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Background: This study reviews long-term outcomes of partial wrist denervation focusing on need for and time to revision procedure. Methods: A retrospective study was conducted of all patients undergoing partial wrist denervation between 1994 and 2014. At average latest follow-up of 6.75 years (range, 1-21 years), clinical and radiographic data and need for revision surgery were recorded. Results: There were 100 wrists in 89 patients (61 male, 28 female) with average age at surgery of 54 years (range, 26-80). Principal diagnoses were arthritis (58%), inflammatory (19%), and posttraumatic arthritis (7%). Average flexion-extension arc was 83% and grip strength 75% of unaffected extremity. Average Mayo Wrist Scores improved from 48 preoperatively to 77 postoperatively. Sixty-nine percent of patients did not undergo other procedures during the time interval studied. Thirty-one percent underwent revision at an average of 26 months following denervation (range, 2-165). Conclusions: Partial wrist denervation is a motion-preserving procedure for patients with refractory wrist pain with 69% in this series requiring no further procedures. The remaining 31% experienced average symptom relief for 2 years prior to ultimately undergoing revision operation.

Superficial radial intraneural ganglion cysts are rare. Only nine previous cases have been described. We provide two examples with a wrist joint connection and review the literature to provide further support for the unifying articular (synovial) theory for the pathogenesis and treatment of intraneural ganglia.

Purpose: The purpose of this report is to review the results of arthroscopic resection of dorsal wrist ganglions., Methods: Forty-one patients with dorsal wrist ganglions had arthroscopic resection: 24 women and 17 men. The average patient age was 29.8 years. All of the patients had some or all of the following: pain, localized swelling, and limited range of motion. Along with clinical examination, 19 wrists had ultrasound or magnetic resonance imaging to confirm diagnosis. Twelve patients had previous injections with recurrence. The average follow-up time to date is 47.8 months (range, 28-97 months)., Results: Overall postoperative motion improved compared with preoperative values. No cases of scapholunate instability were noted. The average postoperative grip strength improved significantly. Only 2 ganglions recurred and required 2 attempts at open resection for successful eradication the ganglion. No major intraoperative or postoperative complications occurred., Conclusion: Arthroscopic ganglionectomy is a safe and reliable alternative to open resection.

The use of implant arthroplasty in the distal radioulnar joint is increasing. Two main types of implants are commonly used, ulnar head prosthesis (UHP) and hemi or semi-constrained total distal radioulnar joint arthroplasty. The literature consists mainly of small patient series. The purpose of this study was to examine our long-term outcomes of distal radioulnar joint arthroplasty. Patient data were collected in a patient registry from 2000 to 2019. The follow-up included radiographic examination, physical examination, Mayo Wrist Scores, pain level, range of motion, and grip strength. Reoperations were recorded. The implants were a semi-constrained prosthesis and a metallic UHP. The mean age at surgery was 50 years. Patient demographics were similar, but the semi-constrained group had a higher preoperative percentage of instability (85 vs 52 percent). The median follow-up time was 30 months for the semi-constrained implants group and 102 months for the UHP group. A total of 53 primary semi-constrained total joint arthroplasties and 102 UHPs were included. The grip strength and Mayo Wrist Score improved for both the implant groups. Pain reduced in 76% of the patients. Supination improved for the semi-constrained total joint arthroplasty group. Lifting capacity was better in the semi-constrained total joint arthroplasty patients. The unadjusted reoperation rate was 23% for the semi-constrained implants group and 34% for the UHP group. Twenty-two implants were bilateral; these had comparable results to unilateral implants. Kaplan–Meier survival curves demonstrated 94% survival rate for the semi-constrained implants group and 87% survival for the UHP group after 5 years. The risk factors associated with reoperation for the combined implant group included younger age at surgery, previous wrist surgery, ulnar shortening, and wrist fusion. Distal radioulnar joint arthroplasty improved functional outcomes in both the implant groups, but reoperations were frequent. The semi-constrained implants group had better lifting capacity. The bilateral implants had comparable outcomes to the unilateral implants. Therapeutic IV. [ABSTRACT FROM AUTHOR]

Ninety-six wrists (56 right and 40 left) in 96 patients (36 males and 60 females, mean age 38, range 15–77 years) underwent repair of ulnotriquetral ligament split tears between 2007 and 2016. Mayo wrist scores, visual analogue scale pain scores, and objective measures including grip strength and range of motion were obtained. Patients were assessed after a mean follow-up of 21 months (range 6–112 months). Ulnotriquetral split tear repair resulted in substantial improvements in pain and function. The mean Mayo wrist score improved from 57 preoperatively to 81 postoperatively, with 84% of patients achieving a good or excellent outcome. Pain scores decreased from 5.8 to 1.2. Grip improved from 25 kg to 29 kg. There was no significant change in range of motion of the wrist. Complications were noted in eight patients, with three experiencing continued pain, four with dysaesthesia of the dorsal sensory ulnar nerve, and one superficial infection. Arthroscopic ulnotriquetral split tear repair significantly reduced pain and improved Mayo wrist scores. Level of evidence: IV [ABSTRACT FROM AUTHOR]

To determine the functional outcome and complications after conversion from a painful and unstable ulnar head prosthesis to a semiconstrained distal radioulnar joint arthroplasty. We conducted a retrospective review of 11 ulnar head prostheses in 10 patients with porous coated stems that were revised to semiconstrained prostheses. The median age of the patients was 47 years. The median number of wrist surgeries prior to conversion was 4 (range, 1–9). The median time from the ulnar head implant to the revision surgery was 47 months. Pre- and postoperative pain levels were recorded. Mayo Wrist Scores were calculated. Grip strength, range of motion, and complications and reoperations were recorded. All patients reported moderate or severe pain before surgery, whereas 3 patients reported moderate pain after surgery. The Mayo Wrist Score improved considerably from a median of 50 before surgery to 65 after surgery. The grip strength and forearm pronation-supination showed no change following surgery. The median wrist flexion-extension range improved considerably. Follow-up was a median of 64 (range, 15–132) months after revision surgery. Removal of the ulnar head implant was described as difficult by the surgeons, except in 1 case where the implant was loose. Resection of bone from the distal ulna was often necessary. One patient needed a reoperation requiring prosthesis removal for aseptic loosening of the stem 5 years after revision. There were 2 nondisplaced periprosthetic fractures successfully treated with cast immobilization and 2 additional minor complications, 1 postoperative stitch abscess, and 1 extensor carpi ulnaris tendinitis. Conversion from an ulnar head implant to a semiconstrained prosthesis provided improved pain scores and function with a low reoperation rate in this patient series. Removal of an ulnar head prosthesis can be technically challenging, but it can be performed leaving enough bone stock for immediate implantation of a semiconstrained implant. Therapeutic V. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the potential effect of partial wrist denervation on wrist kinesthesia, we hypothesized that anesthetizing the anterior interosseous nerve and the posterior interosseous nerve does not impair the kinesthesia. Methods: We performed a double-blinded, prospective, randomized study on 80 healthy volunteers (20–54 y old) to compare the ability to detect active and passive wrist movement in 2 conditions. The test group received an anesthetic block of the anterior and posterior interosseous nerves, and the control group subjects received an injection of saline. The kinesthesia of the 2 groups was then tested in 2 conditions by measuring the error in an active and passive wrist repositioning task. Results were analyzed using a repeated measures analysis of variance. Results: In both active and passive conditions, there was no difference in the repositioning errors between the test group and the control group. Conclusions: Our results show that kinesthesia is not impaired by blocking the anterior and posterior interosseous nerves. These findings are consistent for both active and passive motion. The study gives strong evidence that partial denervation does not impair wrist kinesthesia. However, because only kinesthesia was studied, we cannot conclude that partial denervation is a totally safe procedure for all aspects of proprioception. Type of study/level of evidence: Therapeutic I. [Copyright &y& Elsevier]

Purpose: To develop a 4D [three-dimensional (3D) + time] CT technique to capture high spatial and temporal resolution images of wrist joint motion so that dynamic joint instabilities can be detected before the development of static joint instability and onset of osteoarthritis (OA). Methods: A cadaveric wrist was mounted onto a custom motion simulator and scanned with a dual source CT scanner during radial-ulnar deviation. A dynamic 4D CT technique was utilized to reconstruct images at 20 equidistant time points from one motion cycle. 3D images of carpal bones were generated using volume rendering techniques (VRT) at each of the 20 time points and then 4D movies were generated to depict the dynamic joint motion. The same cadaveric wrist was also scanned after cutting all portions of the scapholunate interosseus ligament to simulate scapholunate joint instability. Image quality were assessed on an ordinal scale (1-4, 4 being excellent) by three experienced orthopedic surgeons (specialized in hand surgery) by scoring 2D axial images. Dynamic instability was evaluated by the same surgeons by comparing the two 4D movies of joint motion. Finally, dose reduction was investigated using the cadaveric wrist by scanning at different dose levels to determine the lowest radiation dose that did not substantially alter diagnostic image quality. Results: The mean image quality scores for dynamic and static CT images were 3.7 and 4.0, respectively. The carpal bones, distal radius and ulna, and joint spaces were clearly delineated in the 3D VRT images, without motion blurring or banding artifacts, at all time points during the motion cycle. Appropriate viewing angles could be interactively selected to view any articulating structure using different 3D processing techniques. The motion of each carpal bone and the relative motion among the carpal bones were easily observed in the 4D movies. Joint instability was correctly and easily detected in the scan performed after the ligament was cut by observing the relative motion between the scaphoid and lunate bones. Diagnostic capability was not sacrificed with a volume CT dose index (CTDIvol) as low as 18 mGy for the whole scan, with estimated skin dose of approximately 33 mGy, which is much lower than the threshold for transient skin erythema (2000 mGy). Conclusions: The proposed dynamic 4D CT imaging technique generated high spatial and high temporal resolution images without requiring periodic joint motion. Preliminary results from this cadaveric study demonstrate the feasibility of detecting joint instability using this technique. [ABSTRACT FROM AUTHOR]

Background: Aspects of afferent inputs, generally termed proprioception, are being increasingly studied. Extraneous factors such as cutaneous inputs can dramatically interfere while trying to design studies in order to determine the participation of the different structures involved in proprioception in the wrist position sense. We tried to determine validity and repeatability of a new wrist joint position measurement device using methodology designed to minimize extraneous factors and isolate muscle and joint inputs. Methods: In order to test the reliability of the system, eighty young-adult subjects without musculoskeletal or neurologic impairments affecting the right upper extremity were tested using a custom made motion tracking system. Testing consisted of two conditions: active reproduction of active placement and passive reproduction of passive placement. Subjects performed two repetitions of each target position (10, 20, and 30° of flexion and extension) presented in a random order. Test- retest reliability was then tested. Results: The average constant error in the passive condition was -0.7° ± 4.7° as compared to the active condition at 3.7° ± 5.1°. Average absolute error in the passive condition was 4.9° ± 2.9° compared to the active condition in which absolute error was 5.9° ± 3.5°. Discussion: Test-retest repeatability in both conditions was less than the 5° magnitude typical of clinical goniometry. Errors in the active condition (less than 2°) were slightly smaller than the passive condition, and the passive condition was also associated with poorer consistency between apparatus sensors and skin sensors. Conclusions: The current system for measurement of wrist joint proprioception allows the researcher to decrease extraneous influences that may affect joint position sense awareness, and will help in future study aiming to determine precisely the role of the different structure involved in proprioception. [ABSTRACT FROM AUTHOR]

Purpose: The diagnostic sensitivity, specificity, and accuracy of 1.5 Tesla (T) and of 3.0T magnetic resonance imaging (MRI) are correlated with wrist arthroscopy findings in patients presenting with ulnar-sided wrist pain. Methods: The records and diagnostic MRI scans of 102 patients who presented between 1997 and 2006 with ulnar-sided wrist pain were evaluated. Preoperative MRI scans at 1.5T (n = 70) and 3.0T (n = 32) were evaluated by 2 experienced musculoskeletal radiologists with different levels of experience who were blinded to the arthroscopic findings. Preoperative MRI findings for the triangular fibrocartilage complex (TFCC), scapholunate, ulnotriquetral, and lunotriquetral ligaments were recorded and compared with findings at diagnostic arthroscopy. The sensitivity, specificity, and accuracy were calculated for both the 1.5T and 3.0T preoperative MRI scans. Statistical comparisons were made using chi-square test and JMP 6.0 software. Results: A tear of the TFCC was identified retrospectively on 1.5T images in 49 of 58 patients and on 3.0T images in 15 of 16 patients. Compared with the gold standard of arthroscopy, 1.5T wrist MRI in this patient population had a sensitivity of 85%, a specificity of 75%, and an accuracy of 83% for reader 1 for the detection of a tear of the TFCC. In the same patient population, 3.0T wrist MRI had a sensitivity of 94%, a specificity of 88%, and an accuracy of 91% for reader 1. For reader 2, the improvement in sensitivity for the lunotriquetral ligament between the 1.5T and 3.0T images was statistically significant. Conclusions: The sensitivity, specificity, and accuracy of 3.0T wrist MRI for the TFCC is consistently higher compared with those of 1.5T wrist MRI. The trend suggests that 3.0T wrist MRI provides improved capability for detection of TFCC injuries. Given the available sample size, however, the confidence intervals around the point estimates are wide and overlapping. Further studies are needed to confirm or refute our results of the estimated sensitivity, specificity, and accuracy parameters. [Copyright &y& Elsevier]

Purpose: The concept of a ligament-splitting dorsal capsulotomy of the wrist has been defined and has been shown to have practical applications. Due to the abundance of peritendinous tissue, however, the ligaments are often difficult to visualize. This article presents a method of defining incision capsular lines based on reliably palpable landmarks. Methods: The palpable landmarks include the sulcus between the scaphoid and trapezoid, the dorsal tubercle of the triquetrum, and the midpoint between Lister’s tubercle and the dorsal rim of the sigmoid notch. These points identify the bisection lines of the dorsal intercarpal and dorsal radiocarpal ligaments. A radial-based capsulotomy can be easily elevated by incising the dorsal wrist joint capsule using these landmarks and then extending the incision along the dorsal rim of the distal radius to the radial styloid process. Results: This method of defining capsular incision lines based on palpable landmarks was used on 253 consecutive dorsal wrist arthrotomies with excellent exposure, accurate splitting of the dorsal radiocarpal and intercarpal ligaments, and no complications. Conclusions: Using specific, palpable landmarks on the dorsal wrist, an accurate estimation of the locations and courses of the dorsal radiocarpal and intercarpal ligaments can be reliably made. Even when poorly visualized, these ligaments can be split longitudinally in a reliable fashion to create a standard, ligament-sparing dorsal capsulotomy. [Copyright &y& Elsevier]

Scapholunate dissociation is a commonly seen and treated form of carpal instability. Several surgical options have been used for the repair of scapholunate instability over the past 50 years. These have included benign neglect, reduction and percutaneous pinning, primary repair, partial fusions, tendon weaves, and combinations of these. Recent advancements in scapholunate repair and anatomy have been aimed at a more physiologic repair. Composite replacement of the entire scapholunate interval, similar to other tendon repairs seen in orthopedic surgery, has become popular. Bone–tissue–bone (BTB) autograft replacement from the foot has been used but the problems of a secondary surgical site have resulted in other graft site selections. Currently more commonly used grafts are bone–retinaculum–bone, third or second metacarpal–carpal bone, or hamate–capitate grafts, all performed with or without screw augmentation. Vascularized autograft replacement on pedicled grafts from the hand is being explored. This review discusses the surgeons’ indications and technical details of the surgery. The lack of long-term outcome measurements for these BTB surgeries makes it difficult for the hand surgeon to determine the appropriate use of these treatment modalities, but early reports have indicated that the BTB graft will be an important part of scapholunate dissociation treatment. [Copyright &y& Elsevier]

Purpose: Laboratory studies evaluating the importance of the stabilizing structures of the distal radioulnar joint (DRUJ) largely have been limited to static design. Clinically, dynamic loading seems to be an important component of DRUJ instability. This study was designed to evaluate the influence of dynamic loading on the stability of the DRUJ with foveal versus styloid triangular fibrocartilage complex (TFCC) disruptions in a laboratory setting. Methods: Twelve fresh-frozen cadaveric upper-extremity specimens were tested using a dynamic simulator to study the contributions of the 2 ulnar insertions of the TFCC to the dynamic stability of the DRUJ. The specimens were tested in 3 loading conditions (no load, agonist loading, antagonist loading) in 3 different states of the TFCC (intact, foveal disruption, styloid disruption). Results: Without load no significant differences were found for the different conditions of the TFCC. Under loaded conditions the foveal insertion had a greater effect on stability than did the styloid insertion. Under agonist loading significant differences were found during supinating and pronating motions. With antagonist loading a significant difference was found only during supination. Conclusions: The study results support the clinical impression that dynamic loading is an important component of DRUJ instability and that disruption of the foveal TFCC insertion into the foveal region of the distal ulna can produce instability. [Copyright &y& Elsevier]