James M. McLean

Translunate fracture with associated perilunate injury: 3 case reports with introduction of the translunate arc concept.

We report 3 cases of translunate fractures with associated perilunate dislocations (or subluxation). We believe the translunate injury reflects a higher-velocity trauma and produces further destabilization of the carpus when compared with the established greater and lesser arc injuries. A modification to Johnsons perilunate injury classification system is proposed: the addition of a translunate arc injury subgroup, which would include all perilunate injuries with translunate fractures.

An association between lunate morphology and scaphoid-trapezium-trapezoid arthritis

The purpose of this study was to determine if an association exists between scaphoid–trapezium–trapezoid arthritis and lunate morphology. Plain neutral posteroanterior radiographs were evaluated for 48 patients with STT arthritis and 96 patients from a control group. Lunate type was determined using capitate–triquetrum (C-T) distance. A type I lunate was defined as a C-T distance ≤2 mm. A type II lunate was defined as a C-T distance ≥4 mm. Lunate type was recorded and compared between those with STT arthritis and a control group. The groups were similar with regard to age, gender and handedness. Type II lunates were found in 83% of cases with STT arthritis and in 64% of controls. STT OA was associated with type II lunate wrists (P = 0.02; OR = 0.35; CI: 0.15–0.82). We postulate that variations in scaphoid motion secondary to lunate morphology may contribute to the development of STT OA.

Cable-augmented, quad ligament tenodesis scapholunate reconstruction: rationale, surgical technique, and preliminary results.

Eight patients underwent scapholunate reconstruction using tensionable suture anchors. Adapted from a modified Brunelli technique, the anchors provide a fixed cable that reduces the scapholunate diastasis and maintains reduction during the healing phase. The flexor carpi radialis tendon graft is advanced through the scaphoid and stabilizes the volar scaphotrapezial ligament, dorsal scapholunate ligament, dorsal intercarpal ligament, and dorsal radiocarpal ligament. The ligament-sparing approach is closed using an ulnar advancement capsulodesis that further reinforces the dorsal intercarpal and dorsal radiocarpal ligament. Good clinical results were obtained. Measured on a visual analog scale (0 to 10), the average pain score improved from 5.8 to 2.1, average patient satisfaction was 7.6, average extension was 56 degrees (91% of contralateral side), flexion was 44 degrees (70% of contralateral side), and grip was strength 41 kg (95% of contralateral side). Radiographic parameters were less favorable. The average scapholunate angle was 71 degrees, radiolunate angle 16 degrees, and scapholunate interval 3.0 mm. The cable-augmented, quad ligament scapholunate ligament reconstruction offers theoretical advantages over previously published techniques, but long-term follow-up is required.

Imaging Recognition of Morphological Variants at the Midcarpal Joint

PURPOSE To compare the imaging methods for identifying the various morphological variations of the articular surfaces at the midcarpal joint. METHODS Thirteen cadaveric wrists were examined by plain neutral anteroposterior radiographs; 2-dimensional computed tomography (CT); 3-dimensional CT reconstruction, and 3-tesla magnetic resonance imaging (MRI). Carpal measurements were performed, and the parameters that defined the scaphoid, lunate, hamate, and capitate morphological types were investigated, with dissection being used as the definitive measure of morphology. The dissection findings were compared to the results of each imaging technique to determine the accuracy of morphological determination from each technique. RESULTS Lunate type was the most accurately identified morphological variant amongst all imaging techniques. Lunate type was most accurately determined from coronal MRI. A lunate with a small, cartilaginous ulnar facet (intermediate type) could be differentiated only by coronal MRI and dissection. Scaphoid type could not be determined accurately using any of the imaging modalities described. Capitate type was most accurately determined from coronal MRI. However, flat and spherical-type capitates could not be routinely differentiated from V-shaped capitates. Hamate type was most accurately determined from 3-dimensional CT reconstruction. CONCLUSIONS Accurate identification of carpal bone morphology is required to improve our understanding of carpal mechanics and pathology. Not all morphological features can be identified radiographically. Direct visualization is required to differentiate types of scaphoid, and to differentiate V-type capitates. MRI provides the most accurate identification of lunate type, and 3-dimensional CT provides the best method of differentiating hamate types.

Repair of the acutely unstable elbow: use of tensionable anchors.

Acute ruptures of the medial or lateral collateral ligaments of the elbow associated with elbow dislocations have traditionally been repaired back to their respective epicondyles using suture anchors or transosseous sutures. Tensioning of those ligaments using conventional techniques had been difficult because of the need to maintain tension while tying and securing sequential knots. Tensionable anchors are a new generation of anchors that have been used for rotator cuff repair, but can be employed for the repair of collateral ligaments and capsular tears. It allows fine control and sequential tensioning of the ligament repair, and on-table assessment of stability before locking the anchor. We present a modified surgical technique for the repair of collateral ligaments repair using tensionable anchors in acute elbow dislocations or fracture dislocations.

An international, multicenter cohort study comparing 6 shoulder clinical scores in an asymptomatic population

HYPOTHESIS The study purpose was to assess 6 shoulder patient-reported outcome measure (PROM) values in asymptomatic, healthy, pathology-free individuals. We hypothesized that there would be no difference in PROM values in pathology-free individuals when considering sex, age, ethnicity, and geographical location. METHODS Electronic questionnaires were completed by 635 individuals (323 Australians and 312 Canadians) without dominant shoulder pathology for the American Shoulder and Elbow Surgeons (ASES) shoulder score; Constant-Murley Shoulder Score (CSS); Oxford Shoulder Score (OSS); University of California, Los Angeles (UCLA) shoulder score; Shoulder Pain and Disability Index (SPADI); and Stanmore Percentage of Normal Shoulder Assessment (SPONSA). Shoulder range of motion and strength were assessed. RESULTS No difference was identified between subjective-only and subjective-objective PROMs. Handedness and a current elbow or wrist problem were not associated with differences in PROM values. Poorer PROM values were associated with a history of an inactive shoulder problem and increasing age. Female participants tended to report similar or poorer PROM scores. No significant difference was found between ethnicities. Geographical location was associated with differences in the ASES shoulder score, UCLA shoulder score, and SPADI but not the CSS, SPONSA, and OSS. CONCLUSIONS Differences in sex, age, and geographical location will affect PROM shoulder scores in pathology-free individuals and should be taken into consideration when PROMs are being used to compare patient outcomes. This study has established normative values for the ASES shoulder score, CSS, OSS, UCLA shoulder score, SPADI, and SPONSA. Future studies assessing a pathologic patient cohort should perform comparisons against a sex- and age-matched control cohort, ideally sourced from the same geographical location.

Cable-Augmented, Quad Ligament Tenodesis Scapholunate Reconstruction.

Maintaining reduction of the scapholunate interval after reconstruction can be difficult. The authors performed scapholunate reconstruction using tensionable suture anchors in 8 patients. The anchors provide a fixed cable that both fixes the graft, and reduces the scapholunate diastasis and maintains reduction. The flexor carpi radialis tendon graft stabilizes not only the volar scaphotrapezial ligament, and dorsal scapholunate ligament, but also the dorsal intercarpal and dorsal radiocarpal ligament. The Berger flap is closed using an ulnar advancement capsulodesis that further reinforces the dorsal intercarpal and dorsal radiocarpal ligament. The mean pain score improved from 5.8 to 2.1. Mean extension was 56° (91% of contralateral side), flexion 44° (70% of contralateral side), and grip strength was 41kg (95% of the contralateral side). The mean scapholunate angle was 71°, radiolunate angle 16° and scapholunate interval 3.0 mm. The cable augmented, quad ligament scapholunate ligament reconstruction offers theoretical advantages but long term follow up is required.

A modified ulnar translocation reconstruction technique for Campanacci grade 3 giant cell tumors of the distal radius using a clover leaf plate.

Background: Campanacci grade 3 giant cell tumors of the distal radius are locally aggressive and in close proximity to the median nerve, articular cartilage, flexor and extensor tendons, and the radial artery. Although several reconstructive techniques have been described, it is unclear to what degree these procedures restore function. Description of Technique: We present a modified ipsilateral ulna translocation technique using a clover leaf plate, for reconstruction of en bloc resected distal radius. This has the theoretical advantage of ensuring a solid, pain-free wrist arthrodesis, while preserving the forearm rotational axis and minimizing functional loss, without the associated donor site morbidity or allograft rejection issues of other reconstructive techniques. Patients and Methods: Between 2006 and 2013, 3 patients underwent this procedure for Campanacci grade 3 giant cell tumors. All patients were right hand–dominant females, aged 24, 35, and 46 years, respectively. Two cases involved the right radius. Patients were reviewed retrospectively with clinical examination, functional assessment [the Toronto Extremity Salvage Score (TESS) for upper limb], and radiographs. The review period was 30, 51, and 41 months, respectively. Results: The length of distal radius resected was 70, 50, and 35 mm, respectively. All achieved clear margins. There were no complications and there have been no recurrences. All ulnocarpal translocations achieved radiographic fusion. Patient’s averaged 80-degree pronation, 70-degree supination, and clinical TESS scores of 86 at most recent follow-up. Conclusions: This technique achieved a painless and functional wrist arthrodesis with partially restored wrist motion, without complications. This technique has the advantage of negating remote donor site morbidity and/or allograft rejection issues of other techniques. Level of Evidence: Level III, therapeutic study.

Normal population reference values for the Oxford and Harris Hip Scores - electronic data collection and its implications for clinical practice.

Background The aim of this study was to assess whether the Harris Hip Score (HHS) and the Oxford Hip Score (OHS) were comparable in normal, healthy, pathology-free individuals of different age, gender, ethnicity, handedness and nationality. The purpose of this study was to establish normal population values for the HHS and OHS using an electronic data collection system. Methods 317 Australian and 310 Canadian citizens with no active hip pain, injury or pathology in the ipsilateral hip corresponding to their dominant arm, were evaluated. Participants completed an electronically-administered questionnaire and were assessed clinically. Chi-square tests, Fishers exact test and Poisson regression models were used where appropriate, to investigate the association between hip scores, ethnicity, nationality, gender, handedness and age. Results There was a statistically significant association between the OHS and age (p<0.0001) and the HHS and age (p = 0.0006); demonstrating that as age increased, normal hip scores decreased. There was no statistically significant association between the HHS and gender (p = 0.1389); or HSS and nationality, adjusting for age (p = 0.5698) and adjusting for gender (p = 0.6997). There was no statistically significant association between the OHS and gender (p = 0.1350). Australians reported a statistically significant 4.2% higher overall OHS value compared to Canadians (p = 0.0490). There was no statistically significant association between the OHS and nationality in age groups 18-79 years. Participants >80 years reported a statistically significant association between the OHS and nationality (p<0.0001). Conclusions Studies using an electronic control group should consider differences in gender, age, ethnicity and nationality when using the HHS and OHS to assess patient outcomes. This study has established an electronic, normal control group for studies using the HHS and OHS. When using the OHS, the control group should be sourced from the same country of origin. When using the HHS, the control group should be sourced from a pre-established control group within a database, without necessarily being sourced from the same country of origin.

Asymptomatic reference values for the Disability of Arm, Shoulder and Hand and Patient-Rated Wrist/Hand Evaluation – electronic data collection and its clinical implications

The purpose of this study was to establish normal asymptomatic population values for the Disability of Arm, Shoulder and Hand and Patient-Rated Wrist/Hand Evaluation in healthy, asymptomatic individuals of different age, gender, ethnicity, handedness and nationality, using electronic data collection. Two-hundred and ninety-two Australian and 293 Canadian citizens with no active wrist pain, injury or pathology in their dominant hand, were evaluated. Participants completed an electronically administered questionnaire and were assessed clinically. There was no statistically significant association between both wrist scores and nationality. There was a statistically significant association between both wrist scores and age, demonstrating that as age increased, normal wrist function declined. This study has established an electronic, asymptomatic control group for future studies using these scores. When using the Disability of Arm, Shoulder and Hand and Patient-Rated Wrist/Hand Evaluation, the control group can be sourced from a pre-established control group within a database, without necessarily being sourced from the same country of origin. Level of evidence: II