Introduction. The wrist is the ”key-stone” of hand function. Painless stability is a prerequisite for the rheumatoid wrist to perform various manual tasks. Synovectomy of the extensor tendons and the wrist joint with a Darrach procedure is offered for painful wrists, which are not controlled by conservative treatment with medication and orthosis.
Introduction. The wrist is the ”key-stone” of hand function. Painless stability is a prerequisite for the rheumatoid wrist to perform various manual tasks. Synovectomy of the extensor tendons and the wrist joint with a Darrach procedure is offered for painful wrists, which are not controlled by conservative treatment with medication and orthosis.
The problem: A few operative procedures were used for
Wrist arthrodesis is a common surgical procedure that provides a high level of functional outcome and pain relief among patients.[1] Upon partial arthrodesis, the wrist experiences changes in load transmission that are influenced by the type of arthrodesis performed. Measuring the load through the wrist joint is difficult, however, combined with computational models [2], it is possible to obtain data regarding the load mechanics of the wrist joint. Although successful fusion rates among patients have been reported, it remains unclear what the biomechanical consequences are. The aim of the study is to quantify pre and post operative load transmission through a cadaveric wrist which has undergone simulated arthrodesis of the radiolunate(RL) joint. An embalmed human wrist was dissected dorsally exposing distal radius, radiocarpal and carpometacarpal joints, and dorsal ligaments. The radioscaphoid(RS) ligament was sacrificed to accommodate insertion of a PPSEN-09375 force sensitive resistor (FSR) into the RS joint. The FSR was calibrated prior to measuring the contact force on the RS joint. The wrist was aligned in the neutral position in cardboard piping, and secured proximally and distally with Dental Plaster (OthoBock Healthcare Plc, Surrey, UK). The midsection of piping was windowed to permit placement of the FSR in the RS joint, and fixation of the RL joint using 2 Kirschner wires. The window was completed circumferentially and the specimen was placed in the Instron where a graduated axial compression was applied at 20 N/min. The results showed that when the
Restoration of normal anatomy following a distal radial fracture is an important factor in determining functional recovery. However, current methods of assessing dorsal tilt and displacement require ‘true’ lateral radiographs, and important reference points are often obscured by metalwork.
Fractured wrist, PreORIF: Using conventional methods, the mean fracture displacement was 2.64mm (0–5.1mm) and the mean dorsal tilt was 23.3 degrees(4 degrees volar tilt to 43 degrees dorsal tilt). Using the dorsal reference ‘line’, in all cases the lunate was either above or transected by the line; mean lunate ratio of 1.61 (0.54–8.05). The mean height of the lunate projecting dorsal to the line was 9.5mm (6.1–16.1mm). Fractured wrist, PostORIF: Apart from one radiograph, the ‘line’ passed superior to the lunate; mean distance of 2.64mm (0–3.9mm), with a mean lunate ratio of 1.13 (0.61–2.74). These measurements correlated well with measurements of dorsal tilt and displacement.
Distal radius fractures are the most common fracture of the upper extremity. Malunion of the distal radius is a common clinical problem after these injuries and frequently leads to pain, stiffness loss of strength and functional impairments. Currently, there is no consensus as to whether not the mal-aligned distal radius has an effect on carpal kinematics of the wrist. The purpose of this study was to examine the effect of dorsal angulation (DA) of the distal radius on midcarpal and radiocarpal joint kinematics, and their contributions to total wrist motion. A passive wrist motion simulator was used to test six fresh-frozen cadaveric upper extremities (age: 67 ± 17yrs). The specimens were amputated at mid humerus, leaving all wrist flexor and extensor tendons and ligamentous structures intact. Tone loads were applied to the wrist flexor and extensor tendons by pneumatic actuators via stainless steel cables. A previously developed distal radius implant was used to simulate native alignment and three DA deformity scenarios (DA 10 deg, 20 deg, and 30 deg). Specimens were rigidly mounted into the simulator with the elbow at 90 degrees of flexion, and guided through a full range of flexion and extension passive motion trials (∼5deg/sec). Carpal motion was captured using optical tracking;
Pain and disability following wrist trauma are highly prevalent, however the mechanisms underlying painare highly unknown. Recent studies in the knee have demonstrated that altered joint contact may induce changes to the subchondral bone density and associated pain following trauma, due to the vascularity of the subchondral bone. In order to examine these changes, a depth-specific imaging technique using quantitative computed tomography (QCT) has been used. We've demonstrated the utility of QCT in measuring vBMD according to static jointcontact and found differences invBMD between healthy and previously injured wrists. However, analyzing a static joint in a neutral position is not necessarily indicative of higher or lower vBMD. Therefore, the purposeof this study is to explore the relationship between subchondral vBMDand kinematic joint contact using the same imaging technique. To demonstrate the relationship between kinematic joint contact and subchondral vBMDusing QCT, we analyzed the wrists of n = 10 participants (n = 5 healthy and n = 5 with previous wrist trauma). Participantsunderwent 4DCT scans while performing flexion to extension to estimate radiocarpal (specifically the
Wrist malalignment, in cases of malunited fractures of the distal radius, is not always a consequence of adaptation of the wrist to new conditions, but an expression of non-diagnosed ligamentous injuries. The aim of our study is to examine if the wrist malalignment is correctable with radius osteotomy. Twenty nine patients (17 female, 12 male) of mean age 51 years, with symptomatic malunited fracture of the distal radius with dorsal angulation, of duration 3 months -47 years, were examined. Twenty seven patients underwent corrective radius osteotomy (open dorsally in 26 cases and closed palmarly in 1 case). Fixation material (plate and screws) was placed on the dorsal side in 23 cases and on the volar side in 4 cases. In all patients measurements on the lateral X-ray view, concerning the reversal of the normal palmar tilt of the radius, the
Twenty five years ago, the 1 st paper concerning
Introduction and Objective. Scapholunate instability is the most common cause of carpal instability. When this instability is left untreated, the mechanical relationship between the carpal bones is permanently disrupted, resulting in progressive degenerative changes in the radiocarpal and midcarpal joints. Different tenodesis methods are used in the treatment of acute or early chronic reducible scapholunate instability, where arthritis has not developed yet and the scapholunate ligament cannot be repaired. Although it has been reported that pain is reduced in the early follow up in clinical studies with these methods, radiological results differ between studies. The deterioration of these radiological parameters is associated with wrist osteoarthritis as previously stated. Therefore, more studies are needed to determine the tenodesis method that will improve the wrist biomechanics better and will last longer. In our study, two new tenodesis methods, spiral antipronation tenodesis, and anatomic front and back reconstruction (ANAFAB) were radiologically compared with triple ligament tenodesis (TLT), in the cadaver wrists. Materials and Methods. The study was carried out on a total of 16 fresh frozen cadaver wrists. Samples were randomly allocated to the groups treated with 3 different scapholunate instability treatment methods. These are TLT (n: 6), spiral antipronation tenodesis (n: 5) and ANAFAB tenodesis (n: 5) groups. In all samples SLIL, DCSS, STT, DIC, RSC and LRL ligaments were cut in the same way to create scapholunate instability. Wrist CT scans were taken on the samples in 4 different states, in intact, after the ligaments were cut, after the reconstruction and after the movement cycle. In all of these 4 states, wrist CTs were taken in 6 different wrist positions. For every state and every position through tomography images; Scapholunate (SL) distance, Scapholunate (SL) angle, Radioscaphoid (RS) angle,
Aim:. To assess the clinical outcomes of patients that had perilunate or lunate dislocations treated with either open or closed reduction and wiring without repair of the scapholunate interosseous ligament (SLIL). Background:. Current literature states that acute perilunate dislocations should be treated with open reduction and repair of the dorsal scapholunate ligament. This is to prevent dissociative carpal instability and potential long term degenerative arthrosis. Methods:. A retrospective review of patients who sustained a perilunate or lunate dislocation, with no associated radial or carpal fracture was conducted. All were treated by reduction and percutaneous wiring without repair of the SLIL. Patients were examined and data was collected regarding patient's pain, range of motion, grip strength, instability and return to work. All patients had a Mayo wrist score. Pre and post-surgical radiographs were assessed and the scapholunate distance, scapholunate angle and the
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
The aim of the study was to investigate, firstly, the force distribution between scaphoid/radius and lunate/radius in the normal wrist and in the presence of a scaphoid fracture, secondly, how stresses and strains at the fractured area change during the healing process and thirdly, how the direction of the applied forces affects load transmission. A 3D finite element model of the normal wrist was initially developed. Two typical scaphoid fractures B2 and B3 according to Herbert’s classification, were investigated. The fractured areas were modeled with a range of modulus of elasticity to resemble the various stages of the healing process. Furthermore, three different directions of the externally applied loads were examined. The applied compressive vertical load in the normal joint was transmitted to the radius through the radioscaphoid and the
Aim: Although several surgical procedures have been proposed for advancedstage Kienböck’s disease, it still remains a difficult therapeutic problem. This study documents the clinical, radiographic and MRI outcomes of ten patients, who underwent lateral closing wedge osteotomy of the distal radius by the same surgeon, after MRI confirmation of advanced Kienböck’s disease. Methods: Ten patients (6 men and 4 women) with a mean age of 28,7 years (range 21–66) were included in this study. Seven had Lichtman stage III-B and three stage IV disease. The lateral closing wedge osteotomy was performed at the distal metaphysis of the radius through a palmar approach and was fixed with a 3,5mm titanium T-plate. The average follow up period was 52 months (range 36–60 months). Results: Substantial pain relief, increase in grip strength and range of wrist flexion and extension were achieved. Clinical results were excellent in two patients, good in five, fair in two patients and poor in one patient according to Nakamura’s postoperative scoring system. Gadolinium enhanced MRI at the latest follow up revealed signs of revascularization of the lunate in 6 cases. Conclusions: Lateral closing osteotomy decreases radial inclination and pressure at the
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
Purpose of the study: Appropriate management of chronic sprains of the scapholunate joint remains a subject of debate. Different surgical techniques have been proposed, from partial arthrodesis of the carpus to ligamentoplasty. We opted for scaphocapitatum arthrodesis. The purpose of this report was to assess clinical and radiological outcome. Material and methods: From 1997 to 2001, 13 arthrodeses (13 patients) were performed for this indication. The procedure involved two screws (n=11), one screw and stapling (n=1), and stapling alone (n=1). A free autologous graft was used in all cases. Mean patient age was 40 years (12 males and one female). These patients were victims of sports accidents (n=8) or occupational accidents (n=5). Mean follow-up was 26 months (range 24–31 months). Variables noted were joint mobility, pain, grasp force and pinch force. Wrist x-rays were used to measure the height of the carpus and the radio-lunate angle. Results: A 31% loss in the radial inclination was noted as as a 14.5% loss in the ulnar inclination. Dorsal flexion of the wrist declined from 60° to 48°, palmar flexion from 47° to 28°. Stiffness mainly involved the radial inclination and palmar flexion. Grasp and Pinch forces improved (125° on average). All patients excep one presented residual pain. Six patients complained of pain only for efforts and six presented invalidating pain. Only seven patients were able to resume their occupational activity. There were three cases of nonunion which required revision to achieve final bone healing (poor outcome). Carpal height improved (0.47±0.54). The mean
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
Treatment of advanced Kienbock’s disease is challenging, and controversial. Palliative procedures should be chosen. The goal of this study was to analyse the results of scaphocapitate arthrodesis with lunarectomy in advanced cases. Fourteen consecutive wrists in 13 patients were re-examined at a ranged follow-up of 31,7 months (range 3 to 103). Preoperative radiographs showed Lichtman stage 3a disease in 4 patients, stage 3b in 9 patients, and stage 4 in the last patient. Eight patients were women, and the involved wrist was the dominant in 8 cases. The age at operation averaged 36,6 years (range 24 to 55). Symptoms consisted in pain or pain with stiffness. Operative techniques consisted through a dorsal approach in excision of the dorsal interosseus nerve, lunarectomy, and scaphocapitate arthrodesis. Autologous bone graft was used in 8 cases, and osteosynthesis used K wires or staples. The wrists were immobilized in arm cast during 6 weeks, and rehabilitation was started. Postoperatively, one patient developed a complex regional pain syndrome. At longest follow-up, patients were very satisfied in 8 cases, satisfied in 4, and poorly or not satisfied in 2 cases. Three wrists were painless, and only one wrist had no improvement. One wrist had no improvement. All the employed patients returned to their original work. Mean wrist motion increased slightly. Flexion increased from 33.3 to 33.9°, extension from 39.6 to 39.3°, ulnar deviation from 20 to 23.7°, and radial deviation from 18.8 to 17°. The arc of motion was useful (Flexion- Extension: 73.7° range, Pronation-Supination: 172.7°) Grip strength increased and reached 64.5% of the controlateral wrist. The mean gain was 5.6 Kg (+199%). The improvement was slow and very progressive over one year. On radiographs the arthrodeseses were consolidated in all cases, but the union seemed partial but asymptomatic in two wrists. Correction of scaphoid in flexion was difficult to obtain. No arthritis or degenerative changes were observed, but the distal radial epiphysis seemed to be reshuffled to the new joint and articular surfaces, with progressive disappearance of the radial lunar notch. Scaphocapitate arthrodesis associated with lunarectomy allows getting a painful and functional wrist. This simple procedure theoretically decreases load across the
Purpose: The purpose of this retrospective study was to detail factors influencing outcome of corticocancellous grafts for the treatment of scaphocarpal non-union and to determine ideal indications. Material and methods: Between 1984 and 1999, this grafting technique was used for 103 patients; we retained for analysis 57 wrists (58 nonunions). Mean follow-up was 106 months. Mean age was 36 years. For 45 patients, non-union occurred because of misdiagnosis. According to the Schernberg classification, eleven nonunions were in zone II, 40 in zone III, and seven in zone IV. Time from fracture to treatment was 35 months on average. The Alno classification of non-union was: stage I=13, stage IIA=20, stage IIA=22, stage IIIA=2, stage IIIB=1. The graft was harvested from the pelvis in 50 cases. Osteosynthesis was associated with a graft in 33 of the 58 cases. Postoperative immobilisation was maintained for 2.7 months on average. Bone healing was achieved within thee months. Results: Thirty-six patients were very satisfied. Twenty-seven had significant pain on the pelvic harvesting site (50 harvestings). Wrist motion was 56.2° flexion, 56° extension, 83° supination, 83° pronation, and 11° radial and 32.7° ulnar inclination. Thumb opposition was noted 9.4/10 and average contraopposition was 4. Mean index of carpal height was 0.547. The mean
Objective: The objective of this study was to clarify the clinical outcome of upper-extremity surgeries for the rheumatoid patients using the Japanese version of the DASH Disabilities of the Arm, Shoulder and Hand questionnaire and to investigate whether the outcome was affected by the activity of the disease. Materials and methods: One hundred and twenty seven surgical procedures in 103 rheumatoid patients (male: 26, female: 77) were included in this study. Surgeries were performed in 4 shoulders (HHR: 4), 35 elbows (TEA: 28, synovectomy: 6 etc.), 60 wrists (Kapandji: 6,