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Background: The main objective of the present study was to present the biomechanical properties of the wrist in patients who underwent scaphotrapeziotrapezoid arthrodesis when compared to a healthy control hand., Methods: The study group consisted of 29 consecutive patients who underwent a scaphotrapeziotrapezoid wrist arthrodesis at least 1 year before the research onset. Both hands of all patients were examined in 4 main categories., Results: Average score obtained in the VAS, before the surgery, without motion of the wrist was 5.21 (SD = 3.04), whereas with wrist motion, it was 8.10 (SD = 1.37). Nineteen (65.52%) patients exhibited weakened wrist muscle strength. After the surgery, only 5 (17.24%) patients declared pain in the wrist. Furthermore, the results obtained in the VAS statistically significant differed from the ones before (p < 0.05). Twenty-eight (96.55%) patients were able to resume their profession. Twenty-seven (93.10%) patients stated that they would opt for the operation again. The peak torque during the analysis of extension of the wrist in the isometric protocol was found to be 8.1 Nm (SD = 2.9), 7.9 Nm (SD = 2.3), and 7.9 Nm (SD = 2.5) in the operated hands and 10.9 Nm (SD = 3.2), 9.6 Nm (SD = 2.9), and 9.1 Nm (SD = 3.8) in non-operated hand for 30° extension, no-flexion, and 30° flexion positions, respectively (p < 0.05)., Conclusion: The current study is the first to present the biomechanical parameters of flexor and extensor muscles of the wrist and fingers in patients after the said procedure. Biomechanical assessments with additional isometric, isotonic, and isokinetic tests provide an opportunity to objectify treatment outcomes and guide appropriate rehabilitation by monitoring its effects., Level of Evidence: III., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: We hypothesised that intercarpal K-wire fixation of adjacent carpal bones would reduce torque and lever force within a fractured scaphoid bone., Methods: In eight cadaver wrists, a scaphoid osteotomy was stabilised using a locking nail, which also functioned as a sensor to measure isometric torque and lever forces between the fragments. The wrist was moved through 80% of full range of motion (ROM) to generate torque and force within the scaphoid. Testing was performed with and without loading of the wrist and K-wire stabilisation of the adjacent carpal bones., Results: Average torque and lever force values were 49.6 ± 25.1 Nmm and 3.5 ± 0.9 N during extension and 41 ± 26.7 Nmm and 8.1 ± 2.8 N during flexion. Torque and lever force did not depend on scaphoid size, individual wrist ROM, or deviations of the sensor versus the anatomic axis. K-wire fixation did not produce significant changes in average torque and lever force values except with wrist radial abduction (P = 0.0485). Other than wrist extension, torque direction was not predictable., Conclusion: In unstable scaphoid fractures, we suggest securing rotational stability with selected implants for functional postoperative care. Wrist ROM within 20% extension and radial abduction to 50% flexion limit torque and lever force exacerbation between scaphoid fragments.

Isolated scaphotrapeziotrapezoid (STT) osteoarthritis has functional consequences on the wrist. The main objective of our study was to evaluate the functional outcomes of patients managed surgically during the last 12 years at the Toulouse University Hospital, regardless of the surgical technique used, for isolated STT osteoarthritis. We performed a single-center retrospective observational study using the CCAM database. The inclusion criteria were patients treated surgically for isolated STT osteoarthritis who did not respond to conservative treatment, with at least 6 months of clinical and radiological follow-up. Twenty-four patients were treated between 2006 and 2018. Partial arthroplasty of the distal pole of the scaphoid with or without interposition and total trapeziectomy had been performed on these patients. The mean follow-up was 79±46.8 months. The wrist range of motion (ROM) and the Kapandji score were not significantly reduced postoperatively. The mean postoperative QuickDASH score was 29.15±8.46. The mean pain assessed using a visual analog scale was 6.6±1.17 preoperatively versus 1.25±1.51 postoperatively (P=0.003). Statistical subgroup analysis found no predictive factor for a better postoperative QuickDASH score, and no surgical technique was superior at halting the progression of intracarpal misalignment and postoperative ROM. Surgical treatment of isolated STT osteoarthritis resistant to conservative treatment leads to significant functional improvement, particularly in terms of pain, without altering the wrist's overall mobility., (Copyright © 2019 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Background: Current techniques for fixation of proximal pole scaphoid fractures utilize antegrade fixation via a dorsal approach endangering the delicate vascular supply of the dorsal scaphoid. Volar and dorsal approaches demonstrate equivalent clinical outcomes in scaphoid wrist fractures, but no study has evaluated the biomechanical strength for fractures of the proximal pole. This study compares biomechanical strength of antegrade and retrograde fixation for fractures of the proximal pole of the scaphoid. Methods: A simulated proximal pole scaphoid fracture was produced in 22 matched cadaveric scaphoids, which were then assigned randomly to either antegrade or retrograde fixation with a cannulated headless compression screw. Cyclic loading and load to failure testing were performed and screw length, number of cycles, and maximum load sustained were recorded. Results: There were no significant differences in average screw length (25.5 mm vs 25.6 mm, P = .934), average number of cyclic loading cycles (3738 vs 3847, P = .552), average load to failure (348 N vs 371 N, P = .357), and number of catastrophic failures observed between the antegrade and retrograde fixation groups (3 in each). Practical equivalence between the 2 groups was calculated and the 2 groups were demonstrated to be practically equivalent (upper threshold P = .010). Conclusions: For this model of proximal pole scaphoid wrist fractures, antegrade and retrograde screw configuration have been proven to be equivalent in terms of biomechanical strength. With further clinical study, we hope surgeons will be able to make their decision for fixation technique based on approaches to bone grafting, concern for tenuous blood supply, and surgeon preference without fear of poor biomechanical properties.

Background: The purpose of this investigation is to compare the radiographic and intraoperative assessment of scaphotrapezoid (ST) joint arthritis in patients with end-stage carpometacarpal (CMC) arthritis of the thumb base. We aim to define the incidence of ST arthritis in this population and determine whether radiographic features such as lunate morphology, dorsal intercalated segment instability (DISI), and scapholunate (SL) diastasis are associated with the incidence of ST arthritis. Methods: We retrospectively reviewed consecutive patients with end-stage CMC arthritis of the thumb treated operatively with trapeziectomy. Preoperative wrist radiographs were reviewed, and the presence of ST arthritis was determined using the Sodha classification. Lunate morphology, DISI, and SL diastasis were noted. Intraoperative grading of ST arthritis was assessed using a modified Brown classification. The specificity and sensitivity of radiographic assessment was compared with the gold standard of intraoperative direct visualization. Results: In total, 302 thumbs met inclusion criteria. End-stage ST joint arthritis determined by intraoperative visual inspection was noted in 31% of cases. No radiographic or demographic variables were found to be risk factors for ST arthritis. Plain radiographs were 47% sensitive and 94% specific in their ability to detect end-stage ST joint arthritis. Conclusions: We report a 31% incidence of end-stage ST joint arthritis in surgically treated patients with CMC arthritis based on visual inspection which is lower than previous literature. Wrist radiographs demonstrate a 47% sensitivity and 94% specificity in predicting end-stage ST joint arthritis. It is imperative to directly visualize the ST joint after trapeziectomy, as radiographs demonstrate poor sensitivity.

Background: The scaphoid cannot be excised without generating substantial carpal dysfunction. The extent and nature of such a destabilizing procedure, however, has never been properly studied in the laboratory., Methods: We used a six-degrees-of-freedom motion tracking device to quantify the changes in carpal alignment produced by isometric simultaneous loading of five wrist motor tendons in 12 fresh normal cadaver arms, before and after excising the entire scaphoid., Findings: In the intact wrist, tendon loading consistently extended and supinated the capitate while flexing the triquetrum. After scaphoidectomy, the opposite rotations were always found: the capitate collapsed into flexion and pronation, whereas the triquetrum migrated proximally, while extending and radial deviating. All these changes were statistically significant., Interpretation: Unless it is supplemented by some sort of midcarpal stabilization, scaphoidectomy alone is much too aggressive as a procedure to be considered a treatment option for wrist osteoarthritis., Level of Evidence: Laboratory study. Not applicable., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Purpose: To summarize the techniques and clinical effectiveness in treating scaphoid nonunion with nickel-titanium (Ni-Ti) arched shape-memory alloy connector in combination with autologous iliac bone grafts., Methods: This study retrospectively analyzed 18 scaphoid nonunion cases treated with arched connectors with autologous iliac bone grafts. Based on scaphoid nonunion, 2 cases were classified as type II (fibrous union), 4 cases as type III (mild sclerotic union), 6 cases as type IV (moderate resorption and sclerosis), 5 cases as type V (severe bone resorption and sclerosis), and 1 case as type VI (pseudarthrosis formation). At the first 4, 8 and 12 weeks after the surgery, wrist anteroposterior, lateral X-ray were obtained, respectively, to evaluate bone healing. Patients who had not yet reached the standard of healing at 12 weeks after surgery would continue to receive additional appointments for follow-up visits, such as 14 weeks, 16 weeks, 18 weeks after surgery, until their imaging studies had achieved satisfactory bone healing. Clinical effectiveness was evaluated comprehensively, based on bone union time, Mayo wrist score, and visual analog pain score., Results: All 18 patients achieved satisfactory reduction and fixation with a mean union time of 4.2 months. Preoperative Mayo wrist score averaged 57.4 and average final postoperative follow-up was 91.4. On the other hand, mean preoperative VAS score was 6.8, and final postoperative follow-up average was 1.6. Mayo wrist score of the overall treatment effectiveness was excellent (90-100) in 12 cases, good (80-90) in 5 cases, and acceptable (60-80) in 1 case with zero poor (below 60) cases observed. Statistical analysis suggested that a statistically significant improvement in fracture healing, wrist function recovery and visual analog pain after surgery when compared to the scores of the patients before surgery., Conclusion: Using Ni-Ti arched shape-memory alloy connector in combination with autologous bone grafting provided a new modality to treat scaphoid nonunions in a less traumatic, convenient to operate and satisfactory manner in treatment outcomes, and thus is worthy of further application.

It was hypothesized that bilateral widening of the scapholunate gap is relatively common in the absence of trauma and that it progresses to radiological carpal instability and scapholunate advanced collapse. Electronic files of 1000 patients with bilateral X-rays were studied in retrospect. Wide scapholunate gaps were bilaterally present in 67 and unilaterally in 51 patients. Scapholunate advanced collapse was observed in 26 patients; in nine it was in both wrists. A trauma was recorded in less than half of the patients with a bilateral wide scapholunate gap. Patients with bilateral wide gaps were younger if signs of carpal instability or osteoarthritis were absent. Bilateral scapholunate widening may not be caused by an acute trauma, but may lead to carpal instability and degenerative changes with advancing age.

Background: The objective of this study was to determine the interfragmentary compression forces generated in a foam model as a function of headless compression screw type (fully threaded and central threadless) and fracture location., Methods: Eighty-eight polyurethane foam models were fixed across a simulated transverse fracture with either a fully threaded screw or a central threadless screw. The location of the transverse fracture varied along the length of the foam model in 2 mm increments for 11 fracture locations. The force generated at the fracture site upon fixation was utilized to determine the interfragmentary compression. Interfragmentary compression was compared using a paired t test and 2-way analysis of variance, with significance set at P < .05., Results: Interfragmentary compression was found to vary based on fracture location and screw type. The fully threaded screw generated significantly greater compression for fracture locations at 12 mm and 18 mm from the top edge of the foam model, while the central threadless screw generated significantly greater compression for fractures located 2 mm from the top edge of the foam model., Conclusions: The central threadless screw and the fully threaded screw had different fracture locations where maximum compression force occurred. The fully threaded screw generated greater compression force toward the screw center due to greater thread purchase. However, the central threadless screw generated greater compression at the most proximal fracture location due to its greater thread pitch toward the screw head. Maximizing interfragmentary compression may aid in reducing nonunion rates associated with the internal fixation of proximal scaphoid fractures.

Intraosseous cysts of the carpus are relatively common benign tumors. They are often discovered by chance and can cause wrist pain thereby requiring appropriate management. While conventional open surgical treatment leads to good results, it has certain disadvantages, the main one being postoperative stiffness. Arthroscopic treatment has been proposed as an alternative for lunate cysts. The present study consisted in evaluating the feasibility and outcomes of arthroscopic treatment for lunate and scaphoid cysts. The main objective was to evaluate the postoperative clinical outcomes at 3 and 18 months. The secondary objective was to evaluate the integration of a cancellous bone graft. We conducted a retrospective study of eight patients who underwent surgery between April 2010 and October 2016. Of these, four had a lunate cyst and four had a scaphoid cyst; all cysts had a dorsal operculum. Patients had disabling wrist pain that did not respond to conservative treatment. The diagnosis was confirmed by radiography and either a CT scan or an MRI. Curettage and cancellous grafts were performed under arthroscopic control. The technique was carried out successfully in all cases. One patient was lost to follow-up. At 18 months, postoperative pain was rated at 1.28 on a visual analog scale. The grip strength (measured with a Jamar dynanometer) was 77% when compared to the contralateral side. There was an improvement in joint range of motion, with an average wrist flexion of 67.5° compared to 48.3° preoperatively and an average wrist extension of 71.5° compared to 47.6° preoperatively. The Patient-Rated Wrist Evaluation (PRWE) score decreased from 69.7 to 12.7, which was a significant decrease. A good integration of the cancellous graft was confirmed at 6 months in all cases by CT scan or MRI. Curettage with a cancellous graft of lunate and scaphoid cysts under arthroscopic control is a technique that allows surgeons to obtain satisfactory clinical results with good integration of the graft., (Copyright © 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

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., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The purpose of this study was to determine if screw placement in the reduction and association of the scaphoid and the lunate (RASL) procedure affected the ability of the scapholunate joint to withstand force. After completely disrupting of the scapholunate ligament in 29 fresh-frozen cadaveric wrists, we placed the RASL screw either distal or proximal to the lateral aspect of the dorsal ridge of the scaphoid and into the dorsal or volar aspect of the lunate. Specimens were subjected to repeated cycles of transcarpal axial force, mimicking clenched-fist loading, until failure. Screw placement distal to the lateral aspect of the dorsal scaphoid ridge was significantly associated with failure when examined manually, radiographically (1.8 vs. 0.5 mm) and using real-time motion capture (diastasis: 1.6 vs. 0.4 mm; Euler angle: 4.5 ° vs. 0.8 °). The lateral aspect of the dorsal ridge is a reliable radiographic landmark on the scaphoid and provides surgeons with a convenient starting point to achieve the most biomechanically stable RASL construct, and, therefore, enhances the potential for an optimal clinical outcome.

Chronic scapholunate ligament (SL) injuries are difficult to treat and can lead to wrist dysfunction. Whilst several tendon reconstruction techniques have been employed in the management of SL instability, SL gap reappearance after surgery has been reported. Using a finite element model and cadaveric study data, we investigated the performance of the Corella, scapholunate axis (SLAM) and modified Brunelli tenodesis (MBT) techniques. Scapholunate dorsal and volar gap and angle were obtained following virtual surgery undertaken using each of the three reconstruction methods with the wrist positioned in flexion, extension, ulnar deviation and radial deviation, in addition to the ulnar-deviated clenched fist and neutral positions. From the study, it was found that, following simulated scapholunate interosseous ligament rupture, the Corella technique was better able to restore the SL gap and angle close to the intact ligament for all wrist positions investigated, followed by SLAM and MBT. The results suggest that for the tendon reconstruction techniques, the use of multiple junction points between scaphoid and lunate may be of benefit. Graphical abstract The use of multiple junction points between scaphoid and lunate may be of benefit for tendon reconstruction techniques.

Scapholunate (SL) instability is the most common dissociative carpal instability condition. It is the most frequent cause of wrist osteoarthritis, defined as scapholunate advanced collapse or SLAC wrist. Familiarity with the SL ligament complex is required to understand the various features of SL instability. Damage to the SL interosseous ligament is the main prerequisite for SL instability; however the extrinsic, palmar and dorsal ligaments of the carpus also come into play. When more than 6 weeks has passed since the initial injury event, SL instability is considered chronic because ligament healing is no longer possible. Before osteoarthritis sets in and when the SL instability is still reducible (scaphoid can be reverticalized), ligament reconstruction surgery is indicated. Since the end of the 1970s, various ligament reconstruction or tenodesis techniques have been described. These techniques are used in cases of chronic, dynamic or static reducible SL instability, when no repairable ligament stump and no chondral lesions are present. The aim is to correct the SL instability using a free or pedicled tendon graft to reduce pain while limiting the loss of mobility and protecting against osteoarthritis-related collapse in the long-term. We will perform a systematic review of the various tenodesis techniques available in the literature., (Copyright © 2017 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Scaphoid nonunions are challenging injuries to manage and the optimal treatment algorithm continues to be debated. Most scaphoid fractures heal when appropriately treated; however, when nonunions occur, they require acute treatment to prevent future complications like scaphoid nonunion advanced collapse. Acute nonunion treatment technique depends on nonunion location, vascular status of the proximal pole, fracture malalignment, and pre-existing evidence of arthrosis. Bone grafting and vascular grafts are common in nonunion management. Chronic nonunions that have progressed to scaphoid nonunion advanced collapse often require a salvage procedure such as four corner fusions, proximal row carpectomy, or wrist fusion. Herein, we review the current literature regarding scaphoid nonunions with regards to their anatomy, natural history, classification, diagnostic imaging, surgical management, and clinical outcomes.

Neither the complex motions of the scapholunate joint, nor the kinematic changes that occur as a result of injury to it, are fully understood. We used electromagnetic tracking within affected bones to evaluate the physiologic motions in the planes of flexion and extension, and of radial and ulnar deviation of human cadaver wrists, before and after complete transection of the scapholunate ligaments. Despite individual variance between each wrist, we were able to establish a pattern in the changes that occurred after scapholunate ligament injury. During the motions examined, the scaphoid showed an increase in translational deviation in almost all motion axes. In contrast, the movement of the lunate seemed to be impaired, especially in radial-ulnar deviation.

Background: Scapholunate advanced collapse (SLAC) of the wrist is the most common degenerative condition of the wrist. Four-corner fusion (4CF) is performed as salvage surgery, though there is limited information on its long-term results. We hypothesized that 4CF is a durable surgery with good clinical long-term function., Methods: A retrospective chart review of patients undergoing 4CF as well as an interview and recent radiographs were obtained. Patients with a follow-up period of less than 10 years were excluded. Long-term evaluation included standard wrist radiographs, wrist range of motion, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Radiographs were evaluated and described by the Kellgren-Lawrence classification., Results: Four hundred eighty-nine wrists underwent a 4CF for SLAC wrist from 1982 to 2003. Twelve patients (15 wrists) were available for follow-up. Average age at surgery was 49.1 years (range, 25-67 years). Average follow-up postsurgery was 18 years (11-27). Scapholunate advanced collapse was the etiology in 13 wrists and scaphoid nonunion advanced collapse in 2 wrists. Average extension/flexion arc was 68.6° (0°-96°), and radial/ulnar deviation arc was 32.9° (0°-5°). QuickDASH scores averaged 7.8 (range, 0-32.5), with only 1 score above 16. Seventy-three percent of radiographs showed minimal to moderate joint destruction, and 27% showed severe joint destruction., Conclusions: Scaphoid excision and 4CF remains a reliable procedure for patients with advanced wrist arthritis. Functional results were good at long-term follow-up despite radiographic changes in the radiolunate joint in 73% of patients. Patient satisfaction was high, and functional impairment was low.

Background: Scapholunate ligament injury is a commonly occurring carpal ligament injury. Pathology associated with scapholunate ligament injury depends on several factors such as the time after injury, type of injury (instability) and the development of osteoarthritis. The aim of this study was to investigate and compare contact mechanics in the lunocapitate and scaphocapitate joints in the normal, injured (scapholunate dissociation) and repaired (postoperative) wrist., Methods: Four human subjects with scapholunate ligament dissociation participated in this study. MR images of normal (contralateral), injured and postoperative wrists were obtained during relaxed condition and during active light grasp. Relaxed MR images were used to construct model geometry (bones with cartilage) for the capitate, lunate and scaphoid. Kinematic transformations were obtained by using image registration between the unloaded and functionally loaded image sets. Joint surface contact mechanics were then calculated., Findings: All contact measures (contact force, pressure, mean pressure and area) tended to increase with injury in both articulations. A significantly higher contact area was found in the injured scaphocapitate joint compared to normal. A significant increase in peak pressure was observed in the postoperative state compared to normal., Interpretation: Injury to the scapholunate ligament increased contact measures, suggesting a risk for onset of osteoarthritis in both the scaphocapitate and lunocapitate joints. Surgical repair appeared to restore most measures of contact mechanics to near normal values, more so for the lunocapitate joint when compared to scaphocapitate joint. The elevated postoperative peak pressures indicate the difficulty to fully restore joint mechanics., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

The treatment of scaphoid nonunion and malunions has undergone a considerable transition since the 1960 modification of Matti's technique by Russe. 1 We present a review of articles with clear data on union rates and functional status to review the current methods of treatment for scaphoid nonunion and malunion., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: A high incidence of nonunion and relatively poor outcomes with prior fixation techniques has precluded scapholunate (SL) arthrodesis as a standard treatment for SL instability. Our purpose was to determine the impact on range of motion (ROM) of simulated SL arthrodesis via headless screw fixation., Methods: We performed baseline wrist ROM for 10 cadaveric wrists using a standardized mounting-and-weights system. Extension, flexion, radial deviation, ulnar deviation, dart-thrower's extension, and dart-thrower's flexion were assessed. Two 3.0-mm headless compression screws were inserted across the SL joint to simulate SL arthrodesis. Goniometric measurements and fluoroscopic imaging were repeated to assess ROM differences after simulated SL arthrodesis. We assessed SL angle and gap during testing to ensure there was no significant motion between the scaphoid and lunate, thus confirming stable simulated fusion. Differences in ROM were compared between baseline and simulated SL arthrodesis using paired t tests., Results: Mean SL angle remained constant between pre- and post-arthrodesis imaging (47° ± 6° vs 46° ± 4°) and did not change during post-arthrodesis ROM testing, indicating a stable simulated fusion. Compared with baseline, SL arthrodesis had a statistically significant reduction in maximum flexion of 6° and 9° based on fluoroscopy and goniometry, respectively, in dart-thrower's extension of 5° and 9° based on fluoroscopy and goniometry, respectively, and in dart-thrower's flexion of 6° for both fluoroscopy and goniometry. No other ROMs after simulated SL arthrodesis were significantly different compared with baseline., Conclusions: The effects of simulated SL arthrodesis on radiocarpal and midcarpal motion compare favorably with motion after SL soft tissue repair and other reconstructive techniques that have been previously reported. The statistically significant decreases in wrist flexion and dart-thrower's extension-flexion after simulated SL arthrodesis are of questionable clinical importance., Clinical Relevance: These results may support reconsidering SL arthrodesis as a viable treatment option for acute or chronic SL instability with regard to apparent minimal adverse effects on functional wrist ROM., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The utility of biomechanical models and simulations to examine clinical problems is currently limited by the need for extensive amounts of experimental data describing how a given procedure or disease affects the musculoskeletal system. Methods capable of predicting how individual biomechanical parameters are altered by surgery are necessary for the efficient development of surgical simulations. In this study, we evaluate to what extent models based on limited amounts of quantitative data can be used to predict how surgery influences muscle moment arms, a critical parameter that defines how muscle force is transformed into joint torque. We specifically examine proximal row carpectomy and scaphoid-excision four-corner fusion, two common surgeries to treat wrist osteoarthritis. Using models of these surgeries, which are based on limited data and many assumptions, we perform simulations to formulate a hypothesis regarding how these wrist surgeries influence muscle moment arms. Importantly, the hypothesis is based on analysis of only the primary wrist muscles. We then test the simulation-based hypothesis using a cadaveric experiment that measures moment arms of both the primary wrist and extrinsic thumb muscles. The measured moment arms of the primary wrist muscles are used to verify the hypothesis, while those of the extrinsic thumb muscles are used as cross-validation to test whether the hypothesis is generalizable. The moment arms estimated by the models and measured in the cadaveric experiment both indicate that a critical difference between the surgeries is how they alter radial-ulnar deviation versus flexion-extension moment arms at the wrist. Thus, our results demonstrate that models based on limited quantitative data can provide novel insights. This work also highlights that synergistically utilizing simulation and experimental methods can aid the design of experiments and make it possible to test the predictive limits of current computer simulation techniques.

Background: To determine the association between lunate morphology and the scapholunate instability using radiographic images, and investigate the association between lunate morphology and scaphoid fracture location., Methods: Between January 2003 and December 2011, we retrospectively evaluated the plain radiographs and computed tomography (CT) images of 70 patients who underwent surgical intervention for a scaphoid nonunion, in order to determine the association between lunate type (I or II) and scapholunate instability or scaphoid fracture location. We determined the scaphoid fracture location using the fragment ratio and measured the radiolunate angle and capitate-triquetrum (C-T) distance., Results: A type II lunate was present in 68.6% (48 of 70 cases). Mean fragment ratio of fracture location was 50.6% in the type II lunate group and 56.2% in the type I lunate group (p = 0.032). Sixteen of the 70 patients had dorsal intercalated segmental instability (DISI) deformities. Nine of 22 cases showed DISI deformity in type I lunate and 7 of 48 cases showed DISI deformity in type II lunate (p = 0.029). However, there were no significant differences between the presence of DISI deformity and fracture location (p = 0.15). Morphologic comparisons by both plain radiography and CT indicated a mean C-T distance in the type I lunate group (22 cases) of 2.3 mm and 5.0 mm in the type II lunate group (48 cases). The C-T distances were significantly correlated with lunate morphology (p = 0.001)., Conclusions: A type II lunate was associated with low incidence of DISI deformity and proximal location of fracture in patients presenting with a scaphoid nonunion.

Objectives: Using four-dimensional CT scan (4DCT), we aimed at showing the kinematics of scapholunate (SL) interval in asymptomatic wrists in comparison with symptomatic contralateral wrists with inconclusive radiographic findings., Methods: This is an IRB approved, HIPPA compliant, retrospective study. Patients suspected of SL interosseous ligament (SLIL) injuries were referred for further evaluation of chronic wrist pain (>3 months). Twelve wrists (11 subjects) with chronic symptoms and inconclusive plain radiographs and 10 asymptomatic wrists (in 10 different subjects) were scanned using 4DCT. The minimum SL interval was measured during three wrist motions: relaxed-to-clenched fist, flexion-to-extension, and radial-to-ulnar-deviation. Changes were recorded using double-oblique multiplanar reformation technique., Results: We extracted the normal limits of the SL interval as measured by dynamic CT scanning during active motion in asymptomatic wrists. In asymptomatic wrists, the average SL interval was observed to be smaller than 1 mm during all motions. In symptomatic wrists, during exams performed with clenched fist (SL interval (mean ± SD) = 2.53 ± 1.19 mm), extension (2.54 ± 1.48 mm) or ulnar deviation (2.06 ± 1.12 mm), the average SL interval was more than 2 mm. In contrast to symptomatic wrists, no significant change in SL interval measurements was detected during wrist motions in asymptomatic wrists. There was a mild to moderate correlation between SL interval change and presence/absence of symptoms (point-biserial correlation coefficients: 0.29-0.55)., Conclusion: In patients with wrist pain suspicious for SLIL injury and inconclusive radiographs, SL interval increase can be detected with 4DCT in the symptomatic wrist compared to the asymptomatic wrist.

Background: Arthroscopic management of scaphoid nonunions has been advanced as a less invasive technique that allows evaluation of associated intrinsic and extrinsic ligamentous injuries; however, few studies have documented the effectiveness of arthroscopic treatment of scaphoid nonunions and which intraarticular pathologies coexist with scaphoid nonunions., Questions/purposes: (1) What are the outcomes of arthroscopic management of scaphoid nonunions as assessed by the proportion of patients achieving osseous union, visual analog scale (VAS) pain score, grip strength, range of motion, Mayo Wrist Score (MWS), and Disabilities of the Arm, Shoulder and Hand (DASH) score? (2) What complications are associated with arthroscopic scaphoid nonunion management? (3) What forms of intraarticular pathology are associated with scaphoid nonunions?, Methods: Between 2008 and 2012, we treated 80 patients surgically for scaphoid nonunions. Of those, 45 (56%) had arthroscopic management. During that time, our general indications for using an arthroscopic approach over an open approach were symptomatic scaphoid nonunions without necrosis of the proximal fragment, severe deformities, or arthritis. Of the patients treated arthroscopically, 33 (73%) were available for followup at least 2 years later. There were five distal third, 19 middle third, and nine proximal third fractures. The mean followup was 33 months (range, 24-60 months). Union was determined by CT taken at 8 to 10 weeks after operation with bridging trabecula at nonunion site. VAS pain scores, grip strength, active flexion-extension angle, MWS, and DASH scores were obtained preoperatively and at each followup visit. The coexisting intraarticular pathologies and complications were also recorded., Results: Thirty-two (97%) scaphoid nonunions healed successfully. At the last followup, the mean VAS pain score decreased (preoperative: mean 4.5 [SD 1.8], postoperative: mean 0.6 [SD 0.8], mean difference: 3.9 [95% confidence interval {CI}, 3.2-4.6], p < 0.001) and the mean active flexion-extension angle increased (preoperative: mean 100° [SD 26], postoperative: mean 109° [SD 16], mean difference: 9° [95% CI, 2-16], p = 0.017). The mean grip strength increased (preoperative: mean 35 kg of force [SD 8], postoperative: mean 50 kg of force [SD 10], mean difference: 15 kg of force [95% CI, 11-19], p < 0.001). The mean MWS increased (preoperative: mean 56 [SD 23], postoperative: mean 89 [SD 8], mean difference: 33 [95% CI, 26-41], p < 0.001) and the mean DASH score decreased (preoperative: mean 25 [SD 18], postoperative: mean 4 [SD 3], mean difference: 21 [95% CI, 15-28], p < 0.001). There were no operation-related complications and no progression of arthritis at the last followup. Seventeen patients had coexisting intraarticular pathology, including nine triangular fibrocartilage complex tears (seven traumatic and two degenerative), 17 intrinsic ligament tears (nine scapholunate interosseous ligament tears and eight lunotriquetral interosseous ligament tears), and five mild radioscaphoid degenerative changes., Conclusions: Arthroscopic management of scaphoid nonunions without severe deformities or arthritis was effective in this small series. Although intraarticular pathologies such as triangular fibrocartilage complex tears and intrinsic ligament injuries commonly coexisted with scaphoid nonunions, patients generally achieved good results., Level of Evidence: Level IV, therapeutic study.

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., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Introduction: Conventional radiographic imaging is the first imaging tool of choice in scaphoid fractures. The majority of undisplaced scaphoid waist fractures unite after 6 weeks of cast immobilization. We hypothesized that conventional radiographic imaging at 6 weeks after injury can both accurately and reliably predict union in undisplaced scaphoid waist fractures., Materials and Methods: Fleiss' kappa statistics were used concerning the opinions of four observers reviewing 47 sets of good-quality scaphoid radiographs of undisplaced scaphoid waist fractures. As reference standard for union, radiographs were taken at a minimum of 6 months after injury to determine validity., Results: Overall agreement was defined as moderate. (κ = 0.583) "No consolidation" (κ = 0.816), "full consolidation" (κ = 0.517) and "partial consolidation" (κ = 0.390) were defined as good, moderate and fair agreement, respectively. The average sensitivity and specificity of diagnosing scaphoid waist fracture union on standard scaphoid radiographs were 0.65 and 0.67, respectively. The positive predictive value for diagnosing union was 0.93 and the negative predictive value was 0.22., Conclusions: Conventional radiographic imaging is accurate and moderately reliable in diagnosing union, and reliable but inaccurate in diagnosing nonunion of scaphoid waist fractures at 6 weeks follow-up.

Objective: To summarize the experience of percutaneous fixation of scaphoid fractures with Herbert screws through volar approach, and provide a reliable and efficient treatment method for scaphoid fractures., Methods: From April 2008 to September 2012,15 patients with scaphoid fractures were treated by percutaneous fixation with Herbert cannulated screws through volar approach including 14 males and 1 female with an average age of 35 years ranging from 25 to 45 years old. Among them, 10 cases were on left side and 5 cases were on right side. Durations from injury to operation ranged from 3 to 10 days with an average of 5 days. All these cases were identified as B2 type according to the Herbert classification based on X-ray and CT scan. In order to assess the function of wrist, all patients were calculated according to Krimmer's score postoperatively., Results: The follow-up period were from 5 to 18 months with an average of 10 months. At 3 months after operation,X-ray was re-checked every month. All the patients achieved bone union with a mean time of 10 weeks (ranged from 7 to 14 weeks) postoperatively. According to Krimmer's score, 14 cases gained 100 scores as perfect and one case got 90 scores as good. The small volar incision of all patients were union at the first period. No operation complications such as infection and nonunion occurred., Conclusion: Percutaneous fixation with Herbert cannulated screws through volar approach is a reliable and efficient treatment method for scaphoid fractures with small invasion, high bone union rate, and fewer complications.

Objective: To evaluate the early clinical and radiographic outcome of scaphoid non-unions treated with Acutrak headless compression screw., Methods: From January 2008 to July 2011,21 patients with scaphoid non-union were treated in our department. There were 18 males and 3 females with a mean age of (23.6 +/- 4.6) years; 12 cases were on right hand and 9 were on left. According to Herbert-Fisher classification, there were 10 cases with type D1, 7 cases with type D2, 3 cases with type D3, and 1 case with type D4. The mean time from injury to operation was (12.4 +/- 2.7) months. All patients were treated with Acutrak headless compression screw fixation (6 cases received 2 screws fixation, 15 cases received 1 screw fixation, and Matti-Russe bone grafting was applied in 7 cases). The carpal height, the scaphoid index and changes of the scapholunate angle were assessed before and after the operation. Range of motion and grip strength were recorded and the wrist function was assessed according to the Patient-Rated Wrist Evaluation (PRWE)., Results: Average duration of follow-up was (21.3 +/- 3.6) months. All the patients attained radiological union in a mean time of (13.3 +/- 2.4) weeks following the operation. No obvious complications were recorded. The surgical treatment allowed the preoperative mean scaphoid index of 0.61 +/- 0.13 and the preoperative mean scapholunate angle of (59.4 +/- 6.8) degree to be improved to 0.69 +/- 0.10 and (44.3 +/- 8.2)degree postoperatively, respectively. There was a substantial improvement in grip strength and pain amelioration after surgery. The preoperative mean PRWE score of 45.2 +/- 4.7 was improved to 76.1 +/- 5.2 postoperatively. All patients returned back to the original work,the average time from surgery to work was (6.0 +/- 1.1) months., Conclusion: For scaphoid non-unions, Acutrak headless compression screw fixation can provide anatomical reduction, provide satisfactory results with a high union rate, well return of function and minimal complications in the early stage.

Purpose: To determine whether symptomatic dorsal wrist ganglions are associated with generalized ligamentous hyperlaxity., Methods: Ninety-six patients (61 females) presenting to hand surgeons for a symptomatic dorsal wrist ganglions were prospectively enrolled in this case-control investigation. Beighton scores were calculated to quantify generalized ligamentous laxity in each patient, and a scaphoid shift test (scapholunate capsuloligamentous laxity evaluation) was performed. A positive scaphoid shift test was defined by both pain and a palpable clunk. Ninety-six individuals without ganglions were then enrolled to form an age and sex frequency-matched control cohort. The control group was similarly assessed for Beighton score and scaphoid shift test. Binary logistical regression was performed to assess the association of ganglions with generalized ligamentous hyperlaxity (Beighton score ≥ 4) while accounting for effects of age and sex., Results: Patients with symptomatic dorsal wrist ganglions demonstrated significantly increased rates of generalized ligamentous hyperlaxity. Among those with ganglions, 27 of 96 (28%) patients exhibited generalized ligamentous hyperlaxity, compared with 12 of the 96 (13%) age- and sex-matched individuals in the control group. Patients with symptomatic dorsal wrist ganglions were also significantly more likely to demonstrate localized scapholunate hyperlaxity with a positive scaphoid shift test (25% positive scaphoid shift test with ganglions vs 1% in controls). In logistical modeling, patients with dorsal wrist ganglions had 2.9 (95% confidence interval [CI] 1.3-6.2) times greater odds of generalized ligamentous hyperlaxity compared with patients without a dorsal wrist ganglion after accounting for patient age and sex., Conclusions: Symptomatic dorsal wrist ganglions were associated with both generalized ligamentous hyperlaxity and a positive scaphoid shift test. Although an association between wrist ganglions and ligamentous hyperlaxity does not prove causation, the possibility of the same underlying pathological entity causing both can be envisioned (ie, abnormal formation or organization of dense regular connective tissue)., Type of Study/level of Evidence: Prognostic III., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Restoring ligamentous control in dissociative carpal instability is a major issue in protecting against osteoarthritis. We present clinical and radiological results for 20 patients who underwent flexor carpi radialis three-ligament tenodesis and were prospectively reviewed at a mean follow-up of 25.1 months. Three-ligament tenodesis significantly relieved pain and increased grip strength, wrist function at the expense of joint stiffness. This improvement was not seen in cases of dynamic instability. However, ligamentous loosening did result in rapid recurrence of radiological anomalies and frequent complications. This study challenges the long-term benefit of three-ligament tenodesis in both dynamic and static chronic scapholunate instability.

We investigated the effects of scapholunate ligament injury on in vivo radiocarpal joint mechanics using image-based surface contact modeling. Magnetic resonance images of 10 injured and contralateral normal wrists were acquired at high resolution (hand relaxed) and during functional grasp. Three-dimensional surface models of the radioscaphoid and radiolunate articulations were constructed from the relaxed images, and image registration between the relaxed and grasp images provided kinematics. The displacement driven models were implemented in contact modeling software. Contact parameters were determined from interpenetration of interacting bodies and a linear contact rule. Peak and mean contact pressures, contact forces and contact areas were compared between the normal and injured wrists. Also measured were effective (direct) contact areas and intercentroid distances from the grasp images. Means of the model contact areas were within 10 mm(2) of the direct contact areas for both articulations. With injury, all contact parameters significantly increased in the radioscaphoid articulation, while only peak contact pressure and contact force significantly increased in the radiolunate articulation. Intercentroid distances also increased significantly with injury. This study provides novel in vivo contact mechanics data from scapholunate ligament injury and confirms detrimental alterations as a result of injury., (Copyright © 2013 Orthopaedic Research Society.)

The aim of this study was to measure inter- and intra-observer agreement on the radiographic classification of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrist. Radiographs of 41 patients with SLAC wrist and 47 patients with SNAC wrist were graded on two separate occasions by four orthopaedic consultants specializing in hand and wrist surgery. Inter-observer agreement was evaluated using the multi-rater kappa value. Landis and Koch criteria were used to assess the level of agreement. Intra-observer agreement was tested by re-grading the radiographs after an interval of 2 to 4 weeks and calculating the weighted kappa value. For SLAC wrist, the inter-observer agreement was moderate (kappa value = 0.59) and intra-observer agreement substantial (kappa value = 0.65). For SNAC wrist, the inter-observer agreement was slight (kappa value = 0.20) and intra-observer agreement was fair (kappa value = 0.29). Radiographic classification of SLAC wrist has moderate reliability and reproducibility, whereas classification of SNAC wrist has limited reliability.

We report on a 15-year-old girl with bilateral scaphotrapezium-trapezoid coalitions and bipartite scaphoids. There was no history of trauma or any other associated pathology. Wrist pain was alleviated by arthrodesis of the pseudarthrosis of the scaphoid component of the coalitions. Coalition of the distal portions of the scaphoids may have interfered with union of 2 ossification centers of the scaphoid. It is also possible that the carpal coalitions predisposed the scaphoid to fracture and that this represents bilateral nonunion., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Summary: This retrospective study examined clinical and radiological outcomes of scaphoidectomy and 4-corner fusion in patients with a scapholunate advanced collapse (SLAC) at 5 and 10 years., Purpose: Partial wrist arthrodesis is commonly performed to treat wrist arthritis because it provides pain relief without sacrificing complete wrist motion. The purposes of this retrospective study were to evaluate clinical and radiological outcomes after scaphoidectomy and 4-corner fusion after more than 10 years of follow-up and to compare the midterm and long-term results., Methods: Forty-two patients were enrolled. The following were evaluated annually: pain (visual analog scale); Disabilities of the Arm, Shoulder, and Hand score; range of motion; grip strength; and Modified Mayo Wrist score. Bony union and arthritic changes in the radiolunate joint were also evaluated radiologically. Midterm and long-term results were compared., Results: The mean (SD) follow-up period was 12.2 (1.43) years. Two patients were excluded from the study because of complications, so the final postoperative evaluation included 40 patients. Visual analog scale and Disabilities of the Arm, Shoulder, and Hand scores improved to a satisfactory level by 5 years after surgery and did not differ significantly between 5 and 10 years. Flexion, extension, and radial deviation were reduced after 5 years compared with preoperative measures, and no difference was found between 5 and 10 years. Ulnar deviation, pronation, and supination did not change significantly after surgery. Grip strength was significantly recovered from 29.7 (4.9) kg at 5 years after surgery to 32.1 (8.5) kg at 10 years. The Modified Mayo Wrist score improved significantly to 83.2 (4.1) at 5 years after surgery but did not differ significantly between 5 and 10 years. All cases showed radiological solid fusion, and the mean (SD) period of union was 9.34 (3.7) weeks. Further radiolunate arthritic change was verified in 2 patients, but Modified Mayo Wrist scores were fair. One patient experienced inexplicable pain; therefore, total wrist fusion was performed at 6 years after surgery., Conclusions: This retrospective cohort study of patients followed up for more than 10 years showed that the midterm and long-term results of 4-corner fusion for stage III SLAC were satisfactory, and arthritic changes in the radiolunate joint were minimal.

Purpose: To investigate in vivo 3-dimensional patterns of dorsal intercalated segment instability deformity resulting from scapholunate dissociation., Methods: We studied 6 patients with stage IV scapholunate dissociation in which there were complete tears of the scapholunate interosseous ligament and dorsal intercalated segment instability deformity. Of these, 3 patients had a dorsally displaced distal radius malunion, a condition known to aggravate or produce a dorsal intercalated segment instability deformity. With the wrist in neutral, we created 3-dimensional bone models of the wrists from computed tomography. We calculated centroid locations of each carpal and the rotational angle of the scaphoid and lunate relative to the radius and compared them with those of 6 normal subjects. The joint contact area was visualized to evaluate congruity of the radiocarpal and midcarpal joints., Results: In the scapholunate dissociated wrists, the scaphoid translated dorsally and radially with rotation in the direction of flexion and pronation. The lunate was extended and supinated. The capitate, trapezoid, and trapezium translated dorsally. Contact area of the radioscaphoid joint shifted dorsoradially owing to dorsoradial subluxation of the scaphoid proximal pole. Congruity was retained in the radiolunate, lunocapitate, and scaphotrapeziotrapezoid joints. In the malunion cases, the scaphoid and distal carpal rows translated more dorsally along dorsal angulation of the distal radius; therefore, incongruity of the radioscaphoid joint became more pronounced., Conclusions: Dorsoradial subluxation of the scaphoid proximal pole over the dorsal rim of the radius led to incongruity of the radioscaphoid joint. Dorsal translation of the distal carpal row occurred with maintaining congruency of the radiolunate, lunocapitate, and scaphotrapeziotrapezoid joints. These results suggest that for realignment of the carpal axis of an advanced scapholunate dissociated wrist, we should restore scapholunate rotational malalignment and reduce the dorsally translated distal carpal row back to the anatomical position., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The scaphoid is the most frequently fractured carpal bone. When investigating fixation stability, which may influence healing, knowledge of forces and moments acting on the scaphoid is essential. The aim of this study was to evaluate cartilage contact forces acting on the intact scaphoid in various functional wrist positions using finite element modeling. A novel methodology was utilized as an attempt to overcome some limitations of earlier studies, namely, relatively coarse imaging resolution to assess geometry, assumption of idealized cartilage thicknesses and neglected cartilage pre-stresses in the unloaded joint. Carpal bone positions and articular cartilage geometry were obtained independently by means of high resolution CT imaging and incorporated into finite element (FE) models of the human wrist in eight functional positions. Displacement driven FE analyses were used to resolve inter-penetration of cartilage layers, and provided contact areas, forces and pressure distribution for the scaphoid bone. The results were in the range reported by previous studies. Novel findings of this study were: (i) cartilage thickness was found to be heterogeneous for each bone and vary considerably between carpal bones; (ii) this heterogeneity largely influenced the FE results and (iii) the forces acting on the scaphoid in the unloaded wrist were found to be significant. As major limitations, accuracy of the method was found to be relatively low, and the results could not be compared to independent experiments. The obtained results will be used in a following study to evaluate existing and recently developed screws used to fix scaphoid fractures., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Introduction: This is single centre retrospective review of a consecutive series of patients with scaphoid nonunion (SNU) treated using the Ilizarov technique without bone graft. Fifteen of the original 18 patients were available for clinical and radiological examination at a minimum follow-up of 5 years (range 5-10 years). An evaluation was made of the late functional results, satisfaction scores, residual symptoms, grip strength and the presence of radiocarpal and scaphoid degenerative changes., Methods: The series consisted of 15 patients; 14 males; 1 female, with a mean SNU duration of 15.7 months, and a mean age of 23.6 years. Patients with carpal instability, humpback deformity, carpal collapse, avascular necrosis or marked degenerative change, were excluded from this treatment method. Following frame application the treatment consisted of three stages: distraction, compression and immobilisation. The technique is detailed herein., Results: Radiographic (CT) and clinical bony union was achieved in all 15 patients after a mean of 88 days (70-130 days). Mean modified Mayo wrist scores initially improved from 21 preoperatively to 86 at previous review, and were 96 at a mean follow-up of 81 months (62-120 months), with excellent results in 10, and good results seen in 5 patients. At latest review the mean grip strengths had returned to 96% of the uninjured hand, and 7 patients had regained full strength; mean wrist flexion/extension arc of motion had also continued to improve to 136° from 131°. All patients returned to their pre-injury occupations and levels of activity at a mean of 117 days. Three patients suffered superficial K-wire infections, which resolved with oral antibiotics. One patient continues to suffer intermittent mild aching in the wrist. No patient suffered loss of scaphoid height, humpback deformity, DISI instability or collapse of the regenerate bone., Conclusion: In these selected patients this technique safely achieved bony union without the need to open the SNU site and without the need for bone graft. These patients also had the capacity to continually improve their wrist function beyond 3 years following their treatment., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Purpose: To determine the role of the carpal ligaments during wrist flexion-extension and to understand whether maintaining integrity of only the dorsal scapholunate ligament (SLL) is adequate for maintaining stability of the scapholunate joint., Methods: This study combined motion analysis and manual digitization of ligament attachment regions to generate predictions of carpal ligament length and implied strain during wrist motion and length changes after simulated ligamentous injury., Results: We modeled 13 ligaments and 22 ligament segments (subportions). We measured ligament length change with respect to wrist angle. A total of 11 segments had minimum stretch or elongation from neutral wrist position over the entire wrist range of motion for any ligament cut condition. The remaining 11 segments had more than 10% stretch in some portion of flexion-extension. In general, ligaments had increased stretch during wrist flexion and after cutting the entire SLL and the dorsal intercarpal ligaments off the scaphoid., Conclusions: Disruption of the membranous and palmar portions of the SLL and the dorsal intercarpal ligament off the scaphoid did not result in the development of an increased 3-dimensional scapholunate gap, as measured by differences in ligament length calculations between the scaphoid and lunate. This may indicate a predynamic instability condition (before clinical signs and x-ray findings) that is stabilized by the dorsal SLL, preventing the increase in the 3-dimensional scapholunate gap. This may also support surgical treatment recommendations, which suggest that repair of the dorsal component only of the SLL will be effective. Disruption of the dorsal intercarpal ligament off the scaphoid or lunate did not result in further significant changes. Therefore, the dorsal SLL has an important role in preventing scapholunate ligament instability., Clinical Relevance: These results provide insight into the abnormal kinematics as various ligaments are compromised., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

An injury to the ligament linking the scaphoid with the lunate is the most common and and budrened with the most negative sequelae cause of the carpal instability. It occurs most frequently as an associated injury at fractures of the distal radius. A review of methods of treatment of the pathology is provided, according to clinical advancement, duration form original trauma and condition of articular structures. Technical complexity of methods is directly related to severity of intrarticular changes. In early, dynamic instabilities, a simple, temporary scapholunate arthrodesis with K-wires is is an useful procedure, preventing further development of chronic instsbility. In later stages. The treatment is technically more demanding, considering re-alignment of carpal anatomy with ligaments or tendons (capsulodesis or tenodesis). An usefulness of arthroscopy in diagnostics and management at any stage of this pathology was emphasized.

Purpose: We compare scaphoid excision and 4-bone arthrodesis (FBA) with proximal row carpectomy (PRC) in terms of contact pressure, area, and location., Methods: Six cadaveric forearms underwent simulated FBA with K-wires. We measured pressures in the radiocarpal joint with Fuji contact film after we applied a 200-N load via the wrist tendons with the wrist in neutral, flexion, and extension. We repeated the experiment after excising the lunate and triquetrum, to create a PRC in the same specimens., Results: Contact pressure in the PRC wrist was significantly greater, by 25%, compared with the FBA wrist for all wrist positions. The PRC wrist had a significantly smaller contact area, by 43%, compared with the FBA wrist. In the FBA wrist, lunate contact was more dorsal in flexion but more volar in extension. In the PRC wrist, capitate contact was more dorsal and radial in flexion, whereas the contact was more volar and ulnar in extension. Comparing contact location, FBA contact was significantly more ulnar than PRC contact in wrist flexion. We found no significant difference in contact translation (the distance between the contact locations in the positions of wrist flexion and extension) for the lunate in FBA or the capitate in PRC., Conclusions: The FBA wrist has significantly lower contact pressure (P < .001), greater contact area (P < .001), and equal contact translation compared with the PRC wrist. These qualities may make FBA less susceptible to degeneration over time. By advancing our understanding of the biomechanics of both wrist procedures, we may better tailor them to the individual patient., Clinical Relevance: Current biomechanical evidence is lacking for common motion-preserving procedures for wrist arthritis. Comparing contact pressure, area, and location provides a biomechanical basis of our clinical understanding of these surgeries., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Introduction: Scaphoid fractures with displacement have a higher incidence of nonunion that can cause pain and reduced movement, strength and function. The aim of this study was to review the evidence available and establish the risk of nonunion associated with management of displaced fractures of the waist of the scaphoid., Methods: Electronic databases were searched using the Medical Subject Headings (MeSH) controlled vocabulary (scaphoid fractures, AND'd with displaced, or nonunion, or non-healing or cast immobilisation, or plaster or surgery). At present, there are no randomised, controlled trials or studies comparing fixation to plaster cast treatment of displaced fractures of the scaphoid. The search was therefore limited to observational studies of displaced fractures of the scaphoid treated in a plaster cast (non-operative group) or fixed surgically (operative group). The criterion for displacement was limited to gap or step of more than 1 mm. In the non-operative group, we compared the outcome of displaced and undisplaced fractures of the waist of the scaphoid treated in a plaster cast. In the operative group, contingency table analysis was used to calculate the odds ratio of nonunion with plaster treatment compared to surgery., Results: In the non-operative group, seven studies were included in a meta-analysis with a total of 1401 scaphoids. Ninety-three percent (1311 scaphoids) of these scaphoid fractures healed in a plaster cast. A total of 207 (15%) of all scaphoid fractures showed displacement of at least 1 mm (gap/step) between fracture fragments. Nonunion was identified in 18% (37/207) of displaced scaphoid fractures treated in a plaster cast. The pooled relative risk of fracture nonunion was 4.4 (95% confidence interval (CI): 2.3-8.7; p=0.00; I(2)=54.3%). In the surgical group, we identified six observational studies in which 157 'displaced' fractures of the scaphoid were surgically fixed. Only two of these fractures did not heal. The odds of nonunion were 17 times higher with plaster cast treatment than surgery., Conclusions: Displaced fractures of scaphoid have a four times higher risk of nonunion than undisplaced fractures when treated in a plaster cast, and the patients should be advised of this risk. Nonunion is more likely if a displaced fracture of the scaphoid is treated in a plaster cast., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Irreparable tears to the scapholunate (SL) interosseous ligament area are common causes of mechanical wrist pain and yet treatment of this condition remains challenging. The reduction association of the SL joint (RASL) technique alleviates pain while preserving wrist function by creating a fibrous pseudarthrosis stabilized by a cannulated screw placed through the SL joint. Although arthroscopic RASL (ARASL) is a minimally invasive alternative to the open procedure, its effectiveness in controlling pain and preserving wrist function has not been established., Questions/purposes: To determinate whether ARASL was obtained relieve pain and restore function to the wrist., Patients and Methods: We reviewed eight patients (nine wrists) who had ARASL for SL instability with a reducible SL ligament tear (chronic lesion) from 2005 to 2009. Seven of eight were males and mean age was 44.5 years (range, 38-56 years). We recorded pain using a scale, the Disabilities of the Arm, Shoulder and Hand (DASH) score, grip strength, and range of motion (ROM). Minimum followup was 12 months (mean, 34.6 months; range, 12-43 months)., Results: The visual analog pain score was rated 5.4 (range, 0-10) preoperatively and 1.5 (1-3) after ARASL. Postoperative grip strength of the wrist was 78% of the contralateral, unaffected wrist. The average postoperative wrist ROM was to 107°, 20% less than the preoperative ROM. The SL angle decreased from 70.5° to 59.3°. In three cases, screws were removed owing to loosening or symptoms., Conclusions: Our preliminary observations suggest ARASL for treating irreparable SL ligament tear is feasible, controls pain, and improves wrist function while preserving ROM. Larger series with longer followup are required to confirm our observations., Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Purpose: To evaluate the biomechanical alterations that occur after traditional scaphoid excision and midcarpal arthrodesis with and without excision of the triquetrum. The hypothesis of this study was that removal of the triquetrum increases the radiolunate contact pressure., Methods: We cyclically moved 10 fresh cadaver wrists using a wrist joint motion simulator while measuring the contact pressures between the proximal carpal row and the distal radius and ulna using a dynamic pressure sensor. We acquired data in the intact wrist, after a midcarpal arthrodesis with the scaphoid excised, and then again with the triquetrum removed, which is also known as a capitolunate arthrodesis., Results: The peak pressures in the radiolunate fossa significantly increased with either of the midcarpal arthrodeses compared with the intact wrist during each of the 3 dynamic wrist motions. In comparing the 2 midcarpal arthrodeses, the peak pressure in the ulnocarpal fossa significantly decreased after the triquetrum was removed during wrist radioulnar deviation and in the static ulnarly deviated position. After arthrodesis, we could identify no differences during any motion or static wrist position in the peak radiolunate pressures with or without the triquetrum., Conclusions: We found that scaphoid excision and 4-corner arthrodesis shifts loads to the radiolunate joint. Isolated capitolunate arthrodesis with excision of the scaphoid and triquetrum further alters carpal kinematics and loading patterns., Clinical Relevance: These findings raise concern about routine excision of the triquetrum when performing a midcarpal arthrodesis., (Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Scaphoid malunion and carpal malalignment can result after scaphoid reconstruction, if the two fragments are not properly reduced before fixation. However, currently there is no information about which degree of deformity or malalignment can be tolerated without impairing clinical function. The purpose of this study was to investigate the influence of the scaphoid morphology and carpal alignment on clinical outcomes after scaphoid reconstruction. A total of 65 patients with an average age of 29 years were followed-up after a mean period of 45 months. In all patients, osseous union after a first-time scaphoid reconstruction in the middle third had been confirmed. Scapholunate (SL) and radiolunate (RL) angles were obtained on plain radiographs as were intrascaphoid (ISA) and dorsal cortical (DCA) angles and the height/length (H/L) ratio of the reconstructed scaphoid on computed tomography (CT) scans. These parameters were correlated with clinical outcome measures. RL angles correlated significantly with wrist range of motion, grip strength and pain levels, whilst SL angles, ISA, DCA and H/L ratio failed to show significant correlations. Our data suggest that clinical outcome is correlated with correct restoration of bone morphology and carpal alignment. After reconstruction, the RL angle should not exceed 10°., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: This study evaluated the effects of Kaltenborn manual therapy on sensory and motor function in elderly patients with secondary carpometacarpal osteoarthritis (CMC OA)., Method: Twenty-nine female patients with secondary CMC OA (70-90 years old) were randomized into Kaltenborn manual therapy and sham groups. This study was designed as a double-blind, randomized controlled trial (RCT). Therapy consisted of Kaltenborn mobilization of posterior-anterior gliding with distraction in grade 3 of the carpometacarpal (CMC) joint of the dominant hand during 6 sessions over 2 weeks. Pain was measured by algometry, as the pressure pain threshold (PPT) at the CMC joint and tubercle of the scaphoid bone. The tip and tripod pinch strength was also measured. Grip strength was measured by a grip dynamometer. Measurements were taken before treatment and after 1 week (first follow-up [FU]) and 2 weeks (second FU)., Results: All values in the sham group remained unchanged during the treatment period. In the treated group, the PPT in the CMC joint was 2.98 ± 0.30 kg/cm(2), which increased after treatment to 4.07 ± 0.53, and was maintained at the same level during the first FU (3.46 ± 0.31) and second FU (3.84 ± 0.36). Similarly, the PPT in the scaphoid bone was 3.61 ± 0.29 kg/cm(2), which increased after treatment to 4.87 ± 0.37, and was maintained at the same level during the first FU (4.44 ± 0.43) and second FU (4.22 ± 0.32). In contrast, we found no differences in the tip, tripod pinch, and grip strength measurements between the treatment and sham groups., Conclusions: This study showed that Kaltenborn manual therapy decreased pain in the CMC joint and scaphoid bone areas of elderly female patients; however, it did not confer an increase in motor function in patients with CMC OA., (Copyright © 2011 National University of Health Sciences. Published by Mosby, Inc. All rights reserved.)

The recent literature shows that a negative ulnar variance could pose a risk factor for scaphoid fractures.The aim of the current study was to determine whether the ulnar variance also affects the healing of a scaphoid fracture.2 cohorts of 50 patients each, with either a scaphoid fracture or a non-union, were retrospectively compared. The ulnar variance was measured on the X-rays using the Gelberman method.The average value of the ulnar variance in patients with a scaphoid fracture was -1.0 mm. The negative ulnar variance was measured in 64% of the patients. In the second group with scaphoid non-union, the average value of ulnar variance was -0.8 mm. The negative ulnar variance was similarly high, in 68% of the patients. Our results demonstrated almost identical values in both groups with regard to ulnar variance or its distribution, neutral, negative or positive, without statistical significance.Thus, we can exclude the negative ulnar variance as a risk factor for the development of non-union in cases of scaphoid fractures., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Chronic scapholunate instability can lead to functional deficits and radiocarpal osteoarthritis. A number of procedures, namely scapho-trapezio-trapezoid (STT) fusion, scaphocapitate (SC) fusion or soft tissue reconstruction procedures, aim to improve function while protecting the wrist from osteoarthritis., Hypothesis: Define the role of scaphocapitate fusion in comparison to STT fusion and capsulodesis and ligament reconstruction., Material and Methods: A clinical, radiographic and functional evaluation was performed on 31 SC fusion cases with an average follow-up of 5 years., Results: Range of motion was 41° in flexion and 39° in extension. Radial-ulnar deviation was 43°. Strength was 32.5 kgf (Jamar). The DASH was 27% and the PRWE was 25%. Fifty percent of the wrists were pain-free at rest. Ninety-four percent of patients were satisfied with the procedure. Seventy-eight percent of patients had returned to their occupation. Radiographic analysis revealed that consolidation was obtained at 10.1weeks. The postoperative radioscaphoid angle was 55° with good radioscaphoid congruence. There was no osteoarthritis in the radioscaphoid joint in 84% of the cases. The non-union rate was 13%., Discussion: These data are similar to the few series that exist. STT fusion leads the same clinical results, but it is technically more difficult and has a higher rate of complications. Capsulodesis and ligament reconstruction provide the same functional results as SC fusion, but with slightly less stiffening. However, these techniques do not seem to protect the wrist from arthritic degeneration at longer follow-up. SC fusion is superior to STT fusion for the treatment of chronic scapholunate instability. This is a pain-relieving intervention with good clinical results and preservation of scaphoid stability. As a component of the surgeon's armamentarium, it can be held in the same regard as capsulodesis and ligament reconstruction for cases of chronic scapholunate instability with a non-reducible scaphoid, or after failure of a soft tissue reconstruction procedure., Level of Evidence: Level 4, retrospective study., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)