Scapholunate Research Articles

Open Surgical Excision of Dorsal Wrist Ganglia: Puncturing the Dome Reduces Surgery Time.

The following study is retrospective and compared the operative time and complications using two techniques of surgical resection of primary dorsal wrist ganglia in adults. Surgery was performed by the senior author (M.M.A.) through a transverse skin incision. The dome of the ganglion is dissected in both techniques. In the first technique (group A patients, n = 20 patients), dissection is continued to the base of the ganglion to reach the stalk near the scapho-lunate ligament. The stalk is transected and cauterized near the ligament. This surgical technique has been practiced by the senior author for 25 years. Over the last 5 years, the author has modified the technique (group B patients, n = 20 patients) by puncturing the dome of the ganglion following dome dissection. About two-thirds of the content of the ganglion is removed, and a mosquito is then used to close the puncture site. Dissection of the base of the ganglion to the stalk becomes easier and quicker, and the stalk is transected and cauterized near the scapho-lunate ligament. There was one recurrence in each group. Other complications were not seen in either group. The mean operative time (SD) was 30.75 (SD = 2.98) minutes for group A; and 20.75 (SD = 2.25) minutes for group B. An independent-samples t test was used to compare the operative time of both groups, which showed the difference was statistically significant (P < 0.001). Our study showed that intentionally puncturing the dome of the ganglion makes the dissection of the base quicker, without increasing the risk of complications.

Surgical repair of posttraumatic injuries of the scapholunate ligament: A literature study.

Scapholunate interosseous ligament rupture can cause wrist issues like pain, strength loss, and cartilage degeneration. While various surgical treatments exist, it's unclear which method is optimal. This study aims to determine the superior treatment approach for scapholunate dissociation. In Pubmed, Embase, Scopus and Web of Science was searched for articles reporting results of surgical repair of scapholunate dissociation. Additional inclusion criteria were English- and Dutch-language articles published between January 2000 and December 2022 with at least 8 patients and at least 1 year of follow-up. Seventeen articles were included, 9 covered tenodesis repair, 2 focused on capsulodesis, 3 on direct scapholunate ligament repair using bone anchors, and 3 on a combination of tenodesis and capsulodesis. No difference could be found between the types of surgical techniques in wrist mobility and grip strength. The Disability of Arm, Shoulder, and Hand score, Visual Analogue Scale for pain and Mayo wrist scores showed no clinically relevant difference. With all methods, normal radiological values were obtained after surgery. The mean scapholunate angle was less than 60° and the scapholunate gap less than 3 mm. However, at longer follow-up an increase in this angle and gap was seen again. This review did not allow to conclude that one technique was better than another to treat scapholunate dissociation because of poor quality of the included studies. Pre- and postoperative values were not always reported, there were insufficient comparative studies, and randomized prospective studies were missing.

Adjunctive Dorsal Spanning Plate Fixation in the Stabilization of Perilunate Dislocations

To compare the biomechanical properties of adjunctive dorsal spanning plate (DSP) fixation with traditional K-wire fixation of perilunate dislocations in a cadaveric model. Fourteen fresh-frozen cadaveric wrists underwent simulated perilunate injury. The specimens were randomly allocated to either K-wire fixation versus K-wire and DSP fixation. Scapholunate (SL) ligament repair was performed in all specimens. The constructs were tested using a robot cyclically and to failure. Fluoroscopic images were obtained of the specimens prior to simulated injury, after fixation, after 10 and 100 loading cycles, and at construct failure. Differences in carpal alignment parameters (SL interval, SL angle, lunotriquetral interval, and capitolunate angle) and load to failure were recorded. There were no statistically significant differences between the two group's carpal alignment parameters after fixation. Specimens fixated with K-wires and DSP required significantly higher loads to achieve construct failure. The only significant difference between the two groups' carpal alignment parameters was SL interval change at failure. Compared with K-wire fixation alone, adjunctive DSP fixation resulted in significantly increased loads to failure and decreased change in SL interval at the time of failure. Adjunctive DSP may be a useful technique in the polytraumatized patient in whom providing back a weight-bearing extremity may be advantageous in the rehabilitation process.

Osteoarthritis of the wrist

The term osteoarthritis (OA) of the wrist can be used as an umbrella term for various, often independent areas of OA, as the wrist is made up of several joints. Radiocarpal OA often occurs after untreated ligament injuries, incorrectly healed bone fractures in the carpus or after radius fractures involving the joint. Atypical sequence of propagation is known for radiocarpal OA following scapholunate (SL) insufficiency or scaphoid pseudarthrosis. Other causes include inflammation, crystal deposits or bone necrosis. Ulnocarpal arthrosis occurs posttraumatically or primarily when there are differences in levels between the ulna and radius. When treating wrist arthrosis, after conservative measures have been exhausted asurgical procedure should be chosen that enables the best possible load-bearing and residual mobility, considering the surgical risks and individual requirements. During salvage operations, the defective cartilage areas are either fused directly or eliminated using appropriate diverting partial fusions and resection arthroplasty. An accurate analysis of the affected zones is crucial for selecting an appropriate intervention.

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.

Scapholunate Ligament Reconstruction With Internal Brace Augmentation Techniques for Chronic Scapholunate Dissociation: A Clinical Follow-up Study.

The scapholunate ligament is the most important stabilizer of the scapholunate articulation. The management of chronic irreversible injuries of this ligament in the absence of preexisting arthritis of the wrist joint remains controversial. Recently, surgeons introduced a novel surgical technique using an internal brace (IB). Several biomechanical studies on this technique have been conducted using cadavers; however, very few studies have discussed the results in detail in actual clinical practice. Therefore, herein, we investigated the radiological and functional results of patients who underwent IB augmentation as a treatment for chronic scapholunate dissociation. This retrospective study was conducted from April 2018 to May 2022. Twenty-two patients with chronic scapholunate dissociation were treated using the IB augmentation technique, of whom 17 were followed-up for at least 1 year. Radiological results, including scapholunate distance, scapholunate angle, and radioscaphoid angle, were collected. Furthermore, clinical parameters, such as the visual analog scale (preoperative and at final follow-up), the Disabilities of the Arm, Shoulder, and Hand scores (preoperatively and at 3, 6, and 12 months postoperatively), and Mayo wrist scores (preoperative and at final follow-up), were measured. The scapholunate distance increased significantly in the affected wrist compared to the unaffected wrist, which improved after reconstruction in all wrist positions ( P < 0.05). Compared to the unaffected wrist, the scapholunate angle increased significantly in all positions ( P < 0.05) except for extension ( P = 0.535) and improved after reconstruction in all wrist positions. The radioscaphoid angle significantly increased compared to the angle of the unaffected wrist in all positions ( P < 0.05) except for extension ( P = 0.602) and clenched fist ( P = 0.556). This angle improved after reconstruction in all wrist positions except for extension ( P = 0.900). The visual analog scale score (7-2, preoperatively and at final follow-up) and Mayo wrist score (53-82, preoperatively and at final follow-up) improved after surgery. The Disabilities of the Arm, Shoulder, and Hand scores also improved after surgery (68, 53, 30, 7, preoperatively and at 3, 6, and 12 months postoperatively). This study revealed that scapholunate ligament reconstruction using an autologous tendon and suture tape is a good reconstruction technique that can improve clinical symptoms and radiographic parameters with a shorter operation time and fewer complications than other reconstruction methods.

Ultrasound-Based Measurement of Dorsal Scaphoid Displacement During Watson Test in Scapholunate Ligament Lesion

Abstract Background Scapholunate ligament lesion (SLL) is the most common ligament lesion in the wrist. The diagnosis of scapholunate ligament injuries in clinical practice is not standardised and there are various clinical and radiological methods that have varying degrees of reliability. Aims The aim of our work was to find a method that was simple, easily reproducible and did not require expensive and time- consuming second-tier examinations. We therefore assessed the reliability of sonography during Watson test (WT) in detecting SLL. Methods 20 patients with MRI and intraoperatively confirmed SLL were assessed preoperatively between July 2020 and April 2023. Sonography was performed on the scaphoid dorsal subluxation (DS) in wrist neutral and during WT and compared with the healthy contralateral side. The DS was measured by two independent investigators and intra- and interobserver reliability were assessed. Results We found a statistically significant difference between DS of the scaphoid of the healthy (0.89 mm, SD 0.67 mm) compared to the pathological side (1.67 mm, SD 0.95 mm). Reliability was very good, and SEM was lower than 0.4 mm for all measurements. Conclusion Sonographic measurement during WT showed promising results with very good reliability; this method could be routinely adopted for the detection and diagnosis of SLL without the need for second-tier examinations.

No Evidence for the Superiority of 3 Tesla Magnetic Resonance Imaging Over 1.5 Tesla Magnetic Resonance Imaging for Diagnosing Wrist Ligamentous Lesions: A Systematic Review and Meta-analysis

PurposesOur aim was to determine the diagnostic accuracy of native MRI regarding different ligamentous lesions of the wrist and to analyze the influence of technical characteristics, such as field strength, application of fat saturation, 3D sequences, and wrist coils. MethodsThe systematic search was performed using MEDLINE, Embase, and CENTRAL databases. Studies that were published before the 12th of February 2024 were included. All studies comparing the diagnostic accuracy of native wrist MRI to that of wrist arthroscopy for suspected ligamentous lesions were included. Results were analyzed by anatomic localization and technical aspects of the MRI. To assess the quality of included studies, we used the revised QUADAS-2 tool. ResultsThe systematic search revealed 5,181 articles. Thirty-seven studies, reporting 3893 ligamentous lesions, were eligible for inclusion. The studies displayed heterogeneity in terms of technical conditions, such as field strength, the use of wrist coils, the application of 3D sequences and fat saturation. Research methods also varied. Overall sensitivity and specificity were 0.78 (0.66 – 0.86) and 0.81 (0.70 – 0.89) for 1.5T MRI, while sensitivity was 0.73 (0.68 – 0.78) and specificity was 0.90 (0.59 – 0.98) for 3T MRI. There was no significant difference between the two subgroups (p=0,3807 and p=0,4248). Sensitivity was 0.82 (0.75 – 0.87) for triangular fibrocartilage complex (TFCC) lesions, 0.63 (0.50 - 0.74) for scapholunate ligament (SL) tears, and 0.41 (0.25 – 0.60) for lunotriquetral ligament (LT) lesions. Specificity for TFCC lesions was 0.82 (0.73 – 0.89), for SL tears 0.86 (0.73 - 0.93), and for LT lesions 0.93 (0.81 – 0.98). ConclusionThe sensitivity and specificity of MRI is influenced by the anatomic location of the lesion and technical conditions. In terms of diagnostic accuracy, no significant difference was found between 1.5T and 3T MRI. Level of EvidenceIII. Systematic review of Level II. - III. studies.

Detection of scapholunate interosseous ligament injury using dynamic computed tomography-derived arthrokinematics: A prospective clinical trial

Scapholunate interosseous ligament injuries are a major cause of wrist instability and can be difficult to diagnose radiographically. To improve early diagnosis of scapholunate ligament injuries, we compared injury detection between bilateral routine clinical radiographs, static CT, and dynamic four-dimensional CT (4DCT) during wrist flexion-extension and radioulnar deviation. Participants with unilateral scapholunate ligament injuries were recruited to a prospective clinical trial investigating the diagnostic utility of 4DCT imaging for ligamentous wrist injury. Twenty-one participants underwent arthroscopic surgery to confirm scapholunate ligament injury. Arthrokinematics, defined as distributions of interosseous proximities across radioscaphoid and scapholunate articular surfaces at different positions within the motion cycle, were used as CT-derived biomarkers. Preoperative radiographs, static CT, and extrema of 4DCT were compared between uninjured and injured wrists using Wilcoxon signed rank or Kolmogorov-Smirnov tests. Median interosseous proximities at the scapholunate interval were significantly greater in the injured versus the uninjured wrists at static-neutral and maximum flexion, extension, radial deviation, and ulnar deviation. Mean cumulative distribution functions at the radioscaphoid joint were not significantly different between wrists but were significantly shifted at the scapholunate interval towards increased interosseous proximities in injured versus uninjured wrists in all positions. Median and cumulative distribution scapholunate proximities from static-neutral and 4DCT-derived extrema reflect injury status.

Artificial intelligence for automated detection and measurements of carpal instability signs on conventional radiographs

ObjectivesTo develop and validate an artificial intelligence (AI) system for measuring and detecting signs of carpal instability on conventional radiographs.Materials and methodsTwo case-control datasets of hand and wrist radiographs were retrospectively acquired at three hospitals (hospitals A, B, and C). Dataset 1 (2178 radiographs from 1993 patients, hospitals A and B, 2018–2019) was used for developing an AI system for measuring scapholunate (SL) joint distances, SL and capitolunate (CL) angles, and carpal arc interruptions. Dataset 2 (481 radiographs from 217 patients, hospital C, 2017–2021) was used for testing, and with a subsample (174 radiographs from 87 patients), an observer study was conducted to compare its performance to five clinicians. Evaluation metrics included mean absolute error (MAE), sensitivity, and specificity.ResultsDataset 2 included 258 SL distances, 189 SL angles, 191 CL angles, and 217 carpal arc labels obtained from 217 patients (mean age, 51 years ± 23 [standard deviation]; 133 women). The MAE in measuring SL distances, SL angles, and CL angles was respectively 0.65 mm (95%CI: 0.59, 0.72), 7.9 degrees (95%CI: 7.0, 8.9), and 5.9 degrees (95%CI: 5.2, 6.6). The sensitivity and specificity for detecting arc interruptions were 83% (95%CI: 74, 91) and 64% (95%CI: 56, 71). The measurements were largely comparable to those of the clinicians, while arc interruption detections were more accurate than those of most clinicians.ConclusionThis study demonstrates that a newly developed automated AI system accurately measures and detects signs of carpal instability on conventional radiographs.Clinical relevance statementThis system has the potential to improve detections of carpal arc interruptions and could be a promising tool for supporting clinicians in detecting carpal instability.

Periarticular Proprioception: Analyzing the Three-Dimensional Structure of Corpuscular Mechanosensors in the Dorsal Part of the Scapholunate Ligament

Introduction: Sensory nerve endings transmit mechanical stimuli into afferent neural signals and form the basis of proprioception, giving rise to the self-perception of dynamic stability of joints. We aimed to analyze the three-dimensional structure of periarticular corpuscular sensory nerve endings in a carpal ligament to enhance our understanding of their microstructure. Methods: Two dorsal parts of the scapholunate ligament were excised from two human cadaveric wrist specimens. Consecutive cryosections were stained with immunofluorescence markers protein S100B, neurotrophin receptor p75, protein gene product 9.5 (PGP 9.5), and 4′,6-diamidino-2-phenylindole. Three-dimensional images of sensory nerve endings were obtained using confocal laser scanning microscopy, and subsequent analysis was performed using Imaris software. Results: Ruffini endings were characterized by a PGP 9.5-positive central axon, with a median diameter of 4.63 μm and a median of 25 cells. The p75-positive capsule had a range in thickness of 0.94 μm and 15.5 μm, consisting of single to three layers of lamellar cells. Ruffini endings were significantly smaller in volume than Pacini corpuscles or Golgi-like endings. The latter contained a median of three intracorpuscular structures. Ruffini endings and Golgi-like endings presented a similar structural composition of their capsule and subscapular space. The central axon of Pacini corpuscles was surrounded by S100-positive cells forming the inner core which was significantly smaller than the outer core, which was immunoreactive for p75 and PGP 9.5. Conclusion: This study reports new data regarding the intricate outer and intracorpuscular three-dimensional morphology of periarticular sensory nerve endings, including the volume, number of cells, and structural composition. These results may form a basis to differ between normal and pathological morphological changes in periarticular sensory nerve endings in future studies.

Complex Axial Carpal Dislocation with Scapholunate Ligament Injury

Abstract Background Axial carpal dislocations (ACDs) are high-impact injuries, involving both proximal and distal carpal rows, adding complexity to the diagnostic and treatment challenges. This article explores a distinctive case of axial radial carpal dislocation, highlighting an irreducible second carpometacarpal joint (CMCJ) and concomitant scapholunate (SL) ligament injury. Understanding the background of axial carpal injuries is crucial for recognizing and addressing these complex cases effectively. Description A 27-year-old man presented with a left wrist injury following a motorcycle accident, revealing an irreducible second CMCJ with a unique ligamentous injury pattern. Despite unsuccessful closed reduction attempts, the surgical intervention involved a dorsal midline incision, fixation of the second CMCJ and SL interval, and ligament repair. Postoperative assessment demonstrated proper alignment with a mild gap in the SL interval, revealing the intricate nature of the injury. Literature Review Existing studies describe a type of axial dislocation starting at the third webspace, traveling through capitate–hamate intervals leading to scaphoid dislocation. However, in the article, we describe a variant of ACD through second CMCJ causing an SL interval instability. Clinical Relevance Recognizing and comprehensively addressing axial radial carpal dislocations are crucial for optimal patient outcomes. The case report contributes valuable insights into the rare pattern of ACD involving SL instability that was missed on initial radiographs but detected through computed tomography scan and thereby managed appropriately. Any CMCJ dislocation should raise a suspicion of axial dislocation unless proved otherwise.

Radiocarpal Osteochondral Allografts for Wrist Pain Postproximal Row Carpectomy

Abstract Background Surgical options for patients with recurrent wrist pain after salvage procedures, such as proximal row carpectomy (PRC), are limited and primarily result in total wrist arthrodesis (TWA). Osteochondral allografting (OCA) offers an additional option to address refractory wrist pain due to arthritis while preserving some range of motion. Case Description A 65-year-old, right hand dominant male developed chronic wrist pain, secondary to untreated scapholunate and triangular fibrocartilage complex ligament tears. The patient underwent a PRC, radial styloidectomy, and partial wrist denervation with good initial pain relief. Two years later, symptoms returned with radiographs demonstrating capitate sclerosis. A salvage arthroplasty with OCA produced relief of symptoms. Literature Review Refractory wrist pain after salvage procedures have traditionally been managed with TWA or less commonly, wrist arthroplasty. Capitate resurfacing and interposition have expanded indications for PRC. OCA is a chondral replacement procedure that utilizes cadaveric cartilage allograft plugs to replace damaged cartilage in various articular joint surfaces. Although OCA used in the lower extremity and shoulder has demonstrated improved pain relief and return of function, it has not been reported in the wrist. Clinical Relevance There are limited options for refractory wrist pain after salvage procedures. We present an additional alternative to TWA, by resurfacing the radiocarpal joint affected by chondromalacia after a PRC. This option offers another treatment modality for recurrent wrist pain while still preserving some element of range of motion.

HEIGHT-TO-LENGTH RATIOS OBTAINED BY WRIST RADIOGRAPHY TO ASSESS SCAPHOID MALUNION: RADIOGRAPHIC AND CLINICAL OUTCOMES OF 32 CASES

Purpose: Scaphoid nonunion and malunion can be observed after scaphoid fracture. While the diagnosis of nonunion is well defined in the literature, there is no consensus on the diagnostic criteria and clinical outcomes of scaphoid malunion. The aim of the study is to define the direct radiography parameters of scaphoid malunion and determine the clinical outcomes. Methods: Patients applied to our clinic with the diagnosis of scaphoid fracture between January 2020 and June 2021, and were analyzed retrospectively. 32 patients treated with surgical or conservative methods were included in the study. Nonunions and cases with a follow-up period of less than 12 months were excluded. Scapholunate (SL) angles and height-to-length (H/L) ratios of scaphoid were measured on wrist radiography to assess scaphoid malunion. Malunion was defined as SL angle &gt;60° and ROC analysis was applied to determine cutoff H/L ratio in wrist radiography. Wrist functionality and pain were evaluated with the Patient-Rated Wrist Evaluation (PRWE) and MAYO scores. The range of motion (ROM) and grip strength were also recorded. Results: Seventeen patients (53.1%) underwent surgery while conservative treatment was applied to the other 15 (46.9%). Of these, six patients (18.8%) met the definition of malunion. According to receiver operating curve (ROC) analysis, the cutoff H/L ratio in posteroanterior wrist radiographs was 0.602 ([Formula: see text] &lt; 0.001) and the cutoff H/L ratio in lateral wrist radiographs was 0.692 ([Formula: see text] = 0.003). The ROM values for flexion/extension and radial/ulnar deviation was smaller in the malunion group ([Formula: see text] = 0.023 and [Formula: see text] = 0.014, respectively). However, no significant difference was observed in pronation/supination values ([Formula: see text] &gt; 0.05). Mean MAYO score was 75.0 in malunion group and 90.0 in nonmalunion group ([Formula: see text] = 0.003). While the mean PRWE value was 24.50 in malunion, it was 14.15 in nonmalunion ([Formula: see text] = 0.023). Conclusion: Evaluation of H/L ratio in wrist radiography provides valuable information in the diagnosis of scaphoid malunion. Scaphoid malunions have poorer functional outcomes.

Retrospective analysis of scaphoid trapezium pyrocarbon implant intervention in STT arthritis: a 3-year follow-up study.

The purpose of this study was to evaluate clinical, patient rated and radiological outcome of the scaphoid trapezium pyrocarbon implant (STPI) at a minimum of three years follow-up. Consecutive patients operated with the STPI due to scaphotrapeziotrapezoidal (STT) arthritis between 2012 and 2019 were included. Patients were evaluated preoperatively and annually after surgery for range of motion, grip strength, key pinch, quick-DASH, pain, and satisfaction. Radiographs were evaluated for implant position, signs of dorsal intercalated segment instability (DISI), capitolunate (CL) angle, scapholunate (SL) distance, and presence of osteophytes. Twenty-six patients (29 implants) were included. Seven implants were revised during the follow up, mainly due to pain: three implants were removed, four patients received a new STPI of a different size, leaving 22 implants in 20 patients available for follow up, 9 males and 11 females. Median age was 61.7 years (51-78 years). Median follow-up time was 68 months (37-105 months). Comparing preoperative status to the last follow-up, wrist extension and deviation, thumb abduction, and grip strength did not change. Key Pinch, quick DASH, pain, and patient satisfaction improved significantly at last follow-up. Radiographic signs of DISI were seen in six cases preoperatively and in 12 cases at last follow-up. At a minimum of three years follow-up, the STPI used for STT-arthritis improve pain, quick-DASH result, and patient satisfaction significantly. ROM and grip strength did not change compared to preoperative values. Radiographic signs of carpal instability were common at the follow-up and the revision rate was high.

Perilunate Dislocations: Cadaveric Model K-Wire Versus Compression Staple Fixation

Repair of perilunate dislocations requires stabilization of the carpal bones, although there is limited research on the preferred method(s) of stabilization. We compared the biomechanical characteristics of K-wire versus staple fixation of scapholunate (SL) and lunotriquetral (LT) intervals in the wrist. After creating a grade IV instability model, 20 cadaver wrists were randomized into 2 stabilization model groups using K-wires or surgical staples across the SL and LT intervals. For each ligament, two K-wires or one surgical staple was used to stabilize the proximal carpal row. Each wrist was loaded with 15 N of force and cycled 5,000 times at an angular velocity of 10 rpm. Displacement between bones was measured at different cycles (10, 100, 500, 1,000, 2,000, 3,000, 4,000, and 5,000). A t test was used for comparisons. For the LT K-wire group, the average displacement at 10 cycles was 0.08 mm, and at 5,000 cycles, 0.163 mm. For the SL K-wire group, the average displacement at 10 cycles was 0.025 mm, and at 5,000 cycles, 0.129 mm. For the LT and SL staple fixation models, the average shifts at 10 cycles were 0.029 and 0.063 mm, and at 5,000 cycles, 0.098 and 0.176 mm, respectively. No significant difference between the fixation models was found at any interval. Notably, in each group, a similar number of small outliers with higher amounts of displacement was observed. Either K-wire or surgical staple stabilization is suitable for perilunate dislocations. The surgical method should be selected based on patient-specific circumstances and the provider's judgment. Therapeutic III.

NanoScope wrist arthroscopy under wide-awake local anesthesia with no tourniquet: A prospective series of 30 consecutive patients

IntroductionWrist arthroscopy is an evolving procedure. The purpose of this study was to report the outcome of diagnostic arthroscopy of the wrist using a new tool, the NanoScope, under wide-awake local anesthesia with no tourniquet (WALANT). Patients and methodsThis was a prospective study of 30 consecutive patients with suspected ligament tear after wrist trauma and remaining symptoms after initial conservative management. All patients had an MRI prior to the NanoScope procedure. ResultsThe patients comprised 17 men and 13 women, with a mean age of 31 years. One patient declined the NanoScope procedure following their MRI. In the remaining 29 patients, NanoScope wrist arthroscopy revealed 19 cases of triangular fibrocartilaginous complex (TFCC) tears and 11 tears of the scapholunate (SL) or lunotriquetral (LT) ligaments. The correlation between preoperative MRI and the findings from NanoScope arthroscopy was poor. Six patients had additional surgery after the NanoScope arthroscopy, comprising three TFCC sutures, one SL and one LT ligament reconstruction respectively, and one wrist arthrodesis. No complications related to the NanoScope arthroscopies were noted. ConclusionNanoScope arthroscopy of the wrist is safe, is well-suited for surgery in WALANT, and has superior diagnostic capacity compared to MRI. Further studies are warranted to determine the role of the NanoScope in the management of wrist ligament pathologies. Level of evidenceThis is a level 4 study.

Arthroscopic Volar Extrinsic Plicature of the Volar Extrinsic Ligaments for Chronic Volar Scapholunate Instability

The scapholunate ligamentous complex consists of the scapholunate interosseous ligament and the surrounding extrinsic ligamentous system. In cases of chronic scapholunate instability, stabilizing the extrinsic ligaments is crucial. This article presents an arthroscopic capsuloligamentous reinforcement plicature that focuses on tightening the volar scapholunate extrinsic ligaments, namely the radioscaphocapitate ligament and long radiolunate ligament, along with indirect tightening of the volar scapholunate interosseous ligament. Although it may be challenging to differentiate the effect of the volar extrinsic plicature from a dorsal capsular reinforcement when both are applied, the volar extrinsic plicature can serve as a beneficial addition to dorsal capsular reinforcement techniques for complex scapholunate instability.

Open Reduction and Transosseous Plasty of the Dorsal Scapholunate Ligament in a Patient with Mayfield type IV Chronic Lunate Dislocation, Case Report, Literature Review and Description of Surgical Technique

Introduction Perilunate dislocations represent 3% of carpal injuries. They begin in a radial direction, destabilizing the scapholunate interval, and as the injury continues, there is a progressive sequence of instability, altering the anatomy of the carpus, causing significant functional deterioration. The acute diagnosis goes unnoticed, evolving into its chronic form. There are few reports of treatment in its chronic phase with a limited number of patients and follow-up evaluation is often limited. Objective We present a case of late diagnosis of chronic lunate dislocation that was managed surgically and review of the existing literature for diagnosis and treatment, as well as the surgical technique for its resolution. Clinical case 66-year-old male, fall from the plane of support, hyperextension mechanism of the right wrist, 2 months of evolution causing pain, progressive increase in volume, functional limitation. Treated with non-steroidal anti-inflammatory drugs for four weeks without improvement. Radiographically, loss of lunate joint congruity - capitate. Magnetic resonance images of avascular necrosis of the lunate. Diagnosing chronic semilunar dislocation of the right hand. Preoperative Quick-Dash 70.4 pts. A double dorsal and volar approach is performed to release the carpal tunnel, place a transosseous cerclage, and three 1.6 mm Kirschner pins in the scapholunate interval; semilunopyramidal and scaphocapitate. Immobilization with antebrachipalmar splint, removal of Kirschner pins at 7 weeks and referral to physical rehabilitation. 20 postoperative weeks, range of motion with flexion of 35° and extension of 30°, without visible sequelae to mobilization, and with Quick-Dash 20.4. Conclusion Early diagnosis and treatment are necessary to prevent the potential risk of avascular necrosis of the lunate and scaphoid, and secondary osteoarthritis. Reconstruction of the chronic pathology of lunate dislocation and scapholunate ligament (SL) remains a major challenge. There are unresolved issues regarding when to perform reconstruction rather than repair and therefore treatment remains controversial.

Accuracy of Wrist MRI in Detecting Synovitis and Correlation with Arthroscopy

Abstract Hypothesis Wrist magnetic resonance imaging (MRI) has shown excellent diagnostic accuracy in evaluating soft-tissue pathology of the wrist including ganglion cysts, ligament tears, and triangular fibrocartilage complex (TFCC) pathology. However, it is unclear how often MRI detects synovitis that is subsequently encountered during wrist arthroscopy and may be a source of pain for patients with symptoms unresponsive to conservative treatment. The aim of this study is to assess the diagnostic accuracy of conventional MRI in the detection of wrist synovitis observed intraoperatively with wrist arthroscopy. Materials and Methods A retrospective chart review was performed on 51 patients who underwent arthroscopy for chronic wrist pain and MRI confirmed wrist pathology that did not resolve with nonoperative treatment. Wrist arthroscopy was performed by three fellowship-trained hand surgeons. While the primary pathology like TFCC or scapholunate ligament tear was identified and treated arthroscopically, it was noted that many of the patients had concomitant synovitis observed arthroscopically that was not identified preoperatively on MRI. Therefore, the diagnosis of wrist synovitis on MRI scan was compared with the observed presence of synovitis at the time of wrist arthroscopy. Results of preoperative MRI without contrast were categorized as true positive, false positive, true negative, and false negative, based upon intraoperative arthroscopic findings. Results In total, 45/51 patients were confirmed to have dorsal and ulnar synovitis on wrist arthroscopy. MRI identified 16/51 patients as having synovitis. Of those 16 patients, 2 were false positives. Conclusion The results demonstrate that conventional MRI without contrast has poor diagnostic accuracy in detecting wrist synovitis. Patients with ligament or chondral pathology or no clearly identifiable pathology on MRI whose clinical symptoms persist despite conservative treatment may have underlying dorsal and ulnar wrist synovitis that is not detected on MRI. Wrist arthroscopy facilitates the identification and treatment of synovitis in patients with concomitant wrist pathology and pain refractory to nonoperative treatment. This study suggests that MRI may have a low sensitivity for identifying wrist synovitis when compared with wrist arthroscopy during the evaluation of patients presenting with wrist pain.