Treatment of Madelung's deformity.

Treatment of Madelung's deformity is still controversial. We reviewed retrospectively 19 patients with Madelung's deformity (two bilateral, 21 cases) who underwent surgery to the radius and ulna to improve range of motion, decrease pain and improve appearance of the wrist. Nineteen patients underwent 21 distal radial osteotomy procedures using three different techniques: subtraction, addition or dome osteotomy. Ulnar shortening and redirection of the distal ulna was performed in 12 cases; a long oblique osteotomy was used in 10 of these cases. The Sauvé-Kapandji technique was performed in five cases, an ulnar distal epiphysiodesis in two cases and a combination of osteotomy and epiphysiodesis in one case. The aim was to reduce the distal radial slope and to restore the orientation and congruity of the distal radio-ulnar joint and to improve its function. Pain was reduced as a result of the procedure: more than 75% of the cases had no or intermittent pain at the review. Pronation improved from 63° to 68° (P=0.467, not significant) and supination improved from 48° to 72° on average (P=0.034, significant). Grip strength increased from 11 to 18 kgf (P=0.013, significant). Madelung's deformity is not always a benign condition and it responds well to corrective osteotomies.

Scaphocapitate arthrodesis for treatment of late stage Kienbock disease.

Symptomatic lunate collapse owing to Kienböck disease is difficult to treat. To define the potential role of scaphocapitate arthrodesis, we reviewed ten patients who underwent scaphocapitate arthrodesis for stage IIIB-IV Kienböck disease at a mean follow-up of 8.75 years (range 1.3-18.6). Clinical variables included ranges of motion, grip strength, pain, return to work, and QuickDASH (disabilities of the arm, shoulder and hand) scores. Radiographs were evaluated for union, carpal height, alignment, ulnar translation, and radiocarpal arthritis. The procedure resulted in functional ranges of motion and good grip strengths. Pain was substantially reduced. The mean QuickDASH score was 27 (range 9.1-56.3). Radiographic analysis showed union in nine patients, maintenance of carpal height with a corrected radioscaphoid angle, and no evidence of ulnar translation. The long-term clinical benefits of scaphocapitate arthrodesis for treatment of collapsed Kienböck disease are demonstrated. However, radiographic signs of radioscaphoid arthritis were often observed in patients with follow-up greater than 10 years.

[Vascularized pisiform transfer in place of lunatum for Kienböck's disease]. / Transfert du pisiforme vascularisé à la place du lunatum dans la maladie de Kienböck.

There is a specific vascularization of the pisiform bone depending on the cubito-dorsal artery, branch of the ulnar artery. The vascularized pisiform bone may be transferred in place of the excised lunatum. The aims are to decrease pain when keeping the mobility, to replace a dead bone, to maintain the distance between scaphoid and triquetrum and radius and capitatum, by preventing the carpal collapse. X-rays and a MRI are performed. The vascularized transfer is indicated at stage III of the usual classifications. The technique is described, insisting on the transferred bone stabilization using ligament reconstructions. Radial shortening or scapho-capitate limited arthrodesis may be combined to reduce the stress on the transferred bone. Fifty-one cases have been performed at stage IIIa or IIIb and sometimes IV of the disease. The maximum follow-up is 15 years. The pain has decreased constantly. Motion in flexion-extension has an increase of more than 35°, radial and ulnar deviation of more than 14°. Strength has been slightly modified to more than 10%. The complications are: one case of "complex regional pain syndrome", one infection reoperated and one infection cured by antibiotics; one reoperation for a proximal row carpectomy. Results of this technique have been published in the literature. This technique provides regularly good results with a long follow-up. A precise technique is mandatory.

[Scaphoid malunion]. / Cal vicieux du scaphoïde.

Scaphoid fracture and healing are often difficult to diagnose. The scaphoid bone may heal in an abnormal position and this malunion is usually in flexion and shortening. Fractures of the mid or distal part of the bone are mainly concerned. This malunion may be the cause of an alteration of the carpal mechanics and finally of osteoarthritis revealed by pain and decrease of motion and strength. The intrascaphoid angle of Amadio helps to calculate the magnitude of the deformity and to plan the correction. This malunion has to be corrected only if symptomatic. Two other types of malunions exist: healing with a rotation of the distal fragment, and healing with irregular contours which may also lead to arthritis. Correction of the malunion will be performed after having assessed precisely measurements of the deformity using comparative X-rays, special views, carpal indices and eventually a dedicated specific software. In the literature may be found a certain number of papers where scaphoid osteotomy combined with a trapezoidal bone graft and a bone fixation using a screw have been performed with success and healing for all cases. This procedure may be performed without hesitation for a symptomatic healed scaphoid, even if it has been operated before for nonunion.

The pathology of the long ulna: anatomy and treatment.

A long ulna, as a result of congenital differential growth, such as Madelung's disease, or injury, commonly a consequence of a malunited distal radial fracture, may present clinically as pain, decreased motion, mainly of pronosupination, and weakness of grip. Secondary effects may include perforations and tears of the triangular fibrocartilage complex, cartilage wear of the proximal surface of lunate and triquetrum and tears of the lunotriquetral ligament. Positive ulnar variance may be evident on X-rays but a prominent ulnar head cannot always be excluded when there is neutral ulnar variance and further investigations, such as an arthroCTscan or arthroscopy, may be necessary. The two principle treatment options are (a) resection of the distal ulna (Darrach's and Sauvé-Kapandji's techniques are commonly used) and (b) techniques preserving the ulnar head, including different modalities of shortening osteotomy. The aim is to regain a congruent distal radioulnar joint, restore painless and normal pronosupination and prevent onset of osteoarthritis of this joint.

[Distal radius malunions in flexion]. / Cal vicieux du radius en flexion.

AIMS: In this paper we will differentiate the clinical management of distal radial fractures with malunion in extension from those with malunion in flexion. Malunions in flexion are rare and radial shortening does not contribute significantly to the deformity. There is always a decrease in the range of motion, especially prono-supination. Besides the usual causes of these malunions, a new iatrogenic cause is becoming prevalent: malunion in flexion occurs when a fracture in extension is treated by posterior intrafocal pinning but the surgery is performed poorly or performed when it is contra-indicated because of volar comminution. PATIENT AND METHODS: We report a retrospective study of 20 cases of distal radius malunion in flexion. The series includes relatively young patients with a mean age of 39.3 of age (24-66). Three types of surgery are compared: 1) an isolated radius extension osteotomy (group 1); 2) an isolated procedure on the ulna (group 2); 3) combined procedures on radius and ulna (Group 3). RESULTS: Results of the three techniques on prono-supination are almost the same, resulting in an almost normal range of motion. Pain decreased from 2.1 (pain for significant strains) to 0.7 (no or climatic pain) in a five-scale classification from 0 to 4. Strength increased by 23% to reach 83.3% of the opposite side. Some differences with malunions in extension should be noted: 1) volar carpal subluxation relative to the radius is present in less than 1/3 of the cases (6/20); 2) adaptive carpus is very rare and independent of the volar displacement (2/20), 3) palmar flexion exists without significant shortening (bone graft rarely necessary); 4) Pronation of the distal fragment results in distal radioulnar joint incongruity. INDICATIONS: The best treatment for young patients is combined radial and ulnar osteotomy. Although a more radical procedure, it is worthwhile for the younger patient in order to recover normal anatomy. Isolated radial osteotomy may be sufficient if pronosupination and radioulnar joint congruity are regained. However, isolated procedures on the distal ulna are only indicated in the elderly, or in patients with little discomfort.

Chondrocalcinosis of the wrist.

Calcium Pyrophosphate Dihydrate Deposition (CPDD) disease has characteristic radiographic features including soft tissue calcification, joint space narrowing, bone sclerosis, subchondral cyst formation without osteophyte formation, and large intraosseous geodes. Triangular fibrocartilage calcification is frequently found and isolated scapho-trapezio-trapezoid (STT) arthritis is specific for CPDD. Distal radio-ulnar (DRUJ), isolated midcarpal joint and piso-triquetral joint involvement also occur. 127 patients were reviewed. Seventy-eight had symptomatic STT joint arthritis, for which 36 underwent surgery. Twenty-two patients had a SLAC wrist deformity for which ten underwent surgery. Eight patients had isolated midcarpal arthritis for which three midcarpal arthrodeses, two four-bone arthrodeses and two carpal tunnel releases were performed. Nineteen patients had a generalized arthritis and seven of the patients underwent surgery: four-corner arthrodesis+scaphoidectomy (one case), carpal tunnel release (two cases) extensor synovectomy (two cases) and trigger finger release (two cases).

[Intraosseus synovial cysts of the lunate bone: diagnostic problems]. / Les kystes synoviaux intra-osseux du semi-lunaire: problèmes diagnostiques.

Intraosseous ganglia is one of the most frequent lytic defect at the wrist. Its location in the lunate may be discovered by chance on an X-ray performed for another reason, or because of wrist pain and very rarely for a lunate fracture. A.P., lateral and oblique X-rays are mandatory. Bone scan, CT scan and MRI may be of help. Differential diagnosis may exist with an ulnar abutment syndrome with a lunate defect and with all the lytic bone tumours, a systemic disease or multiple defects as in overuse syndromes. In some cases, there is a condensation around the defect and a Kienböck's disease may be suspected. Thirty-seven patients have been operated on between 1978 and 2001, of which 70% were females. Average age was 34 years (16-58). Clinical presentation was always wrist pain. In seven cases, another carpal localization was present. Surgical treatment consisted in bone curettage and cancellous bone grafting. In four cases, a ganglia emerging from the scapholunate space in soft tissues was combined. Pain disappeared after the procedure. A few patients had a 20-30 degrees wrist flexion decrease but without functional impairment. Several theories have tried to explain the onset of these intraosseous ganglia. In conclusion, these lesions are another cause of wrist pain. One has to be sure that this is this lesion which is the real cause of wrist pain. A systematic X-ray has to be performed for painful soft tissue wrist ganglia.

[Piso-triquetral osteoarthritis. Thirteen case reports and review of the literature]. / Arthrose pisi-pyramidale. A propos de 13 cas et révision de la littérature.

Piso-triquetral osteoarthritis (OA) is an infrequent cause of ulnar wrist compartment pain. Specific clinical manoeuvres may help for diagnosis. If this aetiology is suspected, a 30 degrees oblique wrist X-ray in supination and sometimes a CT scan with transverse cuts should be performed demonstrating a joint narrowing and osteophytes formation. The FCU-pisiform biomechanical unit transfers the wrist flexion forces. A series of 13 cases of piso-triquetral OA is presented in 12 patients (six females and six men) treated between 1990 and 1997. Mean age was 52.7 y. Pain at resisted motion in flexion and ulnar deviation and strength decrease was always present at clinical examination. Subperiosteal pisiform excision has been constantly performed. Continuity of FCU insertions and its distal ligamentous extensions has been preserved. Mean F-up was 18.1 months (3-57). Pain has disappeared in seven cases and significantly decreased in five. NSD was present in one case. Range of motion and strength was normal in all cases. Ulnar nerve paresthesias has always disappeared. The pisiform bone is not a sesamoid: a true joint with the triquetrum exists. From the phylogenetic point of view, three theories have been proposed: (a) in some species, pisiform is fused with adjacent bones or metacarpals; (b) pisiform is a remnant of a polydactyly hand; (c) pisiform is a remnant of the carpal central row.

Anatomy and histology of the scapholunate ligament.

The scapholunate ligament links the scaphoid to the lunate. It runs transversally at its posterior aspect and obliquely at its anterior aspect, allowing significant relative motion between the two bones. From the neutral position to the full extension position, the lunate rotates by 28 degrees and the scaphoid by 30 degrees; from the neutral position to the full flexion position, the lunate rotates by 30 degrees, whereas the scaphoid rotation is 60 degrees because of the motion of the scaphoid around the capitate. The ligament's dorsal part is shorter and more resistant than the anterior part, allowing a pseudodissociation during flexion. Kauer described an additional movement of the scapholunate pair attributable to differences in the shapes of the scaphoid and lunate proximal poles. The scaphoid curve is more important and the scaphoid needs to glide on the lunate to maintain radioscaphoid congruity. As a result, there is sagittal ligament torsion. This can be a partial explanation for failure of scapholunate arthrodesis. This description of the scapholunate ligament is of interest to understand the relative importance of the three parts of this ligament. It can, in particular, explain the failure of ligamentous reconstruction that considers the scapholigament as a homogeneous structure. In addition, the three parts do not have the same tensile strength. The posterior part is the most resistant to tear forces and needs more than a 300 N tensile stress to fail. The anterior part fails with 150 N stress and the intermediary portion can withstand only a 25 N to 50 N stress. In comparison, the triquetrolunate ligament (which is also divided in three parts--anterior intermediate, and posterior) has failure coefficients opposite those of the scapholunate ligament: The anterior part is more resistant (300 N) than the posterior (150 N); the intermediate part has the same tensile strength as the scapholunate intermediate part. These biomechanical studies demonstrate the importance of the scapholunate ligamentous posterior part in controlling flexion and extension motion and the anterior part for rotational control. Both parts of the ligament are necessary for an harmonious functioning of the scapholunate pair.

Radiocarpal dislocations: classification and proposal for treatment. A review of twenty-seven cases.

BACKGROUND: The radiographic characteristics and treatment of radiocarpal dislocation are not well defined. There have been only two reported series of more than eight patients. Thus, there are many questions concerning treatment and functional results. METHODS: Two groups of patients were defined. Group 1 included all patients with pure radiocarpal dislocation and patients with only a fracture of the tip of the radial styloid process. Group 2 included patients with radiocarpal dislocation and an associated fracture of the radial styloid process that involved more than one-third of the width of the scaphoid fossa. A retrospective review and a clinical evaluation were performed. RESULTS: From 1975 to 1998, we observed twenty-seven cases of radiocarpal dislocation. Four were displaced volarly, and twenty-three were displaced dorsally. Fourteen patients presented with associated lesions. Four patients were treated with closed reduction and immobilization in a plaster cast; five, with percutaneous Kirschner wire fixation and cast immobilization; and two, with an external fixator. Eleven patients had open reduction with Kirschner wire fixation and cast immobilization. The seven patients in Group 1 had a highly unstable injury, and four of the seven patients presented with ulnar translation of the carpus. At the time of follow-up, at an average of 26.8 months, pronation averaged 76 degrees; supination, 66 degrees; wrist flexion, 54 degrees; wrist extension, 54 degrees; radial inclination, 15 degrees; and ulnar inclination, 18 degrees. The average grip strength was 27 kg. Group 2 included twenty patients. Only thirteen, with dorsal dislocation, were evaluated at the time of follow-up, which averaged fifty-one months. At that time, six reported no pain; four, slight pain; and two, moderate pain. Pronation averaged 63 degrees; supination, 76 degrees; wrist flexion, 51 degrees; wrist extension, 56 degrees; radial inclination, 21 degrees; and ulnar inclination, 39 degrees. Grip strength averaged 38 kg. Seven patients had complications. CONCLUSIONS: On the basis of our experience and a review of the literature, we believe that patients with pure radiocarpal dislocation or with radiocarpal dislocation with a fracture of the tip of the radial styloid process should be treated with reattachment of the ligaments through a volar approach. In patients with radiocarpal dislocation and a fracture of the radial styloid process that involves more than one-third of the width of the scaphoid fossa, the ligaments are still attached to the radial fragment. We believe that in this group of patients, exact articular reduction should be performed through a dorsal approach. Additional studies are needed to support these hypotheses.

[Ligament repair and/or capsulodesis in scapholunate instability]. / Bandnaht und/oder Kapsulodese bei skapholunärer Instabilität.

We have reviewed 37 patients with scapholunate instability, operated in Paris between 1979 and 1995 7 months after the injury. There were 12 partial and 18 complete ligament ruptures, but also 4 distensions. The repair was a secondary suture in 16 cases (7 direct, 1 transosseous, 1 combined, 5 anchor, 2 transosseous with anchor). A capsulodesis was performed 7 times as an isolated and 8 times as a combined procedure. 6 previous cases have been treated by ligamentoplasty. We present the results after a mean postoperative follow-up of 27 months, with good results on pain and grip, maintaining a satisfactory range of motion.

Resection of the distal scaphoid for scaphotrapeziotrapezoid osteoarthritis.

Twenty-one patients with symptomatic scaphotrapeziotrapezoid osteoarthritis were treated with partial distal scaphoid excision. In 12 wrists the joint defect was filled with either capsular or tendinous tissue, while in nine no fibrous interposition was done. At an average follow-up time of 29 (range, 12-61) months, 13 wrists were painfree, while eight had occasional mild discomfort. Mean wrist flexion-extension was 119 degrees. Grip and pinch strength improved by an average of 26% and 40% respectively compared with their preoperative status. Fifteen patients returned to their original jobs, while six, who were unemployed, felt unrestricted for activities of daily living. Although patient satisfaction was comparable for both types of treatment, the wrists without fibrous interposition showed significantly greater wrist flexion-extension than patients with soft-tissue interposition. Removal of the distal scaphoid resulted in a DISI pattern of carpal malalignment in 12 wrists. At follow-up, none of these wrists showed further joint deterioration due to residual malalignment.

Soft tissue stabilization in the management of chronic scapholunate instability without osteoarthritis. A 15-year series.

Management of chronic scapholunate instability without osteoarthritis remains controversial. Some surgeons favor partial wrist arthrodesis; others, soft tissue stabilization. Many techniques for soft tissue repair have been described but with few or unpredictable results. We reviewed all our cases of scapholunate instability without osteoarthritis treated by soft tissue stabilization. Since 1979, 37 soft tissue stabilization procedures have been performed to correct dynamic (25) or static (12) scapholunate instability without osteoarthritis. The average time from injury to surgical treatment was 7.2 mos. (range 0.25 to 36 mos.). Three cases were treated within the first month of injury. The choice of repair was determined intraoperatively. The scaphoid shift must be easily reducible to make the case eligible for soft tissue repair. The scapholunate ligament was usually disrupted from palmar to dorsal, and the average amount of disruption was 74%. When scapholunate ligament remnants were of sufficient quality, secondary repair was performed; but if not, ligament reconstruction using tendon grafts or capsulodesis was performed. The procedures used were secondary ligamentous repair in 16 (by direct suture, reinsertion using anchor and/or transosseous reattachment), ligament reconstruction using tendon grafts in 6, capsulodesis in 7 and a combination of these procedures in 8. The mean follow-up was 27 mos. (range 2 to 62 mos.). Postoperatively, there was an 83% decrease in pain. The average wrist motion was 60 degrees extension, 47 degrees flexion, 18 degrees radial deviation and 28 degrees ulnar deviation (92%, 84%, 106% and 88% of preoperative values and 88%, 75%, 78% and 76% of the uninvolved wrists, respectively), and the grip strength was 28 kg (117% of preoperative value and 78% of the uninvolved wrists). On roentgenograms, the mean static scapholunate distance was 4.2 mm (a 26% loss of reduction compared to the early postoperative gap), but scapholunate and radiolunate angles were within normal values (58 degrees and 9 degrees, respectively). At follow-up, one patient presenting a small zone of chondromalacia on the scaphoid at the time of secondary ligamentous repair developed severe radioscaphoid arthritis 15 months postoperatively. The results were further assessed according to the form of instability, delay before surgery, severity of disruption and type of repair. Patients with static instability showed worse clinical and radiological findings than those with dynamic instability. Surgical delay did not influence the outcome. The more severe the ligament disruption was, the poorer were the results. All types of repair had a comparable outcome except those treated by ligament reconstruction using tendon grafts. The results in the latter group were unsatisfactory in terms of motion, grip strength and radiological findings. This technique has been abandoned by the group. In conclusion, soft tissue stabilization is part of the armamentarium in the management of reducible chronic scapholunate instability without osteoarthritis. Ligament reconstruction using tendon grafts gave, in our hands, unsatisfactory results. Otherwise, all types of repair achieved a relatively pain-free wrist, with acceptable motion, grip strength, scapholunate and radiolunate angles but with a wider than normal static scapholunate distance. A longer follow-up is needed to assess the effect of this abnormal gap. Factors that favorably affected the outcome were: dynamic type of instability and partial disruption of the ligament.

Palmar perilunate fracture-dislocation of the carpus.

We report an uncommon palmar translunate, transhamate carpal fracture dislocation. CT-scans with three-dimensional reconstruction were most helpful for the assessment of the injury, which was treated operatively through a palmar approach. The lunate and hamate fractures were fixed using mini-screws and the radial styloid fracture and the scaphoid were reduced and stabilized with K-wires.

[What's new in cosmetic surgery of the hand? Technical notes]. / Quoi de neuf en chirurgie esthétique de la main? Notes techniques.

The author analyses the aesthetic aspects of the hand in three circumstances: trauma, rheumatism, and ageing. He describes the unsightly appearance of certain grafts and flaps and certain amputation stumps and malunions following trauma and emphasizes the cosmetic indication for finger transfer to an adjacent finger in four-finger hands. The main indications for rheumatic digital deformities concern distal deformities: DIP arthrodesis or arthroplasty depending on the finger. In the context of ageing of the hand, related to excess skin and prominent veins, the author proposes a one-stage operation via a palmar incision.

Radio-lunate arthrodesis for distal radial intraarticular malunion.

Eleven cases of symptomatic distal radial intraarticular malunion were treated by radio-lunate arthrodesis from 1983 to 1991. The mean age was 35.3 years. There were 11 men, all manual workers. The mechanism was usually a high velocity injury. The time elapsed since injury was a mean 23 months (2-109 months). The range of motion was, on average, flexion 39 degrees, extension 27 degrees, radial deviation 10 degrees and ulnar deviation 20 degrees. Pain was present on light work and grip strength was 45% of the opposite side. The average step-off was 4.4 mm. The scapho-lunate gap was greater than 3 mm in three cases and 5 mm in one case. An ulnar translation of the carpus greater than 4 mm was present in four cases. Posterior subluxation was significant in three cases. The distal radio-ulnar joint (DRUJ) was totally destroyed in three cases, and incongruent in five. Radio-lunate arthrodesis is performed by a posterior approach. Other procedures were combined, mainly on the DRUJ. The average follow-up was 28.5 months (8-79 months). Healing was achieved in ten out of 11 cases in 45 to 90 days. Pain was absent or moderate after 4 months. The range of motion was 33 degrees in flexion, 39 degrees in extension, 17 degrees in radial deviation and 29 degrees in ulnar deviation. The average post-operative strength was 57% of the opposite side (19 kg/33). Eight patients returned to their previous work and two to lighter work.