A. Lee Osterman

Arthroscopic debridement of triangular fibrocartilage complex tears

This prospective study, begun in 1984, involves 52 consecutive patients treated arthroscopically for triangular fibrocartilage complex (TFCC) tears. Wrist arthrography showed the tear on the initial radiocarpal injection in 86%, and only on the post-stress films in 14%. Triple-phase bone scan was positive in only 66%. Diagnostic arthroscopy showed linear defects in 34%, a central perforation in 46%, and ulnar or peripheral perforations in 20%. However, 11 patients proved to have no visible TFCC tear (9% false-positive arthrography rate, or 9% false-negative rate for arthroscopy). Of the 41 patients followed for 13-42 months, 88% considered the procedure worthwhile, and 73% had complete relief of pain. The authors conclude that arthroscopic debridement of TFCC tears (often with removal of 2-3 mm of ulnar head) may be of benefit in reducing symptoms without increasing clinical ulnar instability. Wrist arthrography is useful in diagnosing perforations but not useful in evaluating the type, size, or significance of the tear.

Proximal row carpectomy: A multicenter study

Twenty patients underwent proximal row carpectomy and were retrospectively evaluated for pain, motion, grip strength, functional activity, and x-ray changes at a mean follow-up of 3 1/2 years. For nonrheumatoid patients, motion decreased 15% after surgery, mean grip strength improved 22%, and 82% believed their conditions were improved and said they would repeat the procedure. The procedure failed in all three patients with rheumatoid arthritis. Patients with mild preoperative arthritic changes had better results than those with advanced disease.

Interosseous Membrane Reconstruction for the Essex-Lopresti Injury

The Essex-Lopresti lesion, or radioulnar longitudinal dissociation, results from an axial load to the forearm with injury to the radial head and disruption of the interosseous membrane and the distal radioulnar joint. Unfortunately, an appreciation of the true extent of injury is not always realized in the acute setting, and patients present later with persistent or new reports of forearm discomfort and wrist and elbow pain. Reconstruction of the central band of the interosseous membrane with a bone-patellar tendon-bone graft is useful in the chronic setting and is described.

Reconstruction of the scapholunate ligament in a cadaver model using a bone-ligament-bone autograft from the foot

This study is an investigation of a new procedure in which the scapholunate interosseous ligament (SLIL) is reconstructed using a bone-ligament-bone autograft from the foot. After investigation, the dorsal medial portion of the navicular-first cuneiform ligament (NFCL) was chosen for testing as a potential donor since it is similar in length and thickness to the SLIL and it is easily harvested with minimal potential donor site morbidity. Eight SLILs and NFCLs were harvested from fresh-frozen cadavers. Biomechanical extensometry testing was performed using an Instron 1000 machine. A 5-mm-wide central portion of the NFCL was tested since this width was compatible with the technical aspects of reconstructing the SLIL. Both ligaments were tested for elastic properties, including stiffness, load to failure, and deformation to failure. Mean length of the NFCL was 7.6 mm (range, 5.5-8.5 mm). Stiffness of the NFCL was 10.6 x 10(5) Nm (range, 8.0-13.0 Nm) compared with 14.4 x 10(5) Nm for the SLIL (range, 10.0-19.5 Nm). Peak load to failure for the NFCL was 1,980 N (range, 1,530-2,940 N) compared with 2,940 N for the SLIL (range, 1,780-4,050 N). Total elongation to failure for the NFCL was 2.50 mm (range, 1.7-3.2 mm) compared with 3.2 mm for the SLIL (range, 2.1-5.2 mm). Thus, the biomechanical characteristics of the NFCL were found to be very similar to those of the SLIL. Having established the biomechanical similarities of the 2 ligaments, we are currently using the NFCL to reconstruct the sectioned SLIL in a fresh-frozen cadaver model. Early results suggest that this procedure is feasible for restoration of normal kinematics of the wrist.

Wrist Arthroscopy: Principles and Clinical Applications

&NA; With the development of better and smaller equipment, arthroscopy of the wrist offers the same benefits achievable with arthroscopy of the knee, shoulder, or elbow—not only diagnostic information but also a therapeutic option. Standardized techniques of performing wrist arthroscopy have been developed to evaluate and treat various wrist disorders, such as lesions of the triangular fibrocartilage complex, intra‐articular distal radius fractures, and scaphoid fractures. Arthroscopy is now performed in the treatment of dorsal‐wrist ganglion cysts and interosseous ligament disruptions, as well as for bone excisions, such as radial styloidectomy, distal ulnar excision (wafer procedure), and proximalrow carpectomy. Compared with open techniques, arthroscopic procedures, such as repair of the triangular fibrocartilage complex, demonstrate better results and improved localization of the injury with a low complication rate. In addition, arthroscopic procedures involve less surgical dissection, less postoperative pain, a shorter recovery time, and an earlier return to work for the patient.

Preiser's disease: Identification of two patterns

PURPOSE A large series of patients with Preisers disease was reviewed to compare 2 potentially different categories of this disorder: complete versus partial vascular impairment of the scaphoid bone as determined by magnetic resonance imaging (MRI). METHODS Nineteen patients with Preisers disease were identified retrospectively from 2 institutions. Using MRI criteria, 2 disease patterns were identified: diffuse necrosis and/or ischemia of the scaphoid (type 1 disease, 11 cases) and segmental vascular impairment of the scaphoid (type 2 disease, 8 cases). Risk factors for osteonecrosis, treatment methods, and serial radiographs were reviewed in all cases. Sixteen patients were examined for the purpose of this study at an average follow-up of 25 months. RESULTS MRI signal changes of necrosis and/or ischemia involved 100% of the scaphoid in type 1 cases and on average approximately 42% in type 2 cases (range, 33% to 66%). In type 1 cases, regardless of the treatment used, the scaphoid typically fragmented and collapsed. In type 2 cases, scaphoid architecture was altered minimally after similar treatment methods. A history of wrist trauma was significantly more common in type 2 cases, and the results of treatment were generally better in this group of patients (mean Mayo modified wrist scores, 86 vs 58 points). CONCLUSIONS This study supports the concept of 2 patterns of scaphoid involvement in Preisers disease. Type 1 cases are characterized by MRI signal changes of necrosis and/or ischemia involving the entire scaphoid bone. Patients in this group have a propensity for scaphoid deterioration. Type 2 cases have MRI signal changes involving only part of the scaphoid. These patients commonly report a history of wrist trauma, show fewer tendencies toward scaphoid fragmentation, and may have a more favorable clinical outcome.

Partial interosseous ligament tears of the wrist : Difficulty in utilizing either primary or secondary MRI signs

Purpose Prior reports on scapholunate ligament (SLL) and lunotriquetral ligament (LTL) tears have evaluated complete tears. As these complete tears have markedly different biomechanical manifestations and surgical considerations than do partial tears, we evaluated the accuracy of MR and the usefulness of secondary MR signs to diagnose partial interosseous ligament tears. Method Fifty wrists in 50 patients underwent arthroscopy following 1.5 T MR. Images were evaluated by two independent blinded observers for normal or partially torn SLL and LTL and for three secondary signs potentially seen as mechanical sequelae of tears: osseous offset, arc disruption, or focal osteoarthritis. Results Arthroscopically, there were 16 SLL and 14 LTL partial tears. Accuracy of primary MR signs of partial tears was lower than that described in the literature for complete tears [sensitivity/specificity (&kgr;) = 0.56/0.56 (0.12)—SLL, 0.31/0.76 (0.13)—LTL]. Secondary signs showed low sensitivity but high specificity, particularly for LTL tears: arc disruption [0.17/0.83 (0.43)—SLL, 0.0/1.00 (1.0)— LTL], focal osteoarthritis [0.32/0.78 (0.18)—SLL, 0.11/0.91 (0.12)—LTL], and focal osseous offset [0.39/0.75 (0.10)—SLL, 0.26/0.93 (0.39)—LTL]. Additionally, there was poor interobserver consistency for both primary and secondary signs. Conclusion The sensitivity of morphologic evaluation for diagnosing partial intercarpal ligament tears, particularly those of the LTL, is limited. Secondary signs increase specificity but have low sensitivity, and with the exception of arc disruption, all signs had poor interobserver agreement.

Prosthetic nerve grafts: A resorbable tube as an alternative to autogenous nerve grafting

The use of a prosthetic nerve graft, composed of a resorbable polyorthoester tube, as an alternative to free autogenous nerve grafting for the treatment of a gap in a peripheral nerve was studied, with a cat sciatic nerve as the model. The results demonstrate that regeneration will occur through a resorbable tube spanning a 1.5 cm gap and reinnervate end organ muscle. In those muscles showing evidence of reinnervation, nerve regeneration through the tubes as assayed by electrophysiologic examination demonstrated no difference compared with autogenous nerve grafts, with the exception that the initial rate of regeneration was delayed by 4 to 6 weeks.

A multicenter prospective review of 640 endoscopic carpal tunnel releases using the transbursal and extrabursal chow techniques

A prospective study involving eight institutions was performed, incorporating 640 cases of carpal tunnel release using a dual portal endoscopic technique. The original transbursal technique described by Chow was used in 110 cases (17%), and the modified extrabursal technique was used in 530 cases (83%). An overall complication rate of 11% was found in the patients in whom the transbursal technique was used, compared with 2.2% in the patients in whom the extrabursal technique was used. The return-to-work status was followed in 291 cases (199 non-workers compensation cases and 92 workers compensation cases). The workers compensation patients returned to work in an average of 57 days, compared with 22 days for non-workers compensation patients. This study suggests the extrabursal dual portal endoscopic technique is associated with fewer complications than the transbursal approach, and patients covered by workers compensation return to work later than non-workers compensation patients.

The effect of a therapy protocol for increasing correction of severely contracted proximal interphalangeal joints caused by dupuytren disease and treated with collagenase injection.

PURPOSE To determine the effect of a specific orthotic intervention and therapy protocol on proximal interphalangeal (PIP) joint contractures of greater than 40° caused by Dupuytren disease and treated with collagenase injections. METHODS All patients with PIP joints contracted at least 40° by Dupuytren disease were prospectively invited to participate in the study. Following standard collagenase injection and cord rupture by a hand surgeon, a certified hand therapist evaluated and treated each patient based on a defined treatment protocol that consisted of orthotic intervention to address residual PIP joint contracture. In addition, exercises were initiated emphasizing reverse blocking for PIP joint extension and distal interphalangeal joint flexion exercises with the PIP joint held in extension to lengthen a frequently shortened oblique retinacular ligament. Patients were assessed before injection, immediately after injection, and 1 and 4 weeks later. There were 22 fingers in 21 patients. The mean age at treatment was 63 years (range, 37-80 y). RESULTS The mean baseline passive PIP joint contracture was 56° (range, 40° to 80°). At cord rupture, the mean PIP joint contracture became 22° (range, 0° to 55°). One week after cord rupture and therapy, the contracture decreased further to a mean of 12° (range, 0° to 36°). By 4 weeks, the mean contracture was 7° (range, 0° to 35°). The differences in PIP joint contracture were statistically significant at all time points except when comparing the means at 1 week and 4 weeks. The results represent an 88% improvement of the PIP joint contracture. CONCLUSIONS In the short term, it appears that severe PIP joint contractures benefit from specific, postinjection orthotic intervention and targeted exercises. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.