Aims

Patients with midcarpal instability are difficult to manage. It is a rare condition, and few studies have reported the outcomes of surgical treatment. No prospective or retrospective study has reported the results of arthroscopic palmar capsuloligamentous suturing. Our aim was to report the results of a prospective study of arthroscopic suture of this ligament complex in patients with midcarpal instability.

Aims

A conventional arthroscopic capsuloligamentous repair is a reliable surgical solution in most patients with scapholunate instability. However, this repair does not seem to be sufficient for more advanced injuries. The aim of this study was to evaluate the functional results of a wide arthroscopic dorsal capsuloligamentous repair (WADCLR) in the management of severe scapholunate instability.

Introduction: We report on our experience of using a vascularised bone graft harvested from the volar face of the radius in the treatment of Kienböck’s disease, with an average follow up of 79 months and a minimum of 5 years.

Materials: We treated 22 patients with Kienböck’s disease. There were 8 women and 14 men whose average age was 31.4 years old (range 18–63 years). Pain was always present and incapacitating in 19 cases. All patients underwent pre-operative tomodensitometry and an MRI, based on LICHTMAN’s classification there were 8 stage II, 10 stage IIIA and 4 stage IIIB.

Methods: The volar carpal artery of the carpus originates from the radial artery and vascularises medial part of the radial epiphysis. Using the same anterior surgical approach it was possible to harvest the pedicled bone graft from this artery and to place it into the lunate for revascularisation. Shortening of the radius was carried out in all cases, as was immobilisation until union of the radius.

Results: Our average follow up is 79 months (range 60–138 months). Pain disappeared completely in 20 cases, and was moderate and tolerable in 2 cases. The average active range of motion was higher than 71°. The average period for return to work was 3.5 months. Post-operative MRI at an average of more than 8 months showed 16 complete revascularisations of the lunate, 5 stabilizations of lesions and one failure which necessitated secondary palliative treatment. There were 4 delayed unions of the radius and one Südeck’s dystrophy. There was a clear correlation between the stage of Kienböck’s disease and the final outcome of surgery.

Discussion: The use of a vascularised bone graft harvested from the anterior face of the radius for the revascularisation of the lunate associated with shortening of the radius has given encouraging results. A longer-term study is necessary.

Purpose: We report our experience with vascularised bone grafts harvested from the anterior aspect of the radius for the treatment of Kienböck disease. We reviewed our patients at minimum three years, average 67 months.

Material and methods: We treated 22 patients with Kienböck disease, eight women and fourteen men, mean age 31.4 years (18–63). Pain was present in all cases and was disabling in nineteen. After systematic computed tomography and magnetic resonance imagine (MRI), the Büchler classification was stage II=8, stage IIA=10 and stage IIIB=4. The transverse anterior artery of the carpus arises from the radial artery and supplies blood to the medial part of the radial epiphysis. The pediculated bone graft fed by this artery can be harvested via the same anterior approach as used to position it in the semilunate for revascularisation. Radial shortening was performed in all cases. The patients were immobilised until the radius healed.

Results: Mean follow-up was 67 months (36–104). Pain resolved completely in all twenty patients. Two patients nevertheless reported moderate pain occasionally. Mean active motion was greater than 71°. Mean time to resumption of former activities was 3.5 months. Postoperative MRI, performed at mean 8 months, demonstrated complete revascularisation of the semilunate in six cases, stable lesions in five, and one failure requiring secondary palliation. There were four cases of late healing of the radial osteotomy and one reflex dystrophy. There was a direct correlation between Kienböck disease stage and final outcome.

Conclusion: Use of a vascularised graft harvested from the anterior aspect of the radius for revascularisation of the semilunate associated with radial shortening has provided encouraging results. Long-term follow-up is needed to verify these results.

Purpose: Ulnolunate disorders secondary to fracture of the radius generally result from inversion of the distal radioulnal index due to the relative shortening of the radius creating a conflict between the head of the ulna and the proximal anterior articular surface of the semilunate and cartilage impingement. Arthroscopy can often provide the diagnosis and minimally invasive treatment.

Material and methods: We reviewed a series of 32 patients, 15 men and 17 women, mean age 66 years (45–82). All presented sequelae of a fracture of the lower quarter of the radius with axial impaction. The ulnar variance was 2.7 mm (2–5). Time from initial fracture to arthroscopic resection was nine months (2–26). All patients presented pain, which was moderate and permanent in 19 and disabling in 13. Overall muscle force was reduced by 50% compared with the healthy side. Motion was limited due to the callus often associated with healing of these fractures. Patients underwent arthroscopy in an outpatient setting under locoregional anaesthesia. The arthroscope was introduced via a 3–4 radiocarpal portal allowing exploration of the joint space. Surgical treatment consisted in milling for partial distal resection of the ulnar head (6R radiocarpal portal). Wrist motion was restored in all cases.

Results: Mean follow-up was 39 months (18–54). Wrist motion was restored immediately in all cases. Pain at the radioulnar joint persisted in two patients. For 26 patients, the preoperative pain disappeared immediately. Muscle force improved compared with the preoperative level but did not reach the level of the healthy side.

Discussion: Arthroscopic treatment of ulnolunate impingement has proven efficacy and safety. It should however be reserved for cases with an inverted distal radioulnar index measuring less than 5 mm. If the ulnar variance is larger, we prefer ulnar osteotomy to shorten the bone. Other techniques are reserved for cases where the distal radioulnar joint is damaged.

Purpose: Arthroscopy of the wrist can be an alternative to open surgery for joint fractures of the radius by checking reduction of often impacted fragments and analysing associated injuries.

Material: Twenty-eight patients (15 men and 13 women) were treated arthroscopically. Mean age was 51 years (range 19–82). There were four fractures of the styloid process of the radius, six posteromedial fractures, eleven 3-fragment T fractures and seven fractures with four or more fragments. There were 19 associated injuries (six lesions of the triangular ligament, four lesions of the luno-triquetral ligament, and nine lesions of the scapho-lunate ligament including four requiring pinning.

Methods: Loco-regional anaesthesia was used for all patients. The elbow was flexed at 90° and the wrist placed under axial traction using a “Japanese” device. After careful cleaning of the joint, reduction was achieved by pinning under arthroscopic and fluoro-scopic guidance. In certain very unstable cases (i.e. the fractures with four or more fragments), additional plate fixation was required. An external prosthesis was worn for 45 days.

Results: Mean follow-up was 21 months (6–36 months). Wrist movement was normal in 24 patients and pain had totally resolved for 27. There were no secondary displacements requiring surgical revision. Horizontalisation of the radius was observed in two cases and inversion of the lower radio-ulnar index (about 0.5 cm) in four. The functional outcome was excellent or good in 22 patients, fair in five, and poor in one due to reflex dystrophy.

Discussion: The indication for surgical treatment of joint fractures is now well recognised. Our results are comparable to those in other series where arthroscopic management has been used for this type of fracture. The quality of the functional results appears to be directly related to the quality of the reduction and fixation achieved under traction.

Conclusion: Arthroscopic management of joint fractures of the lower quarter of the radius enables anatomic reduction necessary for good functional outcome.

Purpose: We report the long-term outcome after treatment of scaphoid nonunion using a graft harvested on the anterior aspect of the radius and vascularised with the anterior carpus artery.

Material and methods: We treated 72 patients, 11 women and 61 men. Mean age was 31.4 years (15–61) and mean delay from initial fracture of the scaphiod to treatment of nonunion was 22 months (4–120 months). Twenty-seven patients had had prior tratments (11 Mati-Russe, 16 screw fixations). Alnot classification was 40 grade 2A, 28 grade 2B and 4 grade 3A. the patients were generally treated as out-patients under locoregional anaesthesia. A single approach was needed. After reduction and fixation of the scaphoid, the graft was harvested from the anterior aspect of the radius and inserted in the bone gap, usually fixed with a temporary pin. A palmar brace was maintained until bone healing.

Results: Bone healing was achieved in 66 patients (91.6%). Mean delay to healing was 9.8 weeks (6–24). Pain relief was achieved in all patients; 59 were completely pain free. Mean flexion improved from 45° to 56° and mean extension from 54° to 65°. Muscle force improved from 50% to 90% of the healthy side. There were three cases of reflex dystrophy, two cases of styloid radial osteoarthritis and three cases of postoperative stiffness requiring secondary arthrolysis. Functional outcome was excellent in 46 patients, good in 13, fair in 9 and poor in 4.

Discussion: The vascularised graft advocated by Judet as early as 1964 has proven its efficacy for repeated nonunions of the scaphoid. In our series, there was a direct correlation between the grade of the nonunion and the final outcome, the best results being obtain for grade 2A.

Conclusion: Use of a bone graft vascularised with the anterior carpus artery only requires on approach, and provides a high rate of bone healing. We recommend this method for first line treatment of nonunion of the scaphoid.