pole avascular necrosis as measured by validated outcome instruments. From 1996 to 2004, 30 consecutive patients with established scaphoid nonunion, proximal pole avascular necrosis, and no prior surgery were treated with open reduction and internal fixation in addition to a vascularized bone graft based on 1,2 intercompartmental supraretinacular artery. A total of 19 patients had nonunions of the scaphoid waist and 11 had nonunions of the proximal pole of the scaphoid. Preoperative and postoperative evaluation included measurement of clinical (grip strength and range of motion), radiographic (scapholunate angle, scaphoid height-to-length ratio, and radioscaphoid arthritis), function (Disabilities of the Arm, Shoulder, and Hand questionnaire) and satisfaction parameters. We recorded union and return to activity and analyzed data both in the aggregate and stratified by nonunion location. Union rate was 28 of 30 (93%) and time to union was 5.1 months (+/-2.4). Significant improvements were found for grip strength, Disabilities of the Arm, Shoulder, and Hand score, satisfaction score, and scaphoid height-to-length ratio (p < .01). No significant difference was found for composite wrist range of motion. Two patients experienced complications and required a second procedure to achieve union. A total of 28 of 30 (93%) of patients returned to work or sports activity at their preinjury level. The results of this investigation support the use of a vascularized bone graft for the treatment of scaphoid nonunions with avascular necrosis of the proximal pole.

Results of Four-Corner Arthrodesis Using Dorsal Circular Plate Fixation

Four-corner arthrodesis with scaphoid excision has been used to reduce pain and preserve functional range of motion for patients with radioscaphoid arthritis. Early results of 4-corner arthrodesis with scaphoid excision using dorsal circular plate fixation are compared with reported results in the literature. We reviewed retrospectively the first 18 four-corner arthrodeses performed with this system by 4 hand surgeons. Two patients had revision surgery for nonunions before the study that were considered failures. Eight patients returned for final radiographs, objective examination, and functional questionnaire. The average follow-up period was 20 months (range, 13-33 mo). These results were compared with reported results in the literature using alternate fixation methods. Radiographic union was achieved in only 3 wrists. Range of motion was 46% that of the opposite normal wrist and grip strength compared with the opposite wrist was 56%. Five patients would have the procedure again and 6 of 8 have returned to their original employment. Four-corner arthrodesis with scaphoid excision using a circular internal fixation plate produced a high number of nonunions. Grip strength and range of motion results also were inferior to those reported in the literature.

Management of the scaphoid during four-corner fusion—a cadaveric study

Purpose To examine the effects of scaphoid retention, inclusion, and excision on wrist motion and radiolunate contact characteristics in a cadaveric model after simulated 4-corner fusion with rigid internal fixation. Methods Seven fresh-frozen cadaveric upper extremities were examined. For all surgical manipulations the motion was measured and contact characteristics were assessed using ultra-low prescale pressure-sensitive film. Results Compared with the intact specimen, simple 4-corner fusion with scaphoid retention led to a significant decrease in extension, radial deviation, and ulnar deviation, but no change in radiolunate contact characteristics. After 4-corner fusion there was no significant difference in motion or radiolunate contact characteristics between scaphoid retention and scaphoid inclusion. After 4-corner fusion scaphoid excision allowed significantly greater radial deviation compared with scaphoid retention and scaphoid inclusion. Compared with the intact specimen 4-corner fusion with scaphoid excision also led to a significant increase in radiolunate contact area and mean contact pressure. Conclusions When performing 4-corner arthrodesis in the absence of radioscaphoid arthritis, scaphoid excision may improve motion at the cost of increased mean radiolunate contact pressure.