A “Congenitally Adapted” TFCC Tear in Radial Longitudinal Deficiency: Case Report and Review of Literature

We present a case of chronic wrist pain in a 14-year-old child with mild radial longitudinal deficiency and radiographic carpal collapse due to the absence of the scaphoid. Wrist arthroscopy demonstrated synovitis and a tear to the TFCC, which would be called “degenerative,” according to the Palmer classification. This was debrided, and the patient is still asymptomatic at long-term follow-up. Review of the literature found one paper with a similar observation in a 17-year-old adolescent. We propose that paediatric “degenerative” tears ought to be called “congenitally adapted” tears.

Is DISI Deformity Related to Presence of a Medial Lunate Facet in Patients with Scapholunate Dissociation?

Background Lunate morphology has been suggested to influence carpal kinematics. Purpose We investigate a possible relation between presence of a medial lunate facet and dorsal intercalated segment instability (DISI) of the wrist in patients with a scapholunate (SL) dissociation. Methods We retrospectively reviewed patients diagnosed with SL dissociation between 2000 and 2017. Lunate morphology was categorized based on radiographs and magnetic resonance imaging (MRI), as type I or II according to Viegas and Galley. DISI was defined as radiolunate angle > 15 degrees and SL instability as SL angle > 60 degrees. SL distance > 3 mm was considered as widening and carpal height ratio < 0.5 was considered as carpal collapse. We used descriptive statistics to report on SL instability and DISI in patients with Viegas type I and type II lunates. We calculated kappa to determine agreement between radiographs and MRI and to determine inter- and intraobserver agreement. Results Of 119 patient files, 79 wrists met the inclusion criteria of which 25 were type I lunates and 54 type II. Similar spreading of the data of both groups was found regarding DISI, SL instability, and SL widening based on radiographic classification of the lunate, even after adding MRI findings. In the presence of carpal collapse, capitate-to-triquetrum distance was higher. We found a substantial inter- and intraobserver agreement for lunate classification. Conclusion Our results suggest a similar prevalence of DISI deformity or enlarged SL angle in patients with type I or II lunate in presence of SL dissociation. The Viegas classification is a reliable and reproducible classification system. Level of evidence This is a Level III, cross-sectional study design.

A “Congenitally Adapted” TFCC Tear in Radial Longitudinal Deficiency: Case Report and Review of Literature

We present a case of chronic wrist pain in a 14-year-old child with mild radial longitudinal deficiency and radiographic carpal collapse due to the absence of the scaphoid. Wrist arthroscopy demonstrated synovitis and a tear to the TFCC, which would be called “degenerative,” according to the Palmer classification. This was debrided, and the patient is still asymptomatic at long-term follow-up. Review of the literature found one paper with a similar observation in a 17-year-old adolescent. We propose that paediatric “degenerative” tears ought to be called “congenitally adapted” tears.

Inter-Rater Reliability of Magnetic Resonance Imaging in Comparison to Computed Tomography and Wrist Arthroscopy in SLAC and SNAC Wrist

The aim of the study was to assess the inter-rater reliability of magnetic resonance imaging (MRI) in comparison to computed tomography (CT) and wrist arthroscopy in patients with scapholunate (SLAC) or scaphoid non-union advanced collapse (SNAC) as well as to evaluate a grading score of cartilage lesions. A total of 42 patients (36 male, 6 female) at a mean age of 45 years (range: 19–65 years) with a SLAC or SNAC wrist who had a preoperative MRI and CT scan as well as underwent arthroscopy of the wrist between 2013 and 2018 were included in this study. Cartilage lesions, as assessed by MRI, CT and wrist arthroscopy, were classified by two hand surgeons in three stages. Inter-rater reliability was evaluated using the Kendall Tau-b test as well as the chi-square test to analyze for trend. The correlation between cartilage lesions, classified by arthroscopy and MRI, was low. A moderate correlation between CT and arthroscopy staging was shown. The highest inter-rater correlation was found between MRI and CT staging. An additionally performed logistic regression showed that progression of cartilage lesions as shown in MRI scans correlates with a restriction of range of motion (ROM). The level of cartilage lesion may be more severely classified in an MRI than during arthroscopy. Arthroscopy remains the gold standard in detecting cartilage lesions and thus in the decision-making process of the definitive treatment in carpal collapse.

The Inter- and Intra-observer Reliability of Three Methods for Evaluating Carpal Collapse

Background: Kienbock’s disease is a rare and debilitating condition. The decision for surgical intervention majorly depends on the extent of the carpal collapse. Therefore, the accurate measurement of carpal collapse is of critical importance. Objectives: The current study assessed the inter and intra-observer reliability of the three most frequent methods in measuring carpal height and determining carpal collapse. Methods: Fifty-Nine photocopied radiograms were reviewed by three observers (one senior orthopedic resident, one fellowship-trained hand surgeon, and one senior radiology resident) at 3 consecutive time points. Besides, one-week intervals were considered between the evaluations. The evaluated measures included the Carpal Height Ratio (CHR), Revised Carpal Height Ratio (RCHR), and Capitate-Radius (CR) index. The reliability of the measurements in determining the carpal height was examined using the Intraclass Correlation Coefficient (ICC). The agreement of the measures on determining the presence or absence of the carpal collapse was assessed by Cohen’s Kappa (K) value. Results: The overall inter and intra-observer reliability of the CR index in quantifying the carpal collapse was measured as 0.863 and 0.942, respectively. The overall inter and intra-observer reliability of CHR in quantifying the carpal collapse was computed to be 0.615 and 0.891, respectively. The overall inter and intra-observer reliability of RCHR in quantifying the carpal collapse equaled 0.412 and 0.792, respectively. The overall K for determining the presence or absence of a carpal collapse was calculated as 0.776, 0.683, and 0.549 for CR index, CHR, and RCHR, respectively. Conclusion: The CR index is the most reliable approach to measure carpal height. Furthermore, it is appropriate for determining the presence or absence of carpal collapse.

Vascularized Bone Grafting for the Treatment of Capitate Avascular Necrosis

Avascular necrosis (AVN) of the capitate bone is a rare condition and it can be related to major trauma or idiopathy. Different treatments are available including soft tissue interposition and intercarpal arthrodesis including lunocapitate, scaphocapitate, four corner, and carpometacarpal fusions. Other surgical options are resection of the proximal pole and revascularization procedures. The main purpose of this article is to present two cases of AVN of the capitate treated with a revascularization procedure using the 4th–5th extensor compartment artery (4th–5th ECA). Two female patients with capitate AVN are reported with an average age of 30.5 years. Both cases were classified as type-I according to Milliez classification. The major complaint in each case was wrist pain that increased during activity. In both cases there was no history of trauma, smoking, diabetes, or hematologic diseases. Both patients had a diminished range of motion, grip, and strength. The definitive diagnosis was made with magnetic resonance imaging. Both patients underwent treatment revascularization of the capitate using a vascularized bone graft based on the 4th–5th ECA. At average follow-up of 12 months, each patient had improved with regards to pain and had increased grip strength. The literature does not describe a specific algorithm treatment for capitate AVN. We recommend revascularization of the capitate using the 4th–5th ECA in type-I Milliez classification in young patients without signs of carpal collapse.

Bone Morphogenetic Protein in Scaphoid Nonunion: A Systematic Review

Background Scaphoid nonunion can lead to carpal collapse and osteoarthritis, a painfully debilitating problem. Bone morphogenetic protein (BMP) has been successfully implemented to augment bone healing in other circumstances, but its use in scaphoid nonunion has yielded conflicting results. Case Description The purpose of this study is to assess the outcomes and complications of scaphoid nonunion treated surgically with BMP. Literature Review A literature review of all available journal articles citing the use of BMP in scaphoid nonunion surgery from 2002 to 2019 was conducted. We included studies that used BMP as an adjunct to surgical treatment for scaphoid nonunions in both the primary and revision settings with computed tomography determination of union. Demographic information, dose of BMP, tobacco use, outcomes, and complications were recorded. A total of 21 cases were included from four different studies meeting inclusion criteria. Clinical Relevance The union rates were 90.5% overall, 100% for primary surgeries, and 77.8% for revision surgeries. Five patients (24%) experienced 11 complications, including four cases (19%) of heterotrophic ossification. Use of BMP in scaphoid nonunion surgery resulted in a 90.5% overall union rate but was also associated with complications such as heterotopic ossification. All included studies used BMP to augment bone graft, screw or wire fixation, or a combination of methods. The efficacy of BMP in scaphoid nonunion is unclear, and a sufficiently powered, randomized controlled trial is needed to determine optimal fixation methods, dosing, and morbidity of the use of BMP. Level of Evidence This is a Level IC, therapeutic interventional study.

Mid-Carpal Joint Sparing Procedure for Idiopathic Avascular Necrosis of Capitate

Background Avascular necrosis of the capitate (AVNC) is an uncommon pathology of the wrist. Several procedures have been described for the treatment of AVNC. The type of treatment varies depending upon the stages. In early stages, revascularization procedures are performed. If secondary osteoarthritis develops, then the treatment options include intercarpal fusion, four corner fusion, prosthesis replacement of the capitate, tendon interposition, and wrist arthrodesis. No long-term study is available for choosing an appropriate method of the treatment for AVNC. Case Description Herein, we report a case of AVNC that was managed by hemi-resection of the capitate with capito-hamate fusion and tendon interposition. One year after surgery, patient was asymptomatic and radiographs revealed fusion of capito-hamate joint and maintenance of the mid-carpal joint space. There was no evidence of carpal collapse. Literature Review All the literature about mid-carpal joint sparing (MCJS) procedures has been reviewed in this report. This is a goal behind writing of this case report as there have been very few publications about these procedures. Clinical Relevance This case illustrates the successful treatment of AVNC by MCJS procedure. The intercarpal fusion and the four corner fusion are one time procedures, and these can be used if the MCJS procedure fails or sometimes, as primary procedure, if the patient gives consent for the same. It appears prudent to save arthrodesis procedures for the future.

Difference in Carpal Alignment between Scapholunate Dissociation and Kienbock Disease: A Retrospective Study

Introduction Scapholunate dissociation is the most frequent type of wrist instability and, if untreated, can lead to wrist osteoarthritis, known as scapholunate advanced collapse. Kienbock disease can also lead to wrist osteoarthritis. Both involve carpal instability; however, the possibility of completely different mechanisms underlying each ligamentous state and carpal malalignment must be considered. Materials and Methods We retrospectively reviewed 17 patients with scapholunate dissociation and 14 patients with Kienbock disease. All arthroscopic findings for scapholunate dissociation were classified as Geissler grade 4. All cases of Kienbock disease were treated by lunate resection and vascularized pisiform transfer without interosseous ligament reconstruction. Carpal alignments were evaluated from pre- and postoperative radiographs. Results Scapholunate dissociation showed greater lunate dorsiflexion and more dorsal locations of the scaphoid and capitate compared with Kienbock disease, but preoperative scaphoid flexion was similar in both groups. Eleven of 17 cases of scapholunate dissociation and no cases of Kienbock disease showed dorsal subluxation of the scaphoid preoperatively. Postoperative radiographs revealed no progression of carpal collapse in either groups. Conclusion This study revealed the sacrifice of the scapholunate/lunotriquetral interosseous ligament do not incur static scapholunate dissociation, and that the secondary stabilizers may preserve carpal alignment.