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Purpose: If early active motion after 3-ligament tenodesis is safe, it may yield more patient comfort and an early return to activities. Therefore, the aim of this study was to investigate whether early active motion is noninferior to late active motion after 3-ligament tenodesis for scapholunate interosseous ligament injuries. Methods: This prospective, multicenter cohort study, using a noninferiority design with propensity score matching, compared a late active motion protocol (immobilization for 10–16 days, wrist therapy in weeks 5–6) with an early active motion protocol (immobilization for 3–5 days, wrist therapy during week 2). Patients who were older than 18 years, had complete baseline information on demographics, and underwent 3-ligament tenodesis were included. The outcome measures were postoperative Patient-Reported Wrist/Hand Evaluation scores, pain, complications, return to work, range of motion, grip strength, and satisfaction with treatment results at 3 months of follow-up. Results: After propensity matching, a total of 108 patients were included. Patient-Reported Wrist/Hand Evaluation and pain scores during physical load following an early active motion protocol were noninferior compared with scores following a late active motion protocol. Furthermore, early active motion did not lead to an increase of complications, differences in range of motion or grip strength, or less satisfaction with the treatment result. An earlier return to work was not observed. Conclusions: Early active motion leads to noninferior results without more complications as compared with late active motion. Based on these findings, early active motion can be considered safe, and might be recommended due to its potential benefits compared with late active motion after 3-ligament tenodesis. Type of study/level of evidence: Therapeutic III.

Purpose The combination of scaphoid rotatory subluxation , dorsal intercalated segment instability, and dorsal scaphoid translation (DST) constitutes stage 5 scapholunate dissociation in the modified classification system of Garcia-Elias. The purpose of this study was to compare the static radiographic outcomes of reduction and association of the scaphoid and lunate (RASL), three-ligament tenodesis (TLT), and anatomic front and back (ANAFAB) reconstructions for stage 5 scaphoid and lunate malrotation and translation. Methods Stage 5 scapholunate dissociation was created in 15 fresh-frozen specimens by cutting the scapholunate interosseous ligament, long radiolunate ligament, dorsal intercarpal ligament, and scaphotrapeziotrapezoid ligament complex. Specimens were randomized to receive 1 of the 3 reconstructive techniques. Radiolunate angle (RLA), scapholunate angle, scapholunate gap, and DST were measured in static fluoroscopic posteroanterior and lateral views in 3 conditions: baseline, injured, and reconstructed. Results Reduction and association of the scaphoid and lunate showed an improved correction of scapholunate gap compared with TLT and ANAFAB. Anatomic front and back demonstrated an improved correction in RLA and scapholunate angle compared with RASL but not TLT. When the reconstruction was compared with baseline, there was a persistent lunate extension for TLT (RLA and scapholunate angle) and RASL (RLA); however, no significant difference in any parameter was found with ANAFAB. Anatomic front and back significantly improved DST, whereas TLT and RASL did not. Conclusions In this cadaveric model of scapholunate dissociation with dorsal intercalated segment instability and DST, each of the 3 repairs had different effects on carpal posture and alignment. While only RASL statistically improved scapholunate gap, only ANAFAB significantly improved DST. Both TLT and RASL improved radiographic parameters; however, each had a persistent increase in the lunate extension following reconstruction. Clinical relevance It may be prudent to consider different reconstructive techniques for different stages of scapholunate instability. Anatomic front and back, a repair that addresses both dorsal and volar ligament stabilizers, provides improved reduction of dorsal intercalated segment instability and DST in stage 5 scapholunate dissociation.

Purpose This study evaluated the biomechanics of Geissler IV (G4) wrists in cadavers and compared them with intact specimens after multiple ligament sectioning to create scapholunate instability. It also evaluated carpal motion changes after sectioning of the lunotriquetral interosseous ligament (LTIL). Methods Eight cadaver wrists determined to be G4 arthroscopically were tested using a wrist joint motion simulator. The LTIL was then sectioned, and carpal motion was recorded again. Carpal motions were compared with 37 normal wrists after sectioning of the scapholunate interosseous ligament and other ligaments to create a G4 wrist. Results Carpal motion of the 37 normal wrists after ligamentous sectioning was similar to motion of the 8 specimens noted to be G4. These wrists did not demonstrate subluxation of the scaphoid that may occur after ligament sectioning. After sectioning of the LTIL, there were significant changes in lunate and triquetral motion. Conclusions These findings support the hypothesis that sectioning multiple ligaments in normal wrists to create scapholunate instability causes average motion comparable to that seen in G4 wrists. Ligamentous sectioning can cause a range of scaphoid instability. Lunotriquetral interosseous ligament sectioning in native G4 wrists caused greater changes in triquetral than scaphoid range of motion. Clinical relevance Patients with arthroscopically determined G4 lesions have an incompetent SLIL and scapholunate instability but do not necessarily have scapholunate dissociation and subluxation. Cadaver studies that evaluate instability by sectioning specific intact wrist ligaments are similar to the G4 specimens and thus are a good approximation of naturally occurring wrist instability. The functionality of secondary stabilizers not seen arthroscopically may explain the differences in motion. Geissler IV wrists and ligament-sectioned wrists are points on the spectrum of carpal instability, which is determined by the extent of damage to multiple ligamentous structures.

PURPOSE The purpose of this study was to evaluate a series of intra-articular distal radius fractures (DRFs) to determine whether patients without radiographic evidence of scapholunate (SL) ligament injury have a difference in outcomes in comparison with patients with radiographic evidence of SL ligament injury and no ligament repair or reconstruction. Our hypothesis is that there are no significant differences in outcomes between patients after treatment of their intra-articular DRF. METHODS A retrospective analysis of patients from a single institution who sustained an intra-articular DRF from January 2006 through January 2019 with minimum 12-month (n = 192) and 24-month (n = 100) follow-up was performed. Patient demographic, clinical, and outcome variables were compared between SL angles less than 70° (cohort 1) and SL angles 70° or greater (cohort 2). Radiographic parameters were measured and recorded at 3 time points: baseline in the contralateral wrist, following closed reduction but prior to surgical intervention, and at final follow-up. Outcomes collected included Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Modified Global Assessment of Function (mGAF), and a visual analog scale (VAS) for pain. RESULTS One hundred ninety-two patients were included. Of these 192 patients, cohort 1 (n = 110) was observed to have median (range) SL angles of 58° (42°-68°) and cohort 2 (n = 82) median (range) SL angles of 74.5° (70°-87°) after closed reduction. Cohort 2 had statistically significant increases in median SL angles from closed reduction to final follow-up (74.5° [range, 70°-87°) to 78.5° (range, 71°-107°). There were no statistically significant differences in QuickDASH disability scores, mGAF scores, and VAS pain scores between the cohorts at initial and final follow-ups. CONCLUSIONS Patient-reported outcomes at 12 and 24 months do not differ between patients without radiographically apparent SL ligament injury (SL angles < 70°) and patients with radiographically apparent SL ligament injury(SL angles ≥ 70°) who do not undergo ligament repair or reconstruction following treatment of their intra-articular DRF. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Purpose To assess the validity and reliability of the posterior radioscaphoid angle (PRSA), an indicator of dorsal displacement of the scaphoid, in distinguishing wrists with and without chronic scapholunate instability (SLI). Methods We prospectively evaluated 40 patients (22 men and 18 women; mean age, 46 ± 13 years) with suspected SLI with radiographs and computed tomography arthrography. Based on these data, 3 groups were defined: positive SLI (n = 16), negative SLI (n = 19), and questionable SLI (n = 5). An independent reader measured the PRSA on sagittal computed tomography images using the same procedure. Results The PRSA median values were significantly lower in the negative SLI group (98°) compared with the positive SLI (110°) and questionable SLI (111°) groups. The difference between the positive SLI and questionable SLI groups was not significant. The best differentiation between patients with and without SLI was obtained with a PRSA threshold value of 103° (specificity of 86% and sensitivity of 79%). Conclusions In this preliminary study, PRSA analysis offers a quantitative tool for the evaluation of dorsal scaphoid displacement in cases of SLI, including for patients presenting with questionable initial radiography findings. Type of study/level of evidence Diagnostic II.

Most current surgical techniques for scapholunate interosseous ligament injuries address the dorsal component only. Previously, volar capsulodesis has been described either as an open approach or an "all-inside" technique. In this article, we report an alternative arthroscopic technique to address volar scapholunate interosseous ligament injuries. Arthroscopic-assisted volar scapholunate capsulodesis may be considered in the treatment algorithm for volar scapholunate interosseous ligament injuries.

Purpose: This study compared the interobserver agreement of arthroscopic classification of suspected scapholunate interosseous ligament (SLIL) pathology with and without midcarpal arthroscopy to help inform diagnostic strategies. It also measured the association of midcarpal arthroscopy with recommendations for reconstructive surgery. The association of midcarpal arthroscopy with the type of surgery recommended was also studied. Methods: Fourteen consecutive videos of diagnostic radiocarpal and midcarpal wrist arthroscopy for suspected SLIL pathology were selected. An international survey-based experiment was conducted among upper extremity surgeons of the Science of Variation Group. Participants were randomized to view either radiocarpal arthroscopic videos or radiocarpal and midcarpal videos. Surgeons rated SLIL pathology according to the Geissler classification and recommended surgical or nonsurgical treatment. If surgical treatment was recommended, they indicated the type of procedure. Results: The interobserver agreement for the Geissler classification was slight/fair for observers who reviewed midcarpal and radiocarpal videos and for those who viewed radiocarpal videos only. Viewing midcarpal videos was associated with higher pathology grades, the recommendation for reconstructive surgery, and a preference for tenodesis over scapholunate ligament repair. Conclusions: Diagnostic wrist arthroscopy for a wrist with normal radiological alignment has poor interobserver agreement. Clinical relevance: The pursuit of a pathology that accounts for wrist symptoms in a nonspecific interview and examination and normal radiographs is understandable; however, the low reliability of the scapholunate pathology of diagnostic arthroscopy might be associated with more potential harm than benefit.

We describe a new radiologic test to assess the integrity of the scapholunate ligament in dynamic scapholunate dysfunction.A bilateral forearm-holding device was designed to perform a comparative radiographic assessment of the scapholunate joint gap during resisted isometric contraction of the extensor carpi ulnaris muscle with full supination of the forearm. The concept is based on the known scaphoid pronation effect of this muscle. Clinical data from 12 patients were collected retrospectively and used to analyze the patients' symptomatic and asymptomatic (contralateral) wrists with a newly developed test called the Bilateral Ulnar Deviation Supination (BUDS) test. A wrist arthroscopy was performed in all cases as a reference standard for the radiologic test.The test was positive in 7 patients, with a mean scapholunate joint gap of 4.8 mm. The mean differences in the scapholunate joint gaps between both wrists were 2.6 mm in BUDS-positive patients and 0.2 mm in BUDS-negative patients. A Geissler stage III or IV scapholunate ligament rupture was confirmed in all BUDS-positive patients; by contrast, BUDS-negative patients exhibited either no lesion or a Geissler stage I injury.The BUDS test is a new radiologic test based on proven biomechanical effects that is able to accurately assess dynamic scapholunate dysfunctions. The analysis carried out found a correlation between radiographic and arthroscopic findings. Further research is needed to confirm the validity and reliability of the test.Therapeutic III.

Purpose The purpose of this study was to identify associations between the clinical manifestations of carpal tunnel syndrome (CTS) and the sonographic measurements of the median nerve in the carpal tunnel. We hypothesized that sonographic changes in the median nerve from proximal to distal along the carpal tunnel would be associated with symptom severity scores. Methods We report on 38 patients with clinical signs and symptoms of CTS in a prospective investigation. Subjects underwent sonographic evaluation with measurement of median nerve cross-sectional area (CSA) at 3 locations: the level of the pronator quadratus, pisiform, and hamate. In addition, we measured dimensions of the carpal tunnel at the levels of the pisiform (inlet) and hamate (outlet). Finally, we recorded maximal thickness of the transverse carpal ligament (TCL). Patients underwent routine clinical evaluation and 31 patients had electrodiagnostic examination. Patients completed the Levine Katz Questionnaire (LKQ) to characterize severity of clinical symptoms. Each clinician was blinded to symptom severity scores. Pearson correlation coefficients were calculated to measure the relationship between LKQ score and sonographic measures. Results Median nerve CSA decreased over the course of the carpal tunnel from proximal to distal in 30 of 38 wrists. A greater absolute change in CSA of the median nerve over the course of the carpal tunnel between the pisiform and the hamate as well as between the pronator quadratus and the hamate correlated with increased severity of clinical symptoms. Increased thickening of the TCL also correlated with greater symptom severity scores. Conclusions Changes in CSA of the median nerve as well as thickening of the TCL correlate with CTS severity. Type of study/level of evidence Diagnostic II.

Purpose We sought to determine surgeon-pathologist agreement with respect to distinguishing between a previously undivided transverse carpal ligament (TCL) and scar during revision carpal tunnel release (CTR). Additionally, we aimed to describe the histologic findings of the TCL and flexor tenosynovium during revision CTR. Methods All patients undergoing revision CTR for persistent or recurrent CTS by a single surgeon between 2013 and 2019 were included. An intraoperative assessment was made as to the presence of scar versus a previously undivided TCL by the surgeon. Two pathology specimens (1 consisting of flexor retinaculum and 1 consisting of tenosynovium) were sent for histopathological analysis with hematoxylin-eosin staining. The pathologist’s assessment of the flexor retinaculum specimen was categorized as either “ligamentous” if a previously undivided TCL was identified or “nonligamentous” if scar or any other tissue was identified. The surgeon’s intraoperative assessment served as the reference standard when comparing the histologic assessment. Results A total of 40 patients underwent 46 revision CTRs. The histologic assessment agreed with the surgeon’s intraoperative assessment of a previously undivided TCL versus a scar in 30 of 46 (65%) cases. In 12 of 46 (26%) revision cases, the surgeon determined that there was a previously undivided TCL. In these 12 cases, the pathologist identified a ligament 17% of the time. Conclusions Surgeon-pathologist agreement is low with respect to determining previously undivided TCLs versus nonligamentous tissue in the setting of revision CTR. The results of this investigation suggest that pathologists (with limited clinical information) have difficulty confirming the clinical diagnosis of persistent CTS with previously unreleased TCL when using routine hematoxylin-eosin staining. Routine biopsy of the TCL during revision CTR may be of limited clinical utility, as it does not alter the diagnosis or management in these cases. Type of study/level of evidence Diagnostic III.

Purpose To compare the kinematic effects of the dorsal fiber-splitting approach for scapholunate ligament repair to a dorsal “window” approach that spares all ligaments. Methods We randomized 24 fresh-frozen paired cadaveric forearms to either the dorsal fiber-splitting capsulotomy approach (FSC) or the dorsal window approach (window) following scapholunate interosseous ligament (SLIL) division. Loaded fluoroscopic radiographs were obtained after each of the 4 testing conditions following cyclic loading (200 cycles; 71 N): (1) intact SLIL, (2) SLIL-division, (3) surgical approach , and (4) closure. FSC specimens were randomly allocated to 2 subgroups for closure with either a suture anchor (n = 6) or a simple running suture closure (n = 6). Radiographic parameter measurements included the scapholunate gap, radiolunate angle, scapholunate angle, and dorsal scaphoid translation. Results Following the FSC, there were significant alterations in all radiographic parameters when compared with the intact and SLIL-division conditions. The window approach did not result in significant changes in any radiographic parameter. When compared to the window approach, all radiographic parameters of the FSC approach were significantly altered. Following closure with suture anchors in the FSC group, radiographic parameters improved, whereas with standard closure they failed to do so. Despite anchor closure, dorsal scaphoid translation, radiolunate angle, and scapholunate angle all remained elevated compared with scapholunate-divided wrists. Conclusions The FSC produced significant changes in carpal posture under load, including scapholunate diastasis, dorsal intercalated segment instability, and dorsal scaphoid translation in SLIL-deficient wrists. The window approach preserved the critical dorsal ligament stabilizers and did not produce changes in carpal posture. Clinical relevance The FSC may create iatrogenic changes in carpal posture that cannot be fully corrected with standard or anchor closure. The window approach does not alter carpal posture and should be considered when performing surgical procedures on the scaphoid or lunate.

The COVID-19 pandemic created unprecedented challenges for the healthcare system. In order to meet capacity demands, hospitals around the world suspended surgeries deemed to be “elective.” In hand surgery, there are numerous pathologies treated on an elective basis, but a delay or absence of care may result in poorer outcomes. We present here an ethical framework for prioritizing elective surgery during a period of resource scarcity. Instead of using the term elective, we define procedures that can be safely delayed based on three considerations. First, a safe delay is only possible if deferral will not result in permanent injury. Second, a delay in care will come with tolerable costs and impositions that can be appropriately managed in the future. Third, a safe delay will preserve the bioethical principle of patient autonomy. In considering these criteria, three case examples are discussed taking into account individual patient characteristics and the pathophysiology of the condition. This framework design is applicable to ambulatory surgery in any period of crises that may strain resources, but further considerations may be important if an operation requires hospital admission.

Purpose The distinction between the dorsal intercarpal (DIC) and dorsal scaphotriquetral (DST) ligaments is imprecise and unclear in the literature. The purpose of our cadaveric study was to define the origins, insertions, and anatomic relationships of the dorsal wrist ligaments and relate these anatomic findings to magnetic resonance imaging (MRI) scans and histology. Methods The study included 17 unmatched fresh-frozen cadaveric specimens (7 male and 10 female), with a mean age of 67.1 years (range, 48–86 years). Wrists with arthritis or carpal malalignment were excluded. Ligaments were dissected and insertion sites were recorded in the radioulnar (width) and proximodistal (length) dimensions, centered at the midpoints of the insertion. Three cadaveric specimens underwent a histologic analysis to demonstrate ligament composition and insertion sites. Three additional cadavers underwent MRI, from which 3-dimensional models were built to model ligament topography. Results The conjoined triquetral insertion of the DIC, DST, and dorsal radiocarpal (DRC) measured 88.5 ± 6.4 mm2. In each specimen, there were 2 distinct deep and superficial components of intercarpal fibers. The deep component inserted on the lunate with an area of 59.0 ± 5.0 mm2. The deep and superficial components diverged as they coursed radially. The superficial component proceeded to the scaphoid ridge, trapezium, and trapezoid, whereas the deep component inserted on the proximal row. The deep fibers blended distally from their lunate insertion with the DST, forming a robust, 2.9 ± 0.8-mm wide extension over the dorsal capitate. The DRC inserted on the lunate, proximal to the DIC and DST insertions, with an area of 23.9 ± 5.4 mm2. Conclusions The dorsal ligament complex forms a firm link across the proximal carpal row and the DST provides extension of the proximal row over the capitate. Clinical relevance This information can guide surgeons while performing a dorsal approach to the wrist and repairing traumatic ligament disruption.

Purpose Selecting treatment for scapholunate (SL) instability is notoriously difficult. Many methods of reconstruction have been described, but no procedure demonstrates clear superiority. New methods proposed use internal bracing (IB) with suture anchors and flat braided suture (FBS), alone or as an augmentation with tendon autograft for SL ligament injuries . Our goal was to use computed tomography (CT) to analyze alignment of the SL joint after 3 different modes of fixation of SL instability: after reconstruction with IB incorporating either tendon autograft or the dorsal intercarpal ligament (DICL), or DICL capsulodesis without FBS. Methods Ten fresh-frozen, matched-pair, forearm-to-hand specimens were used. Serial sectioning of the SL stabilizing ligaments was performed and the SL interval was measured with CT. We reconstructed the SL ligament with DICL capsulodesis alone (DICL) or with IB augmented with either tendon autograft (IB plus T) or DICL (DICL plus IB). The SL interval was measured with CT. Specimens underwent 500 weighted cycles on a jig and were reimaged. Differences in SL interval after repair and cycling were compared. Results Dorsal intercarpal ligament capsulodesis augmented with IB best maintained the SL interval before and after cycling. Dorsal intercarpal ligament capsulodesis alone was inferior to DICL plus IB and IB plus T both before and after cycling. Conclusions Dorsal intercarpal ligament capsulodesis augmented with IB appears to maintain better SL joint reduction than IB with tendon autograft. Clinical relevance This work serves as a necessary step for further study of the biomechanical strength and clinical application of FBS technology in the reconstruction of SL instability. Flat braided suture augmentation of DICL capsulodesis may provide another option to consider for reconstruction of SL instability.

Purpose Reconstruction of the scapholunate ligament (SLL) in the setting of dynamic instability remains a surgical challenge, with lack of consensus on the best reconstructive procedure. Reconstruction of only the dorsal component may lead to volar gapping and abnormal wrist kinematics. This cadaveric active motion simulation study determined whether scapholunate (SL) motion, angulation, and contact are restored following open reconstruction using the extensor carpi radialis longus (ECRL) tenodesis , which reconstructs both the volar and the dorsal SLL components. Methods Seven fresh-frozen cadaveric upper limbs (mean age, 68 ± 10.1 years) underwent a 4-stage protocol of cyclic dart-throw motion and flexion-extension motion (utilizing an active wrist motion simulator that used tendon load/motion-controlled actuation. Scaphoid and lunate motion, relative scaphoid translation, SL angle, and dorsal-volar SL diastasis were measured with (1) wrist ligaments intact, (2) following complete sectioning of the SLL, and (3) following SL reconstruction using the ECRL tenodesis technique. Results Complete SLL sectioning resulted in a typical pattern of SL instability. Following the ECRL tenodesis, lunate extension was not corrected. Scaphoid flexion, however, was not significantly different from the native state in FEM but remained significantly flexed during dart-throw motion. Differential dorsal and volar gapping did not significantly improve following ECRL tenodesis (dorsal, 1.2–2.3 mm; volar, 1.1–1.7 mm). Conclusions This biomechanical study demonstrates that the ECRL tenodesis did not fully restore native carpal kinematics, despite dorsal and volar SLL, and scaphotrapeziotrapezoid reconstruction. Type of study/level of evidence Therapeutic IV.

Purpose Scapholunate (SL) ligament tears in the acute setting can be treated by primary repair through various techniques. The purpose of this study was to compare repair of the SL ligament with suture anchors alone versus repair of the SL ligament augmented with suture tape. Methods Twelve fresh-frozen cadavers (6 matched pairs) underwent a dorsal approach to the wrist and the SL ligament was sharply dissected off of its scaphoid attachment. Six cadavers underwent direct repair of the SL ligament using 2 suture anchors. The other 6 underwent repair of the SL ligament, which was then augmented with suture tape. All specimens then underwent load to failure testing using tensile distraction forces applied by a universal testing system. Maximum load to failure and mode of failure were recorded. Results Maximum load to failure (135 N; SD, 44.94 N) for specimens that were repaired and augmented with the internal brace was higher than that for specimens in the repair-only group (68 N; SD, 14.69 N). Conclusions Biomechanical testing demonstrated a higher maximum load to failure in SL ligament repairs augmented with suture tape compared with a repair-only technique in this cadaveric model. Clinical relevance Acute SL ligament injuries may benefit from suture tape augmentation by increasing the stability of the primary repair. This may prove to be beneficial in higher-demand patients.

Purpose To determine the contact pressures between the scaphoid and lunate and the distal radius during 2 wrist push-up positions before and following scapholunate interosseous ligament (SLIL) sectioning. Methods Eight fresh cadaveric wrists were tested in a neutral flexion-extension (knuckle) push-up position and in an extended push-up position. Pressure measurements were acquired as each wrist was loaded with the wrist in extension and with the wrist in a neutral position. Data were acquired with the SLIL intact and following sectioning of its dorsal, volar, and proximal components. The wrist was disarticulated and a map drawn on each sensor to identify each joint fossa. Results A push-up performed with the wrist in extension caused a significantly greater peak pressure in the radioscaphoid fossa but not in the radiolunate fossa. Moving the wrist into extension caused a significant dorsal movement of the pressure centroid an average of 2.9 mm in the radiolunate fossa and an average of 5.7 mm in the radioscaphoid fossa. Sectioning the SLIL caused the centroid of pressure in the radioscaphoid fossa to significantly move an average 1.4 mm radially. Conclusions A push-up with the wrist in extension causes a significant increase in the pressure in the radioscaphoid fossa but not in the radiolunate. This finding may help explain why degenerative arthritis first develops in the radioscaphoid fossa before involving the radiolunate fossa. As expected, gapping that occurs with SLIL injury was observed here as a radial translation of the scaphoid and not as a movement of the lunate. The new location of scaphoid contact may be an additional reason for the development of radioscaphoid arthritis occurring before radiolunate arthritis. Clinical relevance This study provides a possible explanation as to why degenerative arthritis may first occur in the radioscaphoid fossa.

Purpose Midcarpal instability (MCI) is a cause of chronic wrist pain for which treatment remains controversial. This study's purpose was to determine the outcome of a treatment algorithm for MCI that included immobilization and surgical interventions. Methods We prospectively enrolled 23 consecutive patients (12 males, average age 27 years) with 27 symptomatic wrists. All had generalized wrist pain with an average duration of 22 months. All had MCI and a catch-up clunk that reproduced the symptoms. Initial treatment was full immobilization for 6 weeks. When necessary, recurrence after immobilization was treated with an anatomically based surgical procedure to plicate the dorsal capsule and extrinsic ligaments to stabilize the midcarpal joint. Failure of surgical plication was followed by 4-corner intercarpal arthrodesis when necessary. Patients were observed for instability, grip strength, wrist motion, and Patient-Rated Wrist Evaluation. Results For 22 wrists there was partial relief of symptoms with full-time cast or orthosis immobilization; however, symptoms quickly returned with mobilization. The other wrists had previously been immobilized and patients refused further nonsurgical care. All patients underwent surgical plication of the dorsum of the wrists. Postoperative follow-up (35 months) showed statistically significant improvements in grip strength and Patient-Rated Wrist Evaluation scores. All patients had improved pain at final follow-up. Most improvement was in female patients aged under 25 years, with hypermobility and without major traumatic or work-related injuries. This contrasted with poorer outcomes in men aged over 25years who had moderate or severe trauma that was mostly work-related. Instability recurred in 2 patients who then had a 4-corner arthrodesis. Conclusions Immobilization was not successful in controlling pain and recurrence of instability in patients with MCI. Surgical midcarpal capsular plication was less effective in men with posttraumatic instability. The capsular plication procedure was successful in young female patients with ligament laxity and a history of only minor or repetitive trauma and no history of major trauma. Type of study/level of evidence Therapeutic IV.

Purpose To compare standardized functional and patient-reported early outcomes following trapeziometacarpal arthrodesis (TMA) using a locking cage plate construct with trapezial excision, ligament reconstruction, and tendon interposition (LRTI). Methods This prospective cohort enrolled 50 consecutive patients with trapeziometacarpal osteoarthritis undergoing TMA or LRTI. Demographic data, objective measurements, Sollerman function testing, and patient-reported outcomes were collected before surgery and at various time intervals up to 12 months after surgery. The study was powered to detect a minimally clinically important difference on the Michigan Hand Questionnaire between groups at 12 months. To account for selection bias, we performed between-group statistical analysis of the magnitude of change from preoperative to postoperative data. All complications were recorded. Results There were no significant differences in the amount of change in grip or pinch strength, patient-reported outcomes, or functional hand testing between TMA and LRTI. The TMA group had significantly increased thumb tip opposition distance. The TMA group was complicated by a 26% overall nonunion rate of which 8% were symptomatic. The LRTI group (Wagner incision) had a significantly increased incidence of superficial branch of the radial nerve paresthesia. The incidence of complications was similar between operative groups, but revision surgery was more common after TMA. Conclusions Compared with LRTI, TMA failed to demonstrate superior improvement in strength, standardized functional performance, or patient-reported function and is associated with an increased likelihood of revision surgery in the first 12 months. Trapeziometacarpal arthrodesis with a locking plate and screw construct does not ensure union, although most radiographic nonunions were asymptomatic. Wagner incisions are associated with a significantly increased incidence of superficial branch of the radial nerve paresthesia compared with dorsal trapeziometacarpal exposure. Type of study/level of evidence Therapeutic II.

Purpose The deep component of the distal radioulnar ligament provides translational stability and rotational guidance to the forearm. However, controversy exists regarding the importance of this structure as well as the nature of its attachment to the distal ulna. We aimed to evaluate the topographic anatomy of the distal ulna attachment of both the superficial and the deep components of the radioulnar ligament and to assess the relationship between its internal and its external morphometry. Methods Thirteen human distal ulnae attached by ulnar part of the distal radioulnar ligament were scanned using micro–computed tomography and reconstructed in 3 dimensions. In addition, the distal radioulnar ligaments were examined under polarized light microscopy to determine the histological characteristics of collagen contained within the ligaments. Results The deep limbs have broad marginal insertions at the fovea, whereas the superficial limbs have a circular and condensed insertion to the ulnar styloid. The center of the deep limb was separated from the base of the ulnar styloid by a mean of 2.0 ± 0.76 mm, and this distance was positively correlated with the width of the ulnar styloid. The mean distance between the center of the ulnar head and the center of the fovea was 2.4 ± 0.58 mm. The proportion of collagen type I was lower in the deep limb than in the superficial limb. Conclusions This new observation of the footprint of the radioulnar ligament in the distal ulna indicates that the deep limb may serve as an internal capsular ligament of the distal radioulnar joint, whereas the superficial limb as the external ligament. Clinical relevance Knowledge of the topographic anatomy of the radioulnar ligament’s attachment to the distal ulna may provide a better understanding of distal radioulnar ligament–related pathologies.

Purpose To test the null hypothesis that there is no difference in patient-reported and objective outcomes of revision ligament reconstruction and tendon interposition (LRTI) compared with primary LRTI. Methods This case-control investigation enrolled 10 patients who had undergone revision LRTI at a tertiary care center. All patients had previously undergone primary trapeziectomy with LRTI. Patients with a minimum of 2 years' follow-up were eligible. All patients completed an in-office study evaluation. Controls (treated only with primary LRTI) were matched from our practice to reach a 1:2 case–control ratio. Outcome measures included Michigan Hand Questionnaire (primary outcome), Quick –Disability of the Arm, Hand, and Shoulder ( Quick DASH) questionnaire, visual analog scale (VAS) for pain and improvement, and physical examination. Statistical analyses were conducted to compare patient groups. Results Patients who underwent revision LRTI reported significantly worse outcomes on all measured standardized questionnaires compared with primary patients. The Michigan Hand Questionnaire indicated worse overall outcomes (54 vs 79) as well as worse pain, appearance, and ability to complete activities of daily living. Compared with those who did not undergo revision LRTI, patients who did also reported more impairment ( Quick –Disability of the Arm, Hand, and Shoulder, 47 vs 23), greater pain (VAS pain, 6.3 vs 1), and less improvement after surgery (VAS improvement, 2.7 vs 7.9). There was also a significantly higher rate of patient-reported depression in the revision LRTI group (50% vs 10% of patients treated with primary LRTI). We did not find a significant difference in objective outcomes of pinch strength, grip strength, and thumb palmar abduction between the 2 groups. Conclusion After revision LRTI, patient-reported outcomes indicate worse perceived function and greater pain than are expected following primary LRTI despite similar motion and strength. Revision surgery can be offered in the setting of persistent or recurrent symptoms, but patients should be counseled that improvement of symptoms is unpredictable. Type of study/level of evidence Therapeutic III.

Purpose Although scapholunate interosseous ligament (SLIL) injury is often associated with distal radius fracture, it is frequently missed in x-rays. The purpose of this study was to develop a diagnostic classification based on ultrasonography for SLIL injury and evaluate its diagnostic accuracy. Methods Patients who required surgery for distal radius fracture were included in this study. Ultrasonography and arthroscopy were performed in all patients. The original ultrasonography-based classification of the dorsal part of SLIL was developed as follows: for type A, the SLIL surface was outlined clearly as a continuous flat line; for type B, the SLIL surface was outlined clearly as a continuous bulged line; and for type C, the SLIL surface was not continuous, smooth, or outlined clearly. Arthroscopy was performed at the time of osteosynthesis. We classified its findings according to the arthroscopic classification system of Geissler et al and evaluated interobserver and intraobserver reliabilities for our classification on ultrasonography. We also studied the relationship between the ultrasonographic and arthroscopic classifications. Results In total, 40 patients were included in this study. Weighted κ values for interobserver and intraobserver reliabilities for our ultrasonographic classification were 0.83 (95% confidence interval, 0.70–0.96) and 0.88 (95% confidence interval, 0.77–0.99), respectively. There were 17 patients with type A, 14 with type B, and 9 with type C on ultrasonography. Ultrasonography had a sensitivity of 64% and specificity of 93% for the assumption that type C on ultrasonography corresponded to Geissler grades 3 and 4 on arthroscopy. No patient with type A on ultrasonography was classified as Geissler grades 3 and 4 on arthroscopy. Conclusions We concluded that ultrasonography has a high specificity but low sensitivity for the diagnosis of SLIL injury. Type of study/level of evidence Diagnostic Ⅱ.

PURPOSE Internal bracing (IB) is an augmentation method using high-strength nonabsorbable tape. This study compared scapholunate interosseous ligament (SLIL) repair alone, SLIL repair with IB augmentation (RIBA), and native intact SLIL (NIS) in a biomechanical cadaveric model. METHODS We used 21 specimens of fresh-frozen wrists in this study (7 matched pairs, SLIL repair-only and SLIL RIBA groups; and 7 independent fresh-frozen wrists, NIS group). In the SLIL RIBA group, augmentation using IB was performed after the repair. The specimens were preloaded and cyclically loaded in tension. Maximum extension and hysteresis were measured in all specimens. The specimens were subsequently tested for load to failure. Failure load (yield point load, mean ultimate load, and load at clinical failure) and linear stiffness were calculated. RESULTS In cyclic tensile testing, RIBA showed lower maximum extension and lower hysteresis than repair alone. In load to failure testing, the yield point load was statistically higher in the RIBA (59.3 N) group than in the repair-only (30.4 N) group but showed no significant difference compared with the NIS (90.7 N) groups. Moreover, the RIBA (98.5 N) group showed higher and lower mean ultimate loads than the repair-only (37.7 N) and NIS (211.8 N) groups, respectively. Load at clinical failure was higher with RIBA than with repair alone (3-mm extension: 70.0 vs 26.4 N; 4-mm extension: 84.1 vs 33.4 N). Repair alone and RIBA had comparable linear stiffness (38.2 vs 44.1 N/mm). CONCLUSIONS Although SLIL RIBA did not recreate biomechanical properties equivalent to those of NIS, it demonstrated a significantly higher strength than repair alone. CLINICAL RELEVANCE Repair with IB augmentation could serve as a novel surgical technique that enhances SLIL direct repair through biomechanical support.

Purpose Partial intercarpal ligament injuries can coexist with scaphoid nonunions. However, whether these injuries should be debrided simultaneously when scaphoid nonunions are treated is unclear. The purpose of this study was to compare union rates and clinical outcomes after arthroscopic management of scaphoid nonunions, in which coexisting partial ligament injuries were, or were not, simultaneously debrided. Methods This retrospective study included 46 patients with scaphoid nonunions and coexisting partial intercarpal ligament injuries who underwent arthroscopy-guided bone grafting and fixation (K-wires or headless screws) between March 2008 and May 2014 with a minimum follow-up of 1 year. None of the cases had necrosis of the proximal fragment (determined by contrast-enhanced magnetic resonance imaging), severe deformities, or advanced arthritis. The partial intercarpal ligament injuries were either simultaneously debrided (25 patients; group D) or not debrided (21 patients; group ND). Visual analog scale pain scores, grip strength, flexion-extension arc of the wrist, Mayo Wrist Scores, and Disabilities of Arm, Shoulder, and Hand scores were used to compare clinical outcomes between the 2 groups. Results The nonunions united in 93% (43 of 46) of the patients. There were no differences between the 2 groups with regard to patient demographics, preoperative outcome measures, location of scaphoid nonunion, and degree of ligament injury. The overall union rate was similar between group D (92%; 23 of 25) and group ND (95%; 20 of 21). At a median follow-up of 24 months for group D and group ND, the visual analog scale pain score, grip strength, Mayo Wrist Scores, and Disabilities of the Arm, Shoulder, and Hand scores were significantly improved in both groups, compared with preoperative scores. Flexion-extension arc showed no change in both groups compared with preoperative angles. All of the follow-up measurements were similar in the 2 groups. Conclusions In patients who underwent arthroscopic bone grafting and fixation of scaphoid nonunions, simultaneous debridement of incidentally found partial intercarpal ligament injuries did not result in a better union rate or clinical outcomes than not debriding the partial ligament injuries. Type of study/level of evidence Therapeutic III.

Purpose To determine the relative roles of the dorsal and volar portions of the scapholunate interosseous ligament (SLIL) in the stability of the scaphoid and lunate. Methods Sixteen fresh cadaver wrists were moved through physiological motions using a wrist joint simulator. Electromagnetic sensors measured the motion of the scaphoid and lunate. Data were collected with the wrist intact, after randomly sectioning the dorsal SLIL first (8 wrists) or the volar SLIL first (8 wrists), and after full ligamentous sectioning. Differences in the percent increase in scaphoid flexion or lunate extension were compared using a t test with significance set at P Results Sectioning the dorsal SLIL accounted for 37%, 72%, and 68% of the increase in scaphoid flexion in wrist flexion-extension, radioulnar deviation, and dart throw motion as compared with complete SLIL sectioning. Sectioning the volar SLIL accounted for only 7%, 6%, and 14%, respectively. In the same 3 motions, sectioning the dorsal SLIL accounted for 55%, 57%, and 58% of the increase in lunate extension, whereas volar SLIL sectioning accounted for 27%, 28%, and 22%. Conclusions The dorsal SLIL provides more stability to the scaphoid and lunate in biomechanical testing. The volar SLIL does provide some, although less, stability. Clinical relevance Although this study supports the critical importance of dorsal SLIL repairs or reconstructions, it also shows that there may be some value in implementing a volar SLIL repair or reconstruction.

The distal radioulnar ligament reconstruction is a technique that may be used for distal radioulnar joint instability without arthritis and failed nonsurgical management; clinical results demonstrate resolved or improved stability. Recent literature has focused on the distal oblique bundle of the interosseous membrane and its contributions to stability. This article describes a technically simple surgical technique to reconstruct the distal oblique bundle and restore distal radioulnar joint stability.

PURPOSE Carpal malalignment following intra-articular fractures has been reported in the literature, with no clear description of possible ligamentous injury leading to the radiological appearance. This study presents a series of patients that developed carpal instability nondissociative (CIND) following acute wrist fractures. The mechanism of injury is postulated by using a cadaveric laboratory investigation. METHOD Twelve patients with average age of 32 years were identified with CIND, between 2013 and 2018. Ten patients with a normal carpal alignment in the initial postoperative radiographs exhibited CIND-palmar radiographically at different postoperative periods, and 2 patients showed CIND-dorsal in the initial postoperative x-rays. Four cadaveric specimens were used to validate this injury pattern. RESULTS In cadaveric dissections, CIND-palmar could be reproduced by applying an axial loading and dorsal shearing force on a wrist with sequential sectioning of dorsal and palmar extrinsic wrist ligaments. For the intra-articular fractures with CIND-dorsal, the cause is likely a result of volar radiocarpal extrinsic ligament injury combined with intra-articular incongruity of the scaphoid fossa. Eight out of the 12 patients had severe wrist pain and underwent additional surgery. Three patients with reducible CIND-palmar had open capsular repair, and 5 patients with fixed nonreducible malalignment were treated with radioscapholunate arthrodesis. At an average follow-up of 2.3 years, pain relief was noted, together with an improvement in grip strength and range of movement. Radiographically, the wrist alignment was corrected and maintained. CONCLUSIONS This article highlights the existence of possible concomitant radiocarpal ligament lesions and residual articular incongruity, associated with acute intra-articular fractures and radiocarpal fracture-dislocations, that destabilize the proximal carpal row into a pattern of nondissociative carpal instability. Early detection of this condition may preserve wrist function by capsular repair, whereas cases with fixed deformity and residual joint incongruity may be best managed with a limited radiocarpal arthrodesis. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic IV.

Purpose The purpose of this exploratory study was to examine the relationship between the tensile and the torsional properties of the native scapholunate interosseous ligament (SLIL) and kinematics of the scaphoid and lunate of an intact wrist during passive radioulnar deviation. Methods Eight fresh-frozen cadaveric specimens were transected at the elbow joint and loaded into a custom jig. Kinematic data of the scaphoid and lunate were acquired in a simulated resting condition for 3 wrist positions—neutral, 10° radial deviation, and 30° ulnar deviation—using infrared-emitting rigid body trackers. The SLIL bone-ligament-bone complex was then resected and loaded on a materials testing machine. Specimens underwent cyclic torsional and tensile testing and SLIL tensile and torsional laxity were evaluated. Correlations between scaphoid and lunate rotations and SLIL tensile and torsional properties were determined using Pearson correlation coefficients. Results Ulnar deviation of both the scaphoid and the lunate were found to decrease as the laxity of SLIL in torsion increased. In addition, the ratio of lunate flexion-extension to radial-ulnar deviation was found to increase with increased SLIL torsional rotation. Conclusions Our findings support the theory that there is a relationship between scapholunate kinematics and laxity at the level of the interosseous ligaments. Clinical relevance Laxity and, specifically, the tensile and torsional properties of an individual’s native SLIL should guide reconstruction using a graft material that more closely replicates the individual’s native SLIL properties.

Various surgical treatment options have been described to address chronic scapholunate dissociation. The Scapholunate Axis Method (SLAM) is a new technique used to reconstruct the scapholunate interosseous ligament. It is biomechanically advantageous compared with other ligament reconstruction techniques but clinical studies are lacking. We describe a previously unreported complication of avascular necrosis of the lunate after the SLAM procedure.

The Andrew J. Weiland Medal is presented by the American Society for Surgery of the Hand to a mid-career researcher dedicated to advancing patient care in the field of hand surgery. The Weiland Medal for 2017 was presented to the author at the annual meeting of the American Society for Surgery of the Hand. The purpose of this article is to present current evidence on how biomechanics and morphology influence the pathophysiology of thumb carpometacarpal joint (CMC) osteoarthritis.

Injury to the scapholunate interosseous ligament is one of the most common causes of carpal instability and can impart considerable compromise to the patient's hand function. However, the management of scapholunate ligament injuries remains a dynamic concept, especially with regard to the multitude of options and techniques that exist for its surgical treatment. We present a thorough review of scapholunate anatomy and morphology, and the role of the scapholunate articulations in the kinetics and pathomechanics of wrist instability. We also review the current literature on the biomechanical properties of the scapholunate ligament and its subcomponents. A sound understanding of the anatomy and biomechanics of the scapholunate ligament can clarify its instability and may better orient current reconstructive procedures or pioneer better future techniques.

Purpose To evaluate the biomechanical properties of 3 scapholunate repair techniques. Methods In 51 cadavers, the scapholunate ligament was exposed through a dorsal approach, incised at its scaphoid insertion, and repaired using 1 of 3 techniques: 2 single-loaded suture anchors, 2 double-loaded suture anchors, or 2 transosseous sutures. Twenty-four repaired specimens underwent load to failure (LTF) testing using tensile distraction on a servo-hydraulic machine. Twenty-seven specimens underwent cyclical testing to measure gap formation at the scapholunate joint. Results The mode of failure was suture pullout through the substance of the ligament in 22 specimens, failure at the bone suture interface in 1, and anchor pullout in 1. Double-loaded anchor repairs demonstrated a significantly higher mean ultimate LTF compared with single-loaded anchor (91 N vs 35 N) and transosseous (91 N vs 60 N) repairs. Transosseous repairs demonstrated a higher mean ultimate LTF compared with single-loaded suture repairs (60 N vs 35 N). After 300 cycles, the average gap for the transosseous repair group was double that for the single- and double-loaded repairs, although not statistically significant. Conclusions Primary scapholunate ligament repairs using double-loaded suture anchors demonstrated significantly higher strength compared with single-loaded anchors and transosseous repairs. On cyclic loading, transosseous repairs demonstrated the greatest gap formation with no measurable difference between single- and double-loaded repairs. Clinical relevance In a cadaveric model for primary repairs, double-loaded suture anchors demonstrated the highest LTF and offer a similar but unproven performance in vivo .

Purpose To determine the efficacy of scapholunate (SL) temporary screw fixation to maintain the reduction of SL interval after ligament debridement, repair, or reconstruction. Methods A total of 36 patients who had chronic SL instability were included. Arthroscopic debridement was performed for dynamic instability, and primary repair or reconstruction of the SL ligament was performed for static instability. We then used SL screw fixation for the protection of the repair or reconstruction. Screws were removed when loosening was noted on x-ray. Results The average patient age was 43 years. Eleven had dynamic instability, and 25 had static instability. The average follow-up was 7.9 years. Nearly 95% of the patients had no more than mild pain. The average ranges of movement of the wrist were 55° extension, 51° flexion, 26° ulnar deviation, and 15° radial deviation. Postoperative x-ray revealed an average SL angle of 56°. The average SL gap was 2.5 mm. Both of these radiographic parameters were maintained at final follow-up. Dorsal intercalated segmental instability (DISI) deformity was not corrected in 2 patients. One patient had avascular changes in the proximal scaphoid and lunate but remained asymptomatic at 7 years postoperatively. There was no further intercarpal and radiocarpal degeneration. Conclusions Temporary SL screw fixation together with arthroscopic debridement, ligament repair, or reconstruction provided a stable closure of the SL interval and satisfactory clinical and functional results along with a low incidence of complication. Type of study/level of evidence Therapeutic IV.

Purpose To investigate whether applied radiofrequency energy (RFE) for shrinkage of the scapholunate interosseus ligament reaches temperatures required for ligament shrinkage while leaving adjacent structures unaffected. Methods Standard wrist arthroscopy was performed on 7 pairs of cadaveric limbs with continuous saline irrigation and gravity-assisted outflow through an 18-gauge needle. We subjected 14 scapholunate ligaments to treatment with monopolar (n = 7) or bipolar (n = 7) RFE for ligament shrinkage. Temperature was recorded simultaneously inside the dorsal part of the scapholunate interosseus ligament at a depth of 0.9 ± 0.1 mm and at 6 other sites in and around the wrist because thermal shrinkage starts at 60°C to 65°C. Results We observed an increase in temperature corresponding to the time of energy application. The highest measured peak temperatures at the scapholunate ligament were 43°C (monopolar) and 32°C (bipolar). Mean temperatures at 30 seconds of application were 29°C ± 7°C (monopolar) and 28°C ± 3°C (bipolar). Conclusions Temperatures sufficiently high to induce ligament shrinkage were not reached with either monopolar or bipolar RFE. We did not monitor temperature levels responsible for damage on adjacent cartilage or immediately adjacent capsular tissue in this setting. Clinical relevance This study suggests that RFE for capsular shrinkage in the wrist is safe but ineffective.

Purpose To determine the force required to maintain reduction of Geissler grade 4 scapholunate dissociations during physiological wrist motions. Methods Fresh-frozen cadaveric wrists with Geissler grade 4 scapholunate dissociations were identified by arthroscopy. Following reduction, a load cell was attached to measure the force across the scapholunate joint at a neutral position and during 4 different wrist motions re-created using a servohydraulic wrist simulator, including a large flexion-extension motion (FEM), small and large dart-thrower’s motions (DTMs), and a large DTM with ulnar offset. Results Five wrists with isolated preexisting scapholunate interosseous ligament (SLIL) tears were analyzed. The force required to maintain reduction was significantly greater in extension than in flexion during the large FEM and large DTM with ulnar offset. The forces were significantly larger in this study of preexisting SLIL dissociations compared with results from a prior study of acutely sectioned SLILs. In addition, forces to maintain reduction during DTMs were significantly less than forces during FEMs. Finally, a set of 3 wrists with preexisting scapholunate and lunotriquetral interosseous ligament (LTIL) tears were identified and had significantly decreased forces to maintain reduction at maximum extension and had decreased maximal forces during a cycle of motion compared with the wrists with isolated SLIL tears. Conclusions The forces required to maintain reduction of a Geissler grade 4 wrist are higher than forces after acutely sectioned SLIL. The forces are greater in extension than in flexion and less during the DTM compared with the FEM. Wrists with both SLIL and LTIL tears required less force to maintain reduction than those with isolated SLIL tears. Clinical relevance This study helps determine the strength of reconstruction required to maintain reduction of a Geissler grade 4 scapholunate dissociation.

Pisotriquetral instability is an often-overlooked condition that can lead to ulnar-sided wrist pain and dysfunction. Various case series and biomechanical studies have been published regarding the diagnosis and treatment of this condition. We review current methods for examining, diagnosing, and treating pisotriquetral instability.

Purpose There remains a paucity of information regarding the treatment outcomes of dislocation after metacarpophalangeal (MCP) joint arthroplasty. The purpose of this study was to assess the outcomes of surgical and nonsurgical treatment modalities of MCP arthroplasty dislocations. Methods Of 816 MCP joint arthroplasties over a 14-year period, there were 37 (4%) acute MCP joint dislocations that required intervention by a health care professional. Implants involved included 28 nonconstrained implants including pyrocarbon (n = 17) and surface replacement arthroplasty (n = 11), and 9 silicone implants. The analysis included the treatment of dislocations after primary (n = 30) and revision (n = 7) MCP joint arthroplasty. Dislocation was defined as clinical and radiographic evidence of MCP joint prosthetic acute dislocation diagnosed and treated by a fellowship trained hand surgeon. Results Etiologies underlying the dislocations included implant fracture (n = 6), component loosening (n = 2), and soft tissue deficiency (n = 29). Of the 37 dislocations, treatments included 14 nonsurgical (closed reduction, orthosis fabrication) all of which ultimately failed. Surgically, including some of the failed prior procedures, 18 soft tissue stabilization procedures and 21 revision arthroplasties were performed, with 6 that had failed soft tissue stabilization. The soft tissue stabilization procedures had a 28% success rate in achieving a stable MCP joint. Revision arthroplasty had a 71% success rate. Subgroup analysis showed an 86% success rate for silicone revisions and a 43% success rate with nonconstrained revisions, with 80% and 36% 5-year survival free of instability, for the 2 types of implants, respectively. Conclusions The treatment of MCP joint arthroplasty dislocation with revision to silicone implant appears to hold the most promise in achieving a stable MCP joint after an acute prosthetic dislocation. Type of study/level of evidence Therapeutic IV.

Purpose The purposes of this study were to identify the relative frequency of Monteggia fracture patterns and to investigate the required frequency of open reduction of the proximal radiocapitellar joint. Methods We identified 121 Monteggia fractures at a Level I trauma center from 1996 to 2015 and included 119 in this study. These fractures were identified using a database search for the appropriate International Classification of Diseases, Ninth Revision and Current Procedural Terminology codes as well as individual surgeons' logs. Two fellowship-trained hand surgeons reviewed the identified patients' x-rays and operative notes. Each fracture was classified using Bado's original description, excluding transolecranon and Monteggia variants. Results Bado I lesion represented 68% (81 of 119) of Monteggia fractures. Annular ligament incarceration preventing radial head reduction occurred in approximately 17% (14 of 81) of this Bado type. Revision fixation of the ulna was not necessary (none of 119 cases) and functional range of motion (average arc, 117°) was recovered in most patients. The reoperation rate of 20% (23 of 119) was related to the severity of the presenting injury and hardware prominence. Conclusions Most radial head dislocations associated with Monteggia fractures occur anteriorly and will reduce with anatomic plating of the ulna. In cases where the radial head fails to reduce, entrapment of the annular ligament can be expected and open reduction is required. Revision fixation of the ulna to achieve reduction of the radial head is uncommon in our experience. Type of study/level of evidence Prognostic IV.

Purpose The respective roles of the dorsoradial (DRL) and anterior oblique (AOL) ligaments in stability of the highly mobile trapeziometacarpal (TMC) joint remain disputed. Earlier publications have pointed to the AOL as the key stabilizing structure; yet, more recent publications have challenged the stabilizing role of the AOL, favoring the DRL as the main TMC joint stabilizer. We executed an anatomical study of the ligaments, including detailed dissection to quantify the length, width, and thickness of the AOL and DRL and tested the material properties of these ligaments. Methods Thirteen fresh frozen cadaveric thumbs from 9 specimens were used. Length, width, and thickness of the AOL and DRL were measured on magnetic resonance imaging and/or after dissection. Next, the first metacarpal and trapezium were isolated together with both ligaments, and both bones were cut sagittally to isolate a first metacarpal–AOL–trapezium and first metacarpal–DRL–trapezium complex from each thumb. These samples were subjected to cyclic loading in displacement-controlled tests. The obtained force-displacement curves were used to calculate stiffness and hysteresis of each sample. Results Our results showed that the DRL is significantly shorter and thicker than the AOL, which is thin and ill-defined. Our results also indicate that the DRL has a higher stiffness than the AOL, making it a more likely candidate to provide joint stability. Conclusions Although the AOL has been asserted to be the primary restraint to dorsoradial subluxation, this view has been challenged over the past 10 years by several studies. These studies have shown the AOL to be relatively weak and compliant compared with the intermetacarpal and dorsoradial ligaments and have demonstrated that the DRL is the strongest and stiffest ligament of the TMC joint. Our studies confirm these findings. Clinical relevance This study indicates that the DRL is relatively stiff and thick, suggesting it should be repaired or reconstructed when disrupted to restore stability of the TMC joint.

Purpose To identify the unique anatomical characteristic of the extensor carpi radialis brevis (ECRB) origin and points of differentiation from other extensors and to clarify the specific relationship of the ECRB to the underlying structures. Methods We studied the origin of each extensor macroscopically for its muscular and tendinous parts; to identify the relationship between the ECRB origin and the deeper structures, we also examined the attachment of the joint capsule under the ECRB origin. Results The ECRB simply originated as a tendon without any muscle, whereas other extensors originated as a mixture of tendon and muscle. At the anterior part of the ECRB origin, the thin attachment of the joint capsule (average width, 3.3 mm) lay deep to the ECRB and was distinct. However, at the posterodistal portion, the joint capsule, annular ligament, and supinator were intermingled and originated as a single wide sheet from the humerus (average width, 10.7 mm). Conclusions The anterior part of the ECRB origin was delicate, because the ECRB origin was purely tendinous, and the attachment of the articular capsule was thin compared with that of the posterodistal attachment. This thin attachment could be an initial factor leading to the development of lateral epicondylitis. Clinical relevance The results of the current study may enhance magnetic resonance imaging understanding and may help clarify the etiology of the lateral epicondylitis.

Purpose To evaluate the diagnostic utility of scaphoid dorsal subluxation on magnetic resonance imaging (MRI) as a predictor of scapholunate interosseous ligament (SLIL) tears and compare this with radiographic findings. Methods Thirty-six MRIs were retrospectively reviewed: 18 with known operative findings of complete Geissler IV SLIL tears that were surgically repaired, and 18 MRIs performed for ulnar-sided wrist pain but no SLIL tear. Dorsal subluxation of the scaphoid was measured on the sagittal MRI cut, which demonstrated the maximum subluxation. Independent samples t tests were used to compare radiographic measurements of scapholunate (SL) gap, SL angle, and capitolunate/third metacarpal-lunate angles between the SLIL tear and the control groups and to compare radiographic measurements between wrists that had dorsal subluxation of the scaphoid and wrists that did not have dorsal subluxation. Interrater reliability of subluxation measurements on lateral radiographs and on MRI were calculated using kappa coefficients. Results Thirteen of 18 wrists with complete SLIL tears had greater than 10% dorsal subluxation of the scaphoid relative to the scaphoid facet. Average subluxation in this group was 34%. Four of 18 wrists with known SLIL tears had no subluxation. No wrists without SLIL tears (control group) had dorsal subluxation. The SL angle, capitolunate/third metacarpal-lunate angle and SL gap were greater in wrists that had dorsal subluxation of the scaphoid on MRI. Interrater reliability of measurements of dorsal subluxation of the scaphoid was superior on MRI than on lateral x-ray. Conclusions An MRI demonstration of dorsal subluxation of the scaphoid, of as little as 10%, as a predictor of SLIL tear had a sensitivity of 72% and a specificity of 100%. The high positive predictive value indicates that the presence of dorsal subluxation accurately predicts SLIL tear. Type of study/level of evidence Diagnostic II.

Purpose This study primarily aimed to demonstrate the screw-home rotation of the thumb carpometacarpal (CMC) joint and the function of surrounding ligaments during thumb oppositional motion. Methods A 3-dimensional kinematic analysis of the thumb CMC joint was conducted using data derived from computed tomography of 9 healthy volunteers. Scans were obtained in the neutral forearm and wrist position and the thumb in maximum radial abduction, maximum palmar abduction, and maximum opposition. The movements of the first metacarpal and the palmar and dorsal bases on the trapezium during thumb oppositional motion from radial abduction through palmar abduction were quantified using a coordinate system originating on the trapezium. In addition to the kinematic analyses, the length of virtual ligaments, including the anterior oblique, ulnar collateral, dorsal radial, dorsal central (DCL), and posterior oblique ligament (POL), were calculated at each thumb position. Results From radial abduction to opposition of the thumb through palmar abduction, the first metacarpal was abducted, internally rotated, and flexed on the trapezium. The palmar base of the first metacarpal moved in the palmar-ulnar direction, and the dorsal base moved in the palmar-distal direction along the concave surface of the trapezium. Although the DCL and POL lengthened, the lengths of other ligaments did not change significantly. Conclusions During thumb oppositional motion, internal rotation of the first metacarpal occurred, with the palmar base rotating primarily with respect to the dorsal base. The DCL and POL may be strained in thumb functional positions. Clinical relevance Kinematic variables indicated a screw-home rotation of the thumb CMC joint and the contribution of the dorsal ligaments to the stability of the rotation on the pivot point.

Scapholunate instability can lead to posttraumatic dysfunction of the wrist. If unrecognized, it commonly leads to degenerative osteoarthritis. Numerous reparative techniques have been proposed with mixed long-term success. We present a technique that uses a distally based strip of the extensor carpi radialis longus to better maintain reduction of the scaphoid and reconstruct the volar and dorsal scapholunate ligament and the scaphotrapezium-trapezoid ligament. To illustrate the technique, we describe a clinical case with 17 months of follow-up.

Purpose To assess the wrist joints of healthy volunteers in extended and loaded states versus the unloaded state by using computed tomography (CT) to analyze the in vivo 3-dimensional movements in the distal radioulnar joint (DRUJ). Methods The dominant arms of 9 volunteers with healthy wrists were studied. We mounted a compression device onto the elbows in an inverted position. A 0-kg and 7-kg load each was applied during low-dose radiation CT imaging and a bone model was produced. We marked the insertion sites for the 4 radioulnar ligaments stabilizing the DRUJ: palmar superficial radioulnar ligament (PS-RUL), dorsal superficial radioulnar ligament (DS-RUL), dorsal deep radioulnar ligament (DD-RUL), and palmar deep radioulnar ligament (PD-RUL). Using Marai’s method, each ligament was virtualized and the length of each simulated ligament was measured. We also computed the 3-dimensional displacement and corresponding rotation of the distal ulna where it comes into contact with the radius in the sigmoid notch. Results The lengths of palmar ligaments (PS-RUL and PD-RUL) increased significantly under loaded conditions, and although not significant, the length of dorsal ligaments (DS-RUL and DD-RUL) tended to increase. When the wrist was loaded, the ulna rotated toward the open palmar side. Conclusions The length of simulated radioulnar ligaments increased when the wrist joint was loaded in an extended position. This kinematic movement of DRUJ separation under a loading condition is different from physiological active movement. Clinical relevance The 3-dimensional kinematic analysis revealed that palmar radioulnar ligaments were stretched during axial loading, suggesting that a tear of the palmer ligament can result from a fall on an outstretched hand.

Purpose This study examined a palmar beak fracture model to determine which thumb carpometacarpal (CMC) joint ligament is the primary ligament relevant to the pattern of injury. Methods Six fresh-frozen cadaveric wrists were used. The radius, ulna, and first metacarpal were secured and tested with a materials testing system, holding the wrist in 20° extension, 20° ulnar deviation, and 30° palmar abduction of the first metacarpal. Testing consisted of preconditioning cycles followed by compressive loading at 100 mm/s. We confirmed fractures with fluoroscopy and dissected the specimens to examine the CMC joint ligaments. The metacarpal was stressed through a range of motion to determine which maneuvers reduced or displaced the fractures. Results Our model successfully created palmar beak fractures in all cadaveric specimens. All fractures were displaced and intra-articular. The anterior oblique ligament (AOL) was thin and partially attached to the palmar beak fracture fragment. The ulnar collateral ligament was attached in its entirety to the fracture fragment and represented a thicker, more robust ligament compared with the AOL. Radial abduction and pronation of the metacarpal reduced fracture displacement. Extension of the CMC joint or tensioning the AOL did not decrease fracture displacement. Conclusions This model successfully created a reproducible and clinically relevant palmar beak fracture in a biomechanical setting. The primary ligament attached to the palmar beak fracture fragment was the ulnar collateral ligament, and not the AOL as previously described. These findings suggest that the AOL may not be a substantial contributor to palmar beak fracture morphology. Clinical relevance A refined description of the ligamentous anatomy of the palmar break fracture enhances opportunities for improved reduction and treatment of this common hand injury.

Purpose Osteochondral replacement of the proximal scaphoid has been reported using a vascularized flap from the medial femoral trochlea. A concern with this technique is the loss of stability of the scapholunate relationship with resection of the scaphoid proximal pole. Overexpansion of the scaphoid dimensions (overstuffing) during scaphoid reconstruction with the osteochondral flap may play a role in maintaining scapholunate alignment. Our purpose was to determine if overstuffing the scaphoid can correct rotatory carpal instability in a cadaveric model studied radiographically. Methods The radiolunate angle and scapholunate interval were measured for 5 fresh cadaver wrists. We completely incised the scapholunate interosseous ligament and performed an osteotomy to excise the proximal third of the scaphoid to simulate a proximal pole deficiency nonunion and create a dorsal intercalated segmental instability deformity. Radiographic measurements were repeated. The proximal pole of the scaphoid was replaced with its original piece of bone; radiographic measurements were repeated without scapholunate ligament repair. The osteotomy site was overstuffed with a 4-mm sawbone spacer without scapholunate ligament repair, and radiographs were obtained. Results Sectioning of scapholunate ligaments and proximal pole excision successfully created carpal instability demonstrated by abnormal radiolunate angles. Without ligament repair, proximal pole replacement did not restore normal radiolunate angles. Expansion of the scaphoid dimensions corrected radiolunate angles on lateral unloaded radiographs and improved scapholunate intervals on clenched fist radiographs. These findings were statistically significant compared with the unexpanded (replaced) scaphoid. Conclusions These findings suggest that scaphoid reconstruction that results in expansion of the scaphoid's normal dimensions will restore carpal alignment without scapholunate ligament reconstruction. Clinical relevance Osteochondral reconstruction of difficult proximal pole nonunions may not require any preservation or reconstruction of scapholunate integrity if the reconstruction expands the normal dimensions of the native scaphoid. Scapholunate interval and carpal alignment may be restored by scaphoid overstuffing. The effects on increased contact pressure and range of motion require further investigation.

The optimal imaging protocols for magnetic resonance imaging (MRI) of the wrist ligaments are discussed, including the use of magnetic resonance arthrography, and 3 Tesla (T) versus 1.5 T magnetic field strength. The normal MRI appearance of the triangular fibrocartilage complex, capsular, and interosseous wrist ligaments is briefly covered to point out potential diagnostic pitfalls. Numerous examples of common ligamentous pathology discernible on MRI are provided, along with the latest estimates of diagnostic sensitivity and specificity provided by the literature.

Purpose Wrist magnetic resonance imaging (MRI) has established utility in the diagnosis of wrist ligament tears, including complete tears of the ulnotriquetral ligament (UTL) and other components of the triangular fibrocartilage complex. A new type of longitudinal split tear of the UTL has recently been described with no imaging correlate. Our aims were to describe putative MRI findings associated with longitudinal UTL split tears and to assess diagnostic accuracy. Methods We randomly selected 40 patients with arthroscopically proven longitudinal UTL split tears and 20 patients with intact UTLs, all of whom had preoperative 3 T MRI of the same wrist performed, from a list of operative notes spanning from January 1997 through October 2011, filtered with the terms "ulnotriquetral ligament" and "ulnar triquetral ligament." Two musculoskeletal radiologists who were blinded to surgical results and clinical information independently reviewed the exams. They recorded the degree of certainty of whether a longitudinal UTL split tear was present and whether several other hypothesized associated abnormalities were present. Results Overall sensitivity for definitive longitudinal UTL split tear detection on MRI was 58% for reader 1 and 30% for reader 2. Specificity was 60% for both. There were no statistically significant discriminatory findings. Conclusions Among a selected group of patients who all had wrist arthroscopy, preoperative noncontrast 3 T wrist MRI had poor sensitivity and specificity for detection of the longitudinal split type of UTL tear. To date, MRI may be more helpful to exclude potential alternative diagnoses in the patient with ulnar wrist pain. Type of study/level of evidence Diagnostic III.