Palmar Capsuloligamentous Plication in Dorsal Capitolunate Instability: Technique and Preliminary Results.

Midcarpal instability (MCI) is a form of the carpal instability nondissociative pattern and can be differentiated into dorsal, palmar, or extrinsic MCI. Dorsal MCI can frequently be observed in adolescent or adult patients due to trauma or hyperlaxity of the palmar intrinsic carpal ligaments. Clinical stress tests and cinematography are capable to depict the ligamentous instability centered around the capitolunate area. We describe a novel technique which aims to address palmar ligamentous hyperlaxity by plication of the radioscaphocapitate, radiolunotriquetral, and arcuate ligaments, thus closing the so-called space of Poirier. This palmar technique has been used in several cases in isolated form or in conjunction with other concomitant procedures. After the floor of the carpal tunnel and thus the palmar ligaments are exposed and the weak spot meticulously verified, 2 or rarely 3 deep FibreWire pulley sutures are used for capsuloligamentous plication. Among 11 patients, 4 cases (5 operated wrists) with isolated capitolunate capsuloligamentous plication were followed at an average of 2.6 years after surgery. The results were excellent with a mean postoperative Disabilities of the Arm, Shoulder and Hand Score of 9.7 (range, 6.9 to 15.0), mean numerical rating scale of 0 at rest and 1 (range, 0 to 2) during stress. All cases stated that they were very satisfied with the result and all would definitely elect to choose the surgery again. Palmar capsuloligamentous plication has been shown to be a quick, relatively easy and reliable procedure to reduce dorsal MCI in our patient cohort.

Radiocapitellar joint contact pressures following radial head arthroplasty.

PURPOSE: To determine the radial head arthroplasty length that best replicates the native radiocapitellar contact pressure. METHODS: Eight cadaveric elbows (4 matched pairs) with an average age of 73 years were tested. All specimens were ligamentously stable and without visible cartilage wear. Radiocapitellar contact pressures were digitally analyzed during simulated joint loading at 0°, 45°, and 90° of elbow flexion and neutral rotation in the intact specimens and after ligament-preserving radial head arthroplasty at -2 mm, 0 mm, and +2 mm of the native length. The results were analyzed using 1-way analysis of variance and post hoc Tukey pairwise comparison tests. RESULTS: Paired analysis demonstrated significantly decreased mean contact pressures when comparing the native versus the minus 2 groups. Significantly decreased maximum contact pressures were also noted between the native and the minus 2 groups. Examining the mean contact pressures showed no significant difference between the native and the zero group and the native and the plus 2 groups. As for the maximum contact pressures, there was also no significant difference between the native and the zero group and the native and the plus 2 group. CONCLUSIONS: Up to 2 mm of overlengthening may be tolerated under simulated loading conditions without significantly increasing contact pressures of the radiocapitellar joint. Surgeons can use this knowledge along with radiographic parameters and intraoperative examination of elbow stability to gauge the appropriate size of the radial head implant to be used in order to decrease the risk of overstuffing the joint and minimizing radiocapitellar chondral wear. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Ausencia congénita unilateral del escafoides carpiano y displasia del hueso grande. A propósito de un caso / Unilateral congenital absence of the carpal scaphoid associated with dysplasia of the capitate. Presentation of a case

Presentamos un caso de aplasia o ausencia congénita unilateral del escafoides carpiano asociado a displasia del hueso grande. La ausencia congénita del escafoides carpiano es una entidad rara e infrecuente, pero bien documentada. Es el séptimo caso presentado en la literatura. A diferencia de la mayoría de los casos publicados de aplasia/hipoplasia de escafoides carpiano, en nuestro caso no se ha detectado asociación de otras anomalías congénitas tipo hipoplasia o aplasia de musculatura tenar y antebrazo, malformaciones del esqueleto del pulgar, ausencia de huesos sesamoideos o alteraciones del desarrollo de los huesos del antebrazo. El estudio radiológico revela la ausencia congénita del escafoides asociado a una displasia del hueso grande e hipoplasia de la estiloides radial. Se completa el estudio con resonancia magnética nuclear (AU)

We report on a case of aplasia or unilateral congenital absence of the carpal scaphoid associated with dysplasia of the capitate. Congenital absence of the carpal scaphoid is a rare but well-documented condition. As far as we know, the present case is the seventh one reported in the medical literature. Imaging studies (X-ray and MRI) confirmed the absence of the carpal scaphoid associated with a dysplasia of the capitate and malformation of the radial styloid process. Congenital absence of the scaphoid when other congenital abnormalities (such as hypoplasia or aplasia of either forearm bones or thenar eminence, malformations of the skeletal elements of the thumb, absence of sesamoid bones or abnormal development of the forearm bones) do not exist is probably the main feature of the present case report (AU)

Incarceration of the radial head associated with a radial head fracture, radiocapitellar dislocation, and proximal radioulnar translocation.

We present a case report of an individual who sustained a locked proximal radioulnar joint fracture-translocation after a mechanical fall. After a failed attempt at closed reduction, intraoperative exploration revealed that the dislocated and fractured radial head was incarcerated along the medial aspect of the coronoid. After open reduction and internal fixation, the patient went on to uneventful healing and return of adequate function. To our knowledge, this is the first case report documenting an incarcerated fracture-translocation along the radiocapitellar and proximal radioulnar joints that required operative treatment.

Controlled active mobilization after dorsal capsulodesis to correct capitolunate dissociation.

STUDY DESIGN: Case Report. Capitolunate instability is a form of midcarpal instability. If conservative management is unsuccessful, surgical reconstruction is often indicated. However, the literature is limited regarding postoperative management after reconstruction. Often patients are immobilized for a 6- to 12-week period, which can produce secondary complications, including wrist stiffness, tendon adherence, and muscle atrophy. The purpose of the case report was to demonstrate that controlled early mobilization may be implemented postoperatively after dorsal capsulodesis procedures to correct capitolunate instability. This early mobilization may prevent secondary complications, which can be associated with lengthy immobilization periods. A 27-year-old female underwent a dorsal capsulodesis procedure to correct capitolunate instability. The intraoperative findings of the reconstruction and tension on the capsulodesis procedure were communicated to the therapist by the surgeon. This close communication allowed the therapist to institute early controlled mobilization immediately postoperatively using a hinged wrist splint. The patient was followed by our unit for 13 years. Early controlled mobilization using a hinged wrist splint may have maximized the subject's recovery, with no secondary complications. At 13-year follow-up, fluoroscopic and radiographic examination was normal, and no symptoms of pain or instability had reoccurred. In conclusion, early controlled mobilization using a hinged wrist splint may optimize the recovery period while retaining the desired arc of motion that is set intraoperatively. LEVEL OF EVIDENCE: 4.

Comparison of the "contact biomechanics" of the intact and proximal row carpectomy wrist.

PURPOSE: The proximal row carpectomy (PRC) is a clinically useful motion-preserving procedure for various arthritides of the wrist. However, there are few studies on the "contact biomechanics" after PRC. The purpose of this study is to evaluate the contact biomechanics in terms of pressure, area, and contact location of the intact and PRC wrist. METHODS: Six fresh-frozen cadaver forearms were tested in neutral, 45 degrees of flexion, and 45 degrees of extension. In the intact wrist, Fuji UltraSuperLow pressure contact film was placed in the radioulnocarpal joint. The specimen was loaded to a total force of 200 N. We then performed a PRC, and the experiment was repeated using Fuji Low film. The film was scanned and analyzed with a customized MATLAB program. Multivariable analysis of variance with multiple contrast testing and Student's t-test were performed for statistics. RESULTS: In the intact wrist, scaphoid contact pressure averaged 1.4 megapascals (MPa), and lunate contact pressure averaged 1.3 MPa. In terms of contact location, scaphoid contact in the intact wrist significantly moved dorsal and ulnar in flexion and significantly moved volar and radial in extension. Lunate contact significantly moved dorsal in flexion. PRC wrist contact pressure was 3.8 times that of the intact wrist, and the contact area was approximately 26% that of the intact wrist. Lastly, in terms of the amount of contact translation after PRC, the capitate contact translated (7.5 mm) more than did the scaphoid contact (5.6 mm) and had about equal translation to that of the lunate (7.3 mm). CONCLUSIONS: Contact pressure increased significantly and contact area decreased significantly after PRC. There is significant contact translation after PRC (more than scaphoid translation but equal to lunate translation), which provides quantitative support of the theory that translational motion of the PRC may explain its good clinical outcomes.

Case reports: osteonecrosis of the capitate: a pediatric case report.

We present what we think is the first documented occurrence of osteonecrosis of the capitate in a skeletally immature patient. Atraumatic osteonecrosis of the capitate is rare, and all reported cases have occurred in adults. Our pediatric patient was treated with observation and limited immobilization. He achieved a full recovery clinically and radiographically after 1 year. A review of the literature pertaining to osteonecrosis of the capitate also is provided.