Journal of Wrist Surgery最新文献

Background: This study was performed to determine whether an arthroscopic dorsal peripheral triangular fibrocartilage complex (TFCC) repair can stabilize symptomatic distal radioulnar joint (DRUJ) instability in patients with a positive hook test, an intact foveal insertion, and a dorsal peripheral detachment of the TFCC.

Materials and methods: All patients who had an isolated arthroscopic dorsal peripheral TFCC repair performed by the primary author between August 2018 and April 2023 were included in the study. Functional measures of range of motion (ROM), gross grip, lateral pinch, force plate, pronation strength, supination strength, visual analogue scale (VAS) at rest, VAS on use, patient rated wrist evaluation (PRWE), and disabilities of the arm, shoulder, and hand (DASH) were recorded pre- and postoperatively.

Results: For this study 31 patients met the inclusion criteria. Measures taken at a mean of 13.8 months post-surgery demonstrated improvement in all functional parameters, with the exception of ulnar deviation and pronation which remained unchanged. Resolution of symptomatic DRUJ instability was documented in all cases. There were no cases of recurrent instability. There were no complications.

Conclusion: Arthroscopic dorsal TFCC repair can successfully resolve symptomatic DRUJ instability in patients with a positive hook test, a dorsal peripheral detachment of the TFCC, and an intact foveal insertion.

Level of evidence: Level IV.

Objective: Different treatment options exist for the late-stage Kienböck disease (KD). The functional outcomes of patients undergoing scaphocapitate fusion (SCF), tendon ball arthroplasty (TBA), and radius metaphyseal core decompression in stages 3 to 4 KD were investigated.

Materials and methods: This is a retrospective study spanning ∼11 years, conducted at our clinic, involving the operated patient KD. The study included 51 patients with an average follow-up duration of 68 months (range: 16-130 months). Patients who underwent SCF, TBA, and radius metaphyseal core decompression were divided into three groups based on the surgical approach. The range of motion of the wrist joint and grip strength of the operated wrists were assessed alongside the unaffected wrist during follow-up evaluations. Satisfaction levels among patients were measured by comparing groups internally and based on disease stages. Functional outcomes were evaluated using quick disabilities of the arm, shoulder, and hand (Q-DASH) and Mayo wrist scoring scales.

Results: Of the patients, 28 were female (54.9%) and 23 were male (45.1%). The mean age was 34 years (range: 19-62 years). There were 12 patients (23.53%) in the radial decompression group, 10 patients (19.61%) in the SCF group, and 29 patients (56.86%) in the TBA group. When the wrist joint Range of motion (ROM)s are analyzed, the losses in both stages 3A and 3B disease are significant compared with the intact wrist in all three surgical methods. When the groups were compared, a higher loss of wrist joint ROM was observed in the TBA group, especially in Kienböck stage 3B patients ( p  < 0.001). Furthermore, there were no differences between patient scores in stage 3A when assessments were made using Q-DASH and Mayo scores ( p  = 0.156 for Q-DASH and p  = 0.060 for Mayo). In stage 3B, Mayo's results were similar, while the radial decompression group was reported to be more favorable in terms of Q-DASH scores ( p  = 0.035).

Conclusion: KD is surgically treated with various operations identified. In terms of functional outcomes, all three surgeries are considered satisfactory. However, in young and active patients, even in advanced stages of the disease, metaphyseal core decompression should be attempted as an initial treatment due to its easier approach and the avoidance of direct manipulation of the carpus.

Scaphoid fractures are the most frequent fractures of carpal bones, accounting for 70 to 80% of all carpal fractures. Appropriate and early diagnosis of scaphoid fractures is imperative. To relieve symptoms and prevent degenerative changes, scaphoid non-union surgery should aim at healing and restoration of the normal anatomy, and correction of carpal deformities. Since the scaphoid non-unions are a heterogeneous group, and categorization is not easy, the management remains controversial with a reported failure rate as high as 40% and the absence of a "gold standard" treatment. Based on (a) Qu and Von Schroeder's new concepts on the osteogenic ability of the non-union cells stimulated by osteoinductive bone factors; (b) the encouraging results obtained by Illarramedi et al on decompression of the distal radius and ulna in Kiënbock disease treatment; and (c) along with the minimal surgical trauma of percutaneous and arthroscopic techniques, the authors have begun treating scaphoid non-unions without bone graft by using arthroscopic-assisted reduction and internal fixation with metaphyseal core decompression of the distal radius. The technique has also been used in advanced cases with "humpback" deformity and long-standing non-unions. Resting on the observations of CT scans and arthroscopic findings, we have introduced a new comprehensive classification of scaphoid non-union for better categorization and typification and provide an improved treatment approach. We recommend arthroscopic-assisted treatment in young and middle-aged non-smoking patients with scaphoid non-unions. Percutaneous fixation alone is sufficient for stable stages I and II, whereas additional core decompression of the distal radius can be used for unstable stages, for bone defects greater than 10 mm, and for the proximal pole non-unions. This method is not suggested in non-unions with significant sclerosis, with a complete absence of punctate bleeding of the proximal pole, and in those with a very small proximal fragment.

Introduction: We report early outcomes of all-dorsal arthroscopic scapholunate ligamentoplasty (ADAL) in 12 patients.

Materials and methods: Dorsal internal brace and capsulodesis were performed in all patients. In half of the patients, a palmaris gracilis tendon graft was used to reconstruct the dorsal aspect of the scapholunate complex. Patients were evaluated for pain, wrist range of motion, grip strength, clinical scores, and radiological appearance at a mean follow-up of 15.9 months.

Results: We obtained similar results in the technique with and without tendon graft. Visual analog scale (VAS 10) score improved from 6 to 1. Wrist range of motion in Flexion-extension increased from 123 to 144 degrees. Postoperative grip strength was 180% more than preoperative, with a mean Mayo wrist score of 79.5 and quick Disabilities of the Arm, Shoulder and Hand (quickDASH) of 14.9. The radiolunate angle decreased from 29 to 10 degrees, the scapholunate (SL) angle from 83 to 52 degrees, and the scapholunate gap from 6 to 3mm.

Conclusion: ADAL has many advantages compared with other scapholunate ligamentoplasties, including minimal invasiveness, association with internal brace and dorsal capsulodesis, and lower risk of carpal fracture or avascular necrosis. Its short-term results are promising.

Background: Dorsal triangular fibrocartilage complex (TFCC) is a newer entity of its family, which was not included in the Palmer classification. We believe that tear of the dorsal TFCC can cause pain and disability. Literature on this type of tear is limited, in addition, outcomes post-repair, especially arthroscopically, are scarce.

Purposes: This article defines dorsal TFCC anatomy and investigates the clinical and functional outcomes post-TFCC dorsal tear arthroscopic repair.

Materials and methods: An 18-year retrospective review of 32 patients with arthroscopic repair of TFCC dorsal tears was performed. We categorised our patients into group (1) with only isolated TFCC dorsal tear and group (2) also with other concomitant TFCC tear. We evaluated their clinical and functional outcomes and also compared the two groups with other cofactors.

Results: The mean follow-up period was 44 months. In the isolated dorsal tear group ( N  = 17), the wrist performance score was improved from 29 to 37 ( p  = 0.01), the Visual Analog Scale (VAS) score was improved from 6 to 3 ( p  < 0.01), Modified Mayo Wrist Score (MMWS) was improved from 60 to 74 ( p  = 0.01), and the hand grip strength was improved from 18 to 28 kg ( p  = 0.05). In the complex tear group ( N  = 9), VAS score was improved from 6 to 3 ( p  = 0.01) and the MMWS was improved from 44 to 79 ( p  = 0.01). Distal radioulnar joint stability was improved in the isolated group, achieving 100% stability after surgery ( p  < 0.01). No prognostic factors were identified. We noticed that patients who had surgery 9 months post-injury, would have the highest improvement on wrist flexion ( p  = 0.03), comparing with those who had surgery at other time points.

Conclusion: We define dorsal TFCC as the area located between the horizontal dorsal superficial radioulnar ligament and the vertical dorsal capsular wall, that is, the extensor carpi ulnaris subsheath and extensor digiti minimi sheath. To our knowledge, internationally, we have operated and collected the largest series of TFCC dorsal tear arthroscopic repair. Our patients were benefited with significant pain relief with improved daily activities performance.

Clinical relevance: Dorsal TFCC tear can cause symptoms and is often missed, even during arthroscopic examination. We should consider offering wrist arthroscopy to patient who suffers from ulnar-sided wrist pain, even with negative radiological findings and 9 months post-injury, for diagnostic and therapeutic purposes.