Unilateral congenital absence of the lunate and scaphoid.
We report a patient with unilateral absence of the scaphoid and lunate bone of the wrist. Remarkably he had severe osteoarthritis in several other joints.
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We report a patient with unilateral absence of the scaphoid and lunate bone of the wrist. Remarkably he had severe osteoarthritis in several other joints.
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BACKGROUND AND AIMS: Bone morphogenetic protein (BMP) has been shown to induce bone formation and union in long bone defects and nonunions. We report a preliminary study of a composite implant consisting of a biocoral frame, carrier collagen and bovine BMP in the treatment of scaphoid nonunions. MATERIAL AND METHODS: Two proximal and eight waist area scaphoid nonunions were treated using BMP/coral implant combined with either the Matti-Russe procedure (2 cases) or an interpositional bone graft fixed with screws or compression fixation pins (8 cases). In two cases only a one piece BMP/coral implant was used as an interpositional graft and in other cases interpositional autograft was used with granular BMP/coral implant placed between the fragments and the graft. RESULTS AND CONCLUSIONS: Only two wrists resulted in complete union. These preliminary results suggest that composite implant of BMP, as used in the present study, may not solve the problems encountered in the treatment of scaphoid nonunions. Poor vascular conditions in scaphoid may not provide enough mandatory osteogenic cells for BMP to function properly. In avascular conditions coral does not resorb edequately and implants may also work as a sequester between the bone graft and the scaphoid bone and therefore actually inhibit the healing process.
The scapho-capitate fracture syndrome is a rare but severe injury of the carpus. It is characterized by a rotation of the proximal fragment of the capitate bone of 90 or 180 degrees and a fracture of the navicular bone in the intermediate third. This injury is caused by a fall on the outstretched and dorsiflected hand. The scapho-capitate fracture syndrome was firstly described in 1956 by Fenton. There are 31 cases described in literature but none of these involves both hands. Here we describe the first case of scapho-capitate fracture syndrome in both hands, in a 21 year old woman who jumped out of a window with suicidal intentions. She was treated operatively by Herbert-screws and K-wires.
Different surgical techniques have been proposed to treat traumatic scapholunate instability. Deciding which treatment is best for each individual case is not easy. In this article we report an algorithm of treatment based on a number of prognostic factors that may help in this matter. We also report on the promising results obtained using a new technique, the 3-ligament tenodesis, for the treatment of nonrepairable complete scapholunate ligament rupture, causing a reducible carpal malalignment without secondary osteoarthritis. This technique incorporates features from 3 previously described techniques.
Most scaphoid non-unions can be treated successfully with conventional bone graft and screw fixation. Only a few cases with established avascular necrosis of the proximal fragment and previous failed conventional bone grafting should undergo vascularized bone graft. Cases in which the fragments are too small to accommodate a vascularized bone graft are better treated by alternative procedures. This article describes the role of vascularized bone grafting for scaphoid non-union, indications, donor bone selection, the authors' operative technique for vascularized bone graft from the supracondylar region of the femur, outcomes, and complications.
PURPOSE: The goal of this study was to compare the results of open scaphocapitate fusion and revascularization with the results of arthroscopic scaphocapitate fusion and capitate pole excision. TYPE OF STUDY: Prospective randomized study. METHODS: Between April 1997 and January 2000, 16 consecutive patients (5 men and 11 women with a mean age of 31 years [range, 18 to 61]) presenting with Kienböck's disease stage IIIA and stage IIIB were randomized to either open scaphocapitate fusion and lunate revascularization (group I) or fully arthroscopic scaphocapitate fusion and capitate pole excision (group II) groups. Cannulated 3.5-mm ASIF screws were used for the purpose of scaphocapitate fixation in both groups. Operation time, hospital stay, time to fusion, range of wrist motion at final follow-up, grip strength, and return to unrestricted activities of daily living were evaluated at 33 months' follow-up. RESULTS: The mean operating time (153 v 99 minutes), hospital stay (3.6 v 2.3 days), and return to unrestricted daily activities (15 v 5.8 weeks) were shorter in group II. Average time to radiographically evident fusion was shorter in group I (7.25 weeks v 9 weeks). There was a significant increase in grip strength and in range of motion at final follow-up in both groups, and the final grip strength and range of motion was not different between the groups. There were no major complications in either group. CONCLUSIONS: Although the number of patients was small and the follow-up period was short, arthroscopic scaphocapitate fusion and capitate pole excision in stage IIIA and IIIB Kienböck's disease resulted in shorter operating time, shorter hospital stay, earlier return to unrestricted daily activities, and equal range of motion and grip strength as compared with open scaphocapitate fusion and lunate revascularization. Determination of specific surgical indications for the benefits of arthroscopic treatment of Kienböck's disease must be analyzed in larger studies.
In a prospective study 103 patients with clinically or radiologically suspected tears of the scapholunate interosseous ligament were investigated with magnetic resonance imaging (MRI) and wrist arthroscopy. MRI was performed with the conventional technique in 72 cases and after intravenous injection of contrast medium in the remaining 31 patients. The correct diagnosis was made by MRI in 75% of cases and its overall sensitivity and specificity were 63% and 86% respectively. There was no statistical difference in the accuracy of MRI for acute or chronic tears and the use of intravenous contrast medium did not improve its accuracy. In conclusion, MRI is not recommended for the diagnosis of scapholunate ligament injury.
To investigate the occurrence of carpal ligamentous injuries in patients with fractures of the distal radius, the results of 122 wrist arthroscopies were analysed within a retrospective study. Indications for arthroscopy included suspected carpal instability according to radiographic findings and/or the necessity for internal fixation of the radius fracture. Arthroscopy revealed acute scapholunate ligament tears in 84 patients. Scapholunate separation was found to be of prognostic value for ligament tears. There was no association between ligamentous lesions and carpal angles or fracture dislocation. Scapholunate ligament tears were most frequent in sagittal articular fractures. In these cases, wrist arthroscopy should be performed during operative treatment of the radius fracture to allow direct visualization and subsequent repair of ligamentous tears.
This prospective study investigated static scapholunate dissociation (SLD) in wrists associated with distal radius fractures. SLD was detected as a widening of the scapholunate (SL) joint interval by SL gap view. Ninety-six distal radius fractures and 154 normal wrists were investigated by SL gap view, which is better for detecting SLD than the standard posteroanterior (PA) view. Incidences of non-symptomatic SLD detected by SL gap view in normal wrists increased by age. In the young age bracket, incidences of SLD in distal radius fractures were significantly higher than in normal wrists. Our results indicated that in patients younger than 30 years old, SLD in distal radius fractures was a fracture-caused abnormality. In those over 30, ascribing SLD to the fracture was difficult. Close examinations, like arthroscopy and dynamic cineradiography, need to be made in patients with SLD associated with distal radius fractures, especially in those younger than 30.
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The authors compare their results of the management of the pseudoarthrosis of the navicular bone of the wrist with those reported in the literature. The study group included 21 patients and the Synthes 3.0 mm was applied. The authors concentrate on both technical and biological aspects of the therapy, mainly on an appropriate choice of the procedure, quality of the management of the surfaces of the pseudoarthrosis and significance of correct introduction of the device. The rate of the healed pseudoarthroses reached 85.7% in their patient trial group. They conclude that the main prerequisites for a successful outcome are the biological status of the pseudoarthrosis and a thorough management of the pseudoarthrosis surfaces, rather than a type of the implant.
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Proximal row carpectomy has precise indications in cases of severe sequelae of scaphoid fractures. This procedure may be indicated either as first-line treatment in a case of advanced pseudarthrosis with osteoarthritis, particularly radio-scaphoid, or secondarily after scaphoid pseudarthrosis has been unsuccessfully treated by other methods. It is essential to make sure that the head of the capitatum and the radial surface of the lunate bone have a satisfactory appearance on plain X-rays, MRI and occasionally arthroscopy. The overall results of this operation which retains wrist movements and which also preserves a good grip strength are very encouraging, as demonstrated by the series of 48 cases of sequelae of scAphoid fractures treated by this technique.
The use of reverse-flow pedicled vascularized bone grafts from the dorsal distal radius makes it possible to transfer bone with a preserved circulation and viable osteoclasts and osteoblasts. The resultant primary bone healing without creeping substitution within the dead bone is an alternative to conventional bone grafting in aiding or accelerating healing, replacing deficient bone, and/or revascularizing ischemic bone. Recent advances in understanding the anatomy and physiology of vascularized pedicled bone grafts have increased their use in treating a variety of carpal maladies. A basic understanding of the vascular anatomy, as well as the surgical principles and experimental and clinical results of pedicled vascularized bone grafts from the dorsal distal radius, is critical to understanding the use of these grafts in the treatment of scaphoid nonunions and Kienbock's disease.
Functional disabilities of the upper extremities have a considerable social and economic impact so that interest was aroused in developing a valid and reliable instrument suitable for international use. The Disabilities of the Arm, Shoulder, and Hand questionnaire is a self-report measure recording functional limitations in the upper extremity. A German version is now available in German-speaking countries. Previous studies have been concerned with the evaluation of DASH scores. Based on the data of four diagnostic groups, this study explores DASH's ability to identify diagnosis-specific limitations at the item level. The data were pooled and examined with regard to significant differences within the groups. Diagnosis-specific limitations could be identified within all groups, indicating that DASH is capable of expressing diagnostic entities as well as summed scores. Consideration of the individual profiles opens the possibility of using DASH as a prognostic tool to anticipate functional problems arising during rehabilitation following surgical interventions.
Efficiency of surgical treatment in Kienböck's disease has never been proven in the long term. We retrospectively reviewed the charts of the 104 patients treated by various techniques for Kienböck's disease from 1981 to 1999 in our unit. A comparison was made between 19 cases treated conservatively (amongst 59) and 11 cases (amongst 25) treated by scaphotrapeziotrapezoid (STT) arthrodesis with a mean follow-up of 13 years. The two groups were statistically comparable in stage, age, sex ratio, number of manual workers. STT arthrodesis was responsible for an increased loss of mobility, an increase of barometric pain, a longer rehabilitation time and more fractures of lunatum than conservative treatment. Those results question about indications for STT in Kienböck's disease.