Arnold-Peter C. Weiss

Scapholunate ligament reconstruction using a bone-retinaculum-bone autograft

This study was designed to evaluate the use of a locally available bone-retinaculum-bone graft in the reconstruction of the completely torn scapholunate (SL) ligament. Nineteen consecutive patients (14 with dynamic instability and 5 with static instability) underwent SL ligament reconstruction using an autogenous bone-retinaculum-bone graft taken from the third dorsal compartment region. All patients underwent arthroscopy to document a torn SL ligament. The bone plugs on the graft were fitted into the dorsal scaphoid and lunate, respectively, with the retinaculum periosteal soft tissue intervening sleeve arching between these 2 bones. The SL interval was reduced and pinned for 8 weeks with cast immobilization. The follow-up period averaged 3.6 years (minimum, 24 months). Of the 14 patients with dynamic instability, 12 had no pain and 2 had pain with heavy activity of the wrist. Range of motion (ROM) decreased slightly from preoperative values, and grip strength improved 46%. Thirteen patients were completely satisfied and returned to their former work activities, and 1 returned to modified work activities. Of the 5 patients with static instability, 2 had no pain after surgery, 1 had pain with heavy activity, and 2 had constant pain. ROM in this group decreased moderately in extension/flexion from the preoperative values. Grip strength improved 30% from preoperative values. Satisfaction was rated as complete by 1 patient and partial by 2 patients; 2 patients were dissatisfied. Two patients returned to their former jobs, 2 returned to modified duties, and 1 is on disability. Reconstruction of the SL ligament using a bone-retinaculum-bone autograft is predictable in patients with dynamic instability. Use of this technique with static SL instability is questionable; these patients may require a stronger construct to prevent recurrence of the SL gap.

In vivo radiocarpal kinematics and the dart thrower's motion

BACKGROUND Wrist motion is dependent on the complex articulations of the scaphoid and lunate at the radiocarpal joint. However, much of what is known about the radiocarpal joint is limited to the anatomically defined motions of flexion, extension, radial deviation, and ulnar deviation. The purpose of the present study was to determine the three-dimensional in vivo kinematics of the scaphoid and lunate throughout the entire range of wrist motion, with special focus on the dart throwers wrist motion, from radial extension to ulnar flexion. METHODS The three-dimensional kinematics of the capitate, scaphoid, and lunate were calculated from serial computed tomography scans of both wrists of fourteen healthy male subjects (average age, 25.6 years; range, twenty-two to thirty-four years) and fourteen healthy female subjects (average age, 23.6 years; range, twenty-one to twenty-eight years), which yielded data on a total of 504 distinct wrist positions. RESULTS The scaphoid and lunate primarily flexed or extended in all directions of wrist motion, and their rotation varied linearly with the direction of wrist motion (R2= 0.90 and 0.82, respectively). Scaphoid and lunate motion was significantly less along the path of the dart throwers motion than in any other direction of wrist motion (p < 0.01 for both carpal bones). The scaphoid and lunate translated radially (2 to 4 mm) when extended, but they did not translate appreciably when flexed. CONCLUSIONS The dart throwers path defined the transition between flexion and extension rotation of the scaphoid and lunate, and it identified wrist positions at which scaphoid and lunate motion approached zero. These findings indicate that this path of wrist motion confers a unique degree of radiocarpal stability and suggests that this direction, rather than the anatomical directions of wrist flexion-extension and radioulnar deviation, is the primary functional direction of the radiocarpal joint.

Arthroscopic debridement alone for intercarpal ligament tears

This study examined the role of arthroscopic debridement alone for complete and incomplete intercarpal ligament tears of the wrist. Forty-three wrists underwent arthroscopic evaluation for persistent wrist pain and were identified as having isolated scapholunate or lunotriquetral ligament tears treated by arthroscopic debridement alone of the torn ligament edges. At follow-up examination at an average of 27 months, 29 (66%) wrists having a complete scapholunate ligament tear and 36 (85%) wrists having a limited scapholunate ligament tear had either complete symptom resolution or improved symptomatology. Thirty-three (78%) wrists with a complete lunotriquetral ligament tear and 43 (100%) wrists having a limited lunotriquetral ligament tear had complete symptom resolution or improvement. No wrists were noted to have static intercarpal instability pattern changes on follow-up radiographs. Grip strength improved 23% postoperatively. These findings suggest that intercarpal ligament tears, in a majority of patients, may be treated from a symptomatic standpoint by debridement alone for at least several years. The long-term ability of this approach to maintain a pain-free wrist has yet to be determined. No statistically significant difference was noted in the symptomatic improvement rate of scapholunate compared to lunotriquetral ligament debridement.

Comparison of the Findings of Triple-Injection Cinearthrography of the Wrist with Those of Arthroscopy*

Fifty consecutive patients who had a history and clinical findings consistent with internal derangement of the wrist were prospectively entered into a study to compare the findings of triple-injection arthrography with those of arthroscopy of the wrist with use of three portals. Twenty-six patients were men, and twenty-four were women. They had an average age of thirty-six years (range, eighteen to seventy years). The average duration of symptoms in the wrist was eight months (range, one to twenty-four months). The arthrograms of the wrist, which included cineradiographs, were all made and evaluated by the same radiologist. The arthroscopic evaluation of the wrists was performed by two hand surgeons who had previous knowledge of the arthrographic findings. The abnormal findings included in this study were limited to those that should be detectable with both arthrography and arthroscopy. These were full-thickness tears of the scapholunate ligament, the lunotriquetral ligament, and the triangular fibrocartilage. The findings of arthrography were normal in eighteen wrists, demonstrated a single lesion in twenty-one, and demonstrated multiple lesions in eleven. Twelve wrists were noted to have a tear of the scapholunate ligament; fifteen, a tear of the lunotriquetral ligament; and eighteen, a tear of the triangular fibrocartilage. The arthroscopic findings were normal in six wrists, demonstrated a single lesion in twenty-five, and demonstrated multiple lesions in nineteen. Twenty-two wrists were noted to have a tear of the scapholunate ligament; fifteen, a tear of the lunotriquetral ligament; and thirty, a tear of the triangular fibrocartilage. When compared with arthroscopy of the wrist, the sensitivity, specificity, and accuracy of triple-injection cinearthrography in detecting tears of the scapholunate ligament, lunotriquetral ligament, and triangular fibrocartilage, as a group, were 56, 83, and 60 per cent. Although arthrography of the wrist is a well accepted diagnostic modality in the evaluation of pain in the wrist, this study suggests that normal arthrographic findings do not necessarily rule out the possibility of internal derangement of the wrist.

Treatment of de Quervain's disease

This study compared the use of a mixed steroid/lidocaine injection alone, an immobilization splint alone, and the simultaneous use of both in improving symptoms in de Quervains disease. Ninety-three wrists were included in the study, with an average follow-up examination of 13 months. Complete relief of symptoms was noted in 28 of 42 wrists receiving an injection alone, 8 of 14 wrists receiving both an injection and splint, and 7 of 37 wrists receiving a splint alone. No significant difference was noted between the injection alone and injection plus splint groups. A significant difference was seen between the injection alone and splint alone groups and the injection/splint and splint alone groups. Twenty of 45 wrists that underwent operative release demonstrated a septum at the first dorsal compartment. When the need for operative release was used as an outcome result for treatment failure, the injection alone and splint alone groups demonstrated significance. We recommend the use of a mixed steroid/lidocaine injection alone as the initial treatment of choice in this condition. No additional benefit is appreciated by the addition of splint immobilization and, in fact, patients are less restricted with a lower financial burden without its use.

Electrodiagnostic testing and carpal tunnel release outcome

This study examined the correlation of electrodiagnostic test results and symptom outcome after carpal tunnel release. After meeting specific inclusion and exclusion criteria and failing conservative management, 167 patients (227 hands) underwent an open carpal tunnel release. Of 99 hands with a positive electromyographic/nerve conduction velocity study, 93 (93%) had resolved or improved symptoms. This finding compares with a 93% resolution or improvement rate in 27 hands with a negative electromyographic/nerve conduction velocity study and a 93% resolution or improvement in postoperative symptoms in 101 hands on which no electromyographic/nerve conduction velocity study had been performed. Statistical analysis demonstrated no significant differences in final symptom status after carpal tunnel release when comparing patients who had positive, negative, or no electrodiagnostic preoperative testing. Given specific clinical criteria for establishing the diagnosis of carpal tunnel syndrome, electrodiagnostic testing does not appear to correlate with improved final symptomatic outcome after carpal tunnel release.

Ulna-shortening osteotomy after failed arthroscopic debridement of the triangular fibrocartilage complex.

Over a 4-year period, 160 wrist arthroscopies were performed at 1 institution. Ninety-seven patients had central or nondetached ulnar peripheral tears of the triangular fibrocartilage complex (TFCC). All these patients underwent debridement with an arthroscopic shaver. Thirteen of the 97 had persistent pain in the TFCC region for more than 3 months after surgery. At an average of 8 months after failed arthroscopic debridement of the TFCC, all 13 patients underwent a 2-mm-long ulna-shortening osteotomy with fixation by a 3.5-mm 6-hole dynamic compression plate. At follow-up examination (an average of 2.3 years later), 12 of the 13 had complete relief of pain at the ulnar side of the wrist. One patient continued to complain of pain with moderate to heavy activity use of her hand. Four of the 13 had postoperative complications: 1 had traumatic pull-out of the screws requiring reinsertion and distal radius bone graft, 1 had nonunion at 4 months after surgery that required iliac crest bone graft, and 2 had pain necessitation hardware removal. All 4 of these patients had no further problems at final follow-up evaluation. There was no statistically significant difference between the arthroscopic debridement alone cohort and the arthroscopy/ulna-shortening subgroup relative to ulnar variance or incidence of associated lunotriquetral ligament tears. On the basis of these findings the authors recommend a 2-mm-long ulna-shortening osteotomy for patients whose previous arthroscopic debridement for central or nondetached peripheral TFCC was unsuccessful in eliminating ulnar-sided wrist pain.

Distal unicondylar fractures of the proximal phalanx.

The records of 38 consecutive patients (38 fractures) who underwent treatment for distal unicondylar fractures of the proximal phalanx were reviewed to evaluate fracture characteristics, mechanism of injury, treatment options, and functional outcomes. Four classes of fracture pattern were defined radiographically. Most fractures occurred during ball sports and involved an axial splitting of extended digits, with the condyle closet to the midline of the hand fracturing most commonly. We believed that the fracture occurred as a result of tension loading due to a distraction force from the collateral ligament. All fractures healed. Follow-up examination averaged 3 years. Five of seven nondisplaced fractures treated with splinting and four of ten displaced fractures treated with reduction and single Kirschner wire fixation displaced. Fractures treated with multiple Kirschner wire fixation had the best final joint motion. Class IV fractures with a small palmar coronal fragment had the poorest final motion. A short period of post-operative immobilization did not adversely affect final proximal interphalangeal joint motion. We recommend multiple Kirschner wire or miniscrew fixation of these fractures as the most predictable method of treatment. Final proximal interphalangeal joint motion is not uniformly excellent in patients with these fractures.

Upper extremity function after wrist arthrodesis.

Several studies have examined the normal range of wrist motion used to accomplish activities of daily living. Little information is present, however, on what functional limitations might be experienced by patients actually undergoing formal wrist arthrodesis. This study undertook comprehensive functional evaluation of 23 patients who underwent wrist arthrodesis for post-traumatic conditions. Follow-up evaluation averaged 54 months and consisted of a clinical questionnaire, the Jebsen Hand Function Test, and a functional rating devised by Buck-Gramcko/Lohmann. Fifteen of the 23 patients returned to their original jobs, and all patients noted that although the vast majority of tasks could still be performed, these tasks were undertaken in a modified fashion. The most difficult daily tasks for patients with a wrist arthrodesis to perform involved perineal care and manipulating the hand in tight spaces. The Jebsen Hand Function Test demonstrated a 64% task completion rate with the fused wrist compared to a 78% task completion rate for the normal wrist. The Buck-Gramcko/Lohmann evaluations demonstrated an average score of 8.3 out of a possible 10. Patients who have undergone wrist arthrodesis can accomplish most activities of daily living and other functional requirements, although some adaptation to accomplish these tasks is required.

Treatment of trigger finger in patients with diabetes mellitus

We present a retrospective study of 54 diabetic patients with 121 trigger digits treated over a 3-year period by one to three injections of corticosteroid mixed with local anesthetic. As a group, diabetic patients responded less favorably to treatment by steroid injection (50% symptom resolution) when compared to reported outcomes of steroid injection treatment for stenosing tenosynovitis in the general population. Insulin-dependent diabetic patients have a higher incidence of multiple digit involvement (59% of patients) and of requiring surgical release for relief of symptoms (56% of digits) when compared to non-insulin-dependent diabetic patients (28% of patients with multiple digit involvement; 28% of digits requiring surgery).