The traditionally accepted etiology of Scapholunate Advanced Collapse (SLAC) requires traumatic rupture of the scapholunate (SL) ligament which leads to abnormal wrist kinematics and thereafter severe localised degenerative arthritis of the wrist. The purpose of this prospective blinded kinematic analysis was to demonstrate that SLAC wrist also exists in the absence of trauma, and that abnormal carpal bone kinematics (specifically, decreased lunate flexion) is the initiating factor. Patients with SLAC and no history of upper extremity trauma were compared with an age matched control group. All patients completed a questionnaire, personal interview, and a physical examination. A specialised flexion / extension radiographic jig was designed to control for the magnitude of force and position of the wrist in all planes. A total of thirty-five subjects (sixty-nine wrists) were retained for the study, including thirty-three non-traumatic SLAC wrists and thirty-six control wrists. The non-traumatic SLAC group had significantly different radiographic kinematic analysis compared to the control group: increased Watson Stage (2 v 0), SL gap (3.4 v 1.8mm), revised carpal height ratio (rCHR) (77 v 68), SL angle in flexion (forty-one v twenty-eight degrees), and decreased radiolunate (RL) joint flexion (nine v twenty-seven degrees). Most importantly flexion of the asymptomatic non-degenerative wrist of the non-traumatic SLAC group was distributed 70% through the lunocapitate (LC) joint and only 30% through the RL joint (p< 0.05). Conversely, flexion was more evenly distributed in the control group (48% LC and 52% RL). Non-traumatic or developmental SLAC does exist. SLAC can thus be classified into non-traumatic (developmental) and traumatic types. Non-traumatic SLAC begins with abnormal wrist kinematics. Over time restricted lunate flexion and normal scaphoid flexion leads to increased SL angles and eventual attrition of the SL ligament and predisposes patients to SLAC despite having no history of trauma

Purpose: To review a clinical series of patients who have had the SLAC (scapho-lunate advanced collapse) procedure. Method: 50 patients with degenerative disorders of the wrist managed by a single surgeon using a single technique. The technique involved excision of the scaphoid and radial styloidectomy. Midcarpal arthrodesis was performed, and was stabilised with staples. The patients were prospectively followed for two years. Results: The majority of patients were satisfied with their outcome and their pain had decreased. Pre-operative flexion/extension was 39 degrees/38 degrees and post-operatively was 32 degrees/35 degrees. The average grip strength did not change. Conclusion: The SLAC wrist procedure is a useful technique for patients who have localised degenerative arthritis of the wrist

Surgical results following proximal row carpectomy modified with proximal capitate resection and dorsal capsule interposition are presented. A consecutive cohort of thirteen patients was operated upon, and outcomes measured by radiograph, physical examination and DASH questionnaire. AROM values of 50° to 105° for the flexion/extension arc, restoration of grip strength to 72% of the contralateral extremity, and an improved functional outcome can be expected; and patients’ perceptions of functional outcome, as measured by the DASH, are significantly improved as early as six weeks. The results of PRC with interposition for stages II and III SLAC wrist were uniformly favorable. Eaton has described two modifications to the proximal row carpectomy (PRC) procedure: partial capitate resection and dorsal capsular interpositional arthroplasty. The objective is to enlarge the radiocarpal interface to form a broad mobile pseudoarthrosis that would disperse compressive forces across the wrist more effectively. We present the first consecutive cohort of patients (n=13) who have undergone this procedure,. We extend the indications for PRC in this series to include those wrists with stage III SLAC deformity; approximately 67% of wrists had capitolunate arthritis. AROM values of 50° to 105° for the flexion/extension arc, restoration of grip strength to 72% of the contralateral extremity, and an improved functional outcome can be expected from PRC with dorsal capsular interpositional arthroplasty. Patients’ perceptions of functional outcome, as measured by the DASH, are significantly improved as early as six weeks following the procedure. Mean flexion/extension arc achieved was 86° (range, 50° to 105°). Radial deviation averaged 13° (range, 10° to 20°), and ulnar deviation averaged 21° (range, 15° to 25°). Grip strength averaged 72% of the contralateral extremity. The mean decline in the revised carpal height ratio was 24%. The mean DASH score was 20.8 (range, 10 to 29). Visual analog pain improved from 9.25 to 2.67 on average, with one patient reporting no pain with heavy exertion. Patients were evaluated by active range of motion ; grip and pinch strength; radiographs; subjective analog pain; and DASH questionnaire

Proximal Row Carpectomy (PRO has been used as an alternative treatment for advanced radiocarpal arthrosis and carpal collapse. Its use has been recommended for Kienbock’s disease, chronic scaphoid nonunion and scapholunate advanced collapse (SLAC) deformity. Materials – Methods: Twenty-three patients were divided into two groups: group 1, consisting of patients with Kienbock’s disease (10 patients), and group 2, consisting of patients with scapholunate advanced collapse (13 patients). The average age was 51 years (range 27–69) for group 1, and 45 years (range 29–57) for group 2. The average follow-up was 30 months for Kienbock’s disease (range, 23–49 months) and 31 months for SLAC deformity of the wrist (range, 24–51 months). Pre-operative staging was performed on all patients utilizing Lichtmann’s (Lichtmann and Degnan, 1993) classification for Kienbock’s disease and Watson’s (Watson and Ballet, 1984) classification for scapholunate advanced collapse. The procedure was performed as described by Jorgansen (1969) utilizing a dorsal midline approach between the third and fourth dorsal compartments. Styloidectomy, preserving the radiocapitate ligament was performed in 7 out of the 23 patients (5 Kienbock’s and 2 SLAC wrist’s patients). Posterior Interosseous Nerve neurectomy was performed in 2 out of the 10 patients with Kienbock’s disease. Results: Statistically significant differences were noted between the Kienbock’s disease group and the SLAC wrist group (p=0.0023). Of the patients who underwent PRC for Kienbock’s disease 9 of 10 patients reported moderate to severe pain at the final follow-up visits. In the scapholunate advanced collapse group, 2 out of 13 patients demonstrated moderate or severe pain. It was noted that the patients in the SLAC wrist group lost less motion overall than those in the Kienbock’s dis ease group (p=0.00l 5). It was noted in the Kienbock’s disease group that at final follow-up the operated hand was weaker than preoperative (p=0.022). In the scapholunate advanced collapse group there was improvement of postoperative grip strength. Conclusion: We currently recommend the use of wrist arthroscopy as an adjunct to determine the status of the lunate articular surface in Kienbock’s disease, before performing a proximal row carpectomy. Our results indicate that despite only minor chondromalacia of the capitate articular surface and lunate facet of the radius, the use of PRC in Kienbock’s has not been rewarding

The February 2015 Wrist & Hand Roundup360 looks at: Toes, feet, hands and transfers… FCR Tendonitis after Trapeziectomy and suspension, Motion sparing surgery for SLAC/SNAC wrists under the spotlight, Instability following distal radius fractures, Bilateral wrist arthrodesis a good idea?, Sodium Hyaluronate improves hand recovery following flexor tendon repair, Ultrasound treatments for de Quervain’s, Strategies for treating metacarpal neck fractures

The natural history of scapholunate ligament injury is unknown. In fact, as far as we can tell, there has been no study examining the long-term natural history of this condition. It has, however, been assumed that the long-term progression of this injury leads to secondary osteoarthritis – scapholunate advanced collapse (the so-called SLAC wrist). In this study, we evaluated the clinical condition of 11 patients with proven scapholunate ligament injuries that had declined further treatment in an attempt to quantify any long-term disability. Whilst there was on-going pain and functional limitation in the injured wrist, there was no rapid progression of the osteoarthritis or SLAC wrist deformity

Although articular chondrocalcinosis is a frequently seen disorder, the broad clinical variations of forms affecting the wrist are more recently and more rarely described. Chondrocalcinosis of the wrist is an evolutionary disorder, which can initially be well treated medically. Further in the natural evolution, scaphoradial joint destruction occurs followed by midcarpal wear. Until now one form of chondrocalcinosis, developing scapholunate dissociation and tending towards a SLAC (Scapho-Lunate Advanced Collapse) wrist, has been well documented. We state that there exists a pathway which does not lead to any scapholunate gap and is less often associated with a ST (Scapho-Trapezium) osteoarthritis. This isolated form of chondrocalcinosis of the wrist has been mistaken for SLAC or SNAC (Scaphoid Non-union Advanced Collapse) wrists, because its clinical and radiological resemblance. We propose to call this form the SCAC (Scaphoid Chondrocalcinosis Advanced Collapse) wrist. It is seen in elderly patients. There is a long evolution for several years, and most patients have an extensive medical history before the correct diagnosis is being made. We describe the typical clinical and radiological evolution on five patients. According to the amount and pattern of cartilage destruction we propose a radiological classification in four grades. The five cases presented were all seen in grade III. Two of them underwent previous surgery; a styloidectomy in one and a scaphoid replacement by a titanium prosthesis in the other. Three patients had previous carpal tunnel release. All five have been treated by a hamatoluno-capitate arthrodesis, with resection of the scaphoid and triquetrum (according to Delattre’s technique). Results are described and discussed

Longstanding un-united scaphoid fractures or scapholunate insufficiency can progress to degenerative wrist osteoarthritis (termed scaphoid non-union advanced collapse (SNAC) or scapho-lunate advanced collapse (SLAC) respectively). Scaphoid excision and partial wrist fusion is a well-established procedure for the surgical treatment of this condition. In this study we present a novel technique and mid-term results, where fusion is reserved for the luno-capitate and triquetro-hamate joints, commonly referred to as bicolumnar fusion. The purpose of this study was to report functional and radiological outcomes in a series of patients who underwent this surgical technique. This was a prospective study of 23 consecutive patients (25 wrists) who underwent a bicolumnar carpal fusion from January 2014 to January 2017 due to a stage 2 or 3 SNAC/SLAC wrist, with a minimum follow-up of one year. In all cases two retrograde cannulated headless compression screws were used for inter-carpal fixation. The clinical assessment consisted of range of motion, grip and pinch strength that were compared with the unaffected contralateral side where possible. Patient-reported outcome measures, including the DASH and PRWE scores were analysed. The radiographic assessment parameters consisted of fusion state and the appearance of the radio-lunate joint space. We also examined the relationship between the capito-lunate fusion angle and wrist range of motion, comparing wrists fused with a capito-lunate angle greater than 20° of extension with wrists fused in a neutral position. The average follow-up was 2.9 years. The mean wrist extension was 41°, flexion 36° and radial-ulnar deviation arc was 43° (70%, 52% and 63% of contralateral side respectively). Grip strength was 40 kg and pinch strength was 8.9 kg, both 93% of contralateral side. Residual pain for activities of daily living was 1.4 (VAS). The mean DASH and PRWE scores were 19±16 and 29±18 respectively. There were three cases of non-union (fusion rate of 88%). Two wrists were converted to total wrist arthroplasty and one partial fusion was revised and healed successfully. Patients with an extended capito-lunate fusion angle trended toward more wrist extension but this did not reach statistical significance (P= 0.07). Wrist flexion did not differ between groups. Radio-lunate joint space narrowing progressed in 2 patients but did not affect their functional outcome. After bicolumnar carpal fusion using retrograde headless screws, patients in this series maintained a functional flexion-extension arc of motion, with grip-pinch strength that was close to normal. These functional outcomes and fusion rates were comparable with standard 4-corner fusion technique. A capito-lunate fusion angle greater than 20° may provide more wrist extension but further investigation is required to establish this effect. This technique has the advantage that compression screws are placed in a retrograde fashion, which does not violate the proximal articular surface of the lunate, preserving the residual load-bearing articulation. Moreover, the hardware is completely contained, with no revision surgery for hardware removal required in this series

Complex carpal injuries can be difficult to assess and manage. They usually occur following high energy injuries to the wrist. Imaging in the form of traction views and a CT scan can help understand the detail of the fracture dislocation pattern. Perilunate dislocations and perilunate fracture dislocations are commonly managed with a dorsal approach to provide an anatomic reduction. A volar approach can be used is median nerve entrapment and allows a surgical repair of the volar aspect of the lunotriquetral ligament. Perilunate dislocations are often classified into greater and lesser arc injuries. The greater arc injuries include fractures which go through the radial styloid, scaphoid, capitate or triquetrum. Lesser arc injuries are through the scapholunate ligament and lunotriquetral ligament. It is common for there to be a combination of greater and lesser arc injuries. We have also identified a complex injury which is a lunate intra-arc injury. This is a fracture through the lunate. With this translunate perilunate dislocation it is important to stabilise the lunate prior to stabilising the remainder of the carpus. The authors have reviewed a series of complex injuries and developed a classification system based on the above findings. In complex cases where reconstruction is difficult then salvage procedures can be performed. SLAC wrist procedure, proximal row carpectomy and full wrist fusion can be performed particularly in highly comminuted cases or cases with a delayed presentation

Introduction. Isolated midcarpal motion during radioulnar deviation could be approximated to be a rotation in a plane of a radiodorsal/ulnopalmar rotation of the wrist, which may coincide with a motion plane of one of the most essential human wrist motions, known as the dart-throwing motion. This has been studied before in normal volunteers using Magnetic Resonance Imaging to study in vivo kinematics of the midcarpal joint in the wrists of normal volunteers. We present the early results of use of biaxial flexible electrogoniometer to study the range of motion in patients with four-corner fusion. Methods. Ten patients with four-corner fusion for SLAC/SNAC wrist were assessed to study flexion-extension, radial-ulnar deviation, and circumduction motions using flexible electrogoniometers. Opposite unaffected wrist was studied to provide normal data. Angle-angle curves (Lissajous's figures) were generated to study the area under the curve and comparison with the normal wrists and also to study the deviation from the neutral axis. Five normal volunteers were also studied to calculate the area under the curve and the axis of deviation during circumduction of the wrist. Results. The coupling action of mid-carpal motion was revealed as obliquity of the axis of motion with extension combined with radial deviation in normal wrists. This was lost in patients with four-corner fusion as revealed with decrease of obliquity in Lissajous's figures from 19 degrees to 5 degrees. There was 80% reduction in the area in the curve of the figures in comparison to normal wrists (4000 to 960 degree-degrees). Discussion. Electrogoniometer and Lissajous's figures provide a useful method of assessment of range of motion in patients with four-corner fusion. They could be used in future for comparison with patients undergoing limited wrist fusion to study the disability experienced and for counselling regarding the postoperative limitation in activities of daily living experienced by these patients

Introduction and purpose: The most commonly found degenerative changes in the wrist can be included in two basic patterns of advanced carpal collapse: On the one hand scapholunate advanced collapse (SLAC) and on the other scaphoid nonunion advanced collapse (SNAC). To treat this collapse, Watson described the so-called four-corner arthrodesis, which includes the lunate, capitate, pisiform and hamate bones. The aim of this study is to assess the results obtained using fixation with a Spider plate. Materials and methods: In this study we included a series of 20 patients that underwent 4-corner arthrodesis with a Spider plate. These cases had stage II or III advanced degeneration of the wrist both SLAC and SNAC. We have also used this technique for other indications such as osteochondral lesions of the head of the capitate, mediocarpal arthritis or mediocarpal instability. Results: Mean follow-up was 16 (7–25) months. An important decrease in pain was seen in all cases and postoperative values were as follows: palmar flexion, 38° (range: 12–46); dorsal flexion, 30° (range: 12–45); radial deviation, 12° (range: 0–16); ulnar deviation, 24° (range: 15–40). An increase in fist force was seen after surgery. The arthrodesis healed in all cases, with a slight decrease in carpal height index after surgery. Conclusions: This surgical technique has allowed us to obtain good results determined clinically and by means of X-rays, as well as early motion after surgery

Aims:There is little published on the clinical impact of radial styloidectomy, although resultant instability has been studied in cadaveric models. Methods: Over a ten-year period 31 patients had a radial styloidectomy performed within the Upper Limb Unit. The surgery was performed arthroscopically in 22 patients and via an open approach in 9 cases. A retrospective review of the arthroscopically managed patients is presented. There were 4 females and 18 males with an average follow up of 13.1 months (range 6–53 months) and an average age of 35.4 years (range 18–64). The underlying condition treated was scaphoid non-union in 11 cases, scapholunate collapse in 7, primary osteoarthritis in 3, and one each of scaphoid avascular necrosis and Keinbochñs disease with a SLAC wrist. Patients were independently clinically reviewed or completed a wrist assessment questionnaire. The outcome was good or satisfactory in 75% of cases and unsatisfactory in the other 25%. Surgery had been carried out in 13.4% (3 patients) previously and all these patients had a satisfactory outcome. In those patients with a poor outcome, the average time to failure or further surgery was 9 months. Conclusions:Arthroscopic radial styloidectomy is a simple procedure with low morbidity. In patients with localised radial styloid impingement it can reliably provide lasting symptomatic relief in the majority of patients

Purpose: Transscaphoretrolunate dislocation is the most frequent perilunate dislocation of the carpus (65% according to Herzberg). Treatment remains controversial. The aim of this work was to analyse functional outcome in a homogeneous series of 15 patients treated by open reduction and fixation. Material and methods: This retrospective analysis of 15 patients, mean age 34 years was conducted at four years follow-up. Clinical outcome was based on the Cooney clinical scoring chart. Static and dynamic x-rays of the wrist were studied. The dislocations were: type I=9, type IIa=5, type II=1 according to the Alnot classification. The scaphoid fractures were: types III and IV=13, type II=2. A dorsal approach was used for six cases, an anterolateral approach for four and a double approach for five. The carpal tunnel was opened in seven cases. The scaphid fracture was fixed by pins in eleven cases, by screws in four, and associated with a corticocancellous graft in five. The carpus was fixed in seven cases with scapholunate pins, with lunotriquetral pins in seven, and radiolunate pins in three. Results: Mean score was 70±20% with mean flexion 50±17° and mean extension 54±20°. Grip force was 32/45±11 (Jamar). The thumb-index force was 14±5.1. Pain was negligible in 33% of the patients and was disabling in 17%. Climatic pain was reported by 50% of patients; 75% were able to resume their occupational activities. Radiographically we found osetonecrosis of the lunate (n=1), osteonecrosis of the proximal pole of the scaphoid (n=2), non-union of the scaphoid (n=3), radiocarpal osteoarthritis (n=4), SLAC (n=1) and SNAC (n=2). Discussion: Our outcomes were slightly less favourable than those reported in the literature concerning joint motion. Conversely, for pain, duration of sick leave, and percentage of occupational reclassing, our results were the same as reported in the literature. The series shows that radiographic outcome was favourable with 13% radiocarpal osteoarthritis (38% for Herzberg in 2002 at 96 months. The stability of the scaphoid osteosynthesis remains the key to success (two nonunions for four single pin fixatons). A new analysis at longer follow-up would be interesting to determine the arthrogenic results

Purpose of the study: Three-bone arthrodesis, described in 1997, is designed for radiocarpal osteoarthritis with mediocarpal extension. The procedure consists in a capitolunohamate fusion after resection of the scaphoid and the triquetrum. It is associated with carpal shortening proportional to the degree of preoperative wrist stiffness. The objective is to achieve less stiffness than with four-bone fusion. Material and methods: To verify our hypothesis, the first 24 patients (25 wrists) were reviewed with mean 5.2 years (2–8.5 years) follow-up. All wrists were painful and stiff, and presented radiocarpal and mediocarpal osteoarthritis. There were twelve SLAC III, nine SNAC III and four SCAC III. Mean age was 59 years (range 37–79 years). Mean preoperative range of motion was 50.5° flexion-extension (range 10–105°), mean force was 17 kg (range 10–35 kg). Radiological assessment was performed preoperatively and at last follow-up to determine the Youm index (carpal height) and the Bouman index (carpal translation) and to study the radiolunate joint space. Results: At last follow-up, all patients had improved but one. Ten wrists were pain free twelve caused some pain at forced wrist movements, and two caused pain daily but at a level below the preoperative level. One patient still suffered from severe pain and required revision for total radiocarpal arthrodesis. The final mean flexion-extension range of motion was 67.8°, for a 13.3° gain in extension and a 3.8° gain in flexion. Ulnar inclination was improved 14° on average. Mean force was 24 kg (73% of healthy side), for a 40% improvement over the pre-operative force. RAdiographically, there was one case of capitolunate nonunion. The radiolunate space remained unchanged. Carpal height decreased 15% on average and the Bouman index increased from 0.90 to 0.93 with no significant ulnar misalignment on the carpus. Discussion: For pain and force, these results are similar to those achieved with four-bone fusion. The overall results for range of motion are however better for flexion-extension and unlar inclination. In our practice, we have decided to replace the four-bone technique by three-bone fusion because the outcome is a less stiff wrist with a simpler surgical technique. Better results are obtained for stiffer wrists which achieve a significant improvement in motion due to carpal shortening

The August 2015 Wrist & Hand Roundup360 looks at: Scaphoid screws out?; Stiff fingers under the spotlight; Trigger finger: is complexity needed?; Do we really need to replace the base of the thumb?; Scapholunate ligament injuries and their treatment: a missed research opportunity?; Proximal row carpectomy versus four-corner arthrodesis