The Hook Test Is Not Pathognomonic for Foveal Detachment of the Triangular Fibrocartilage.

Background The integrity of the foveal insertion of the triangular fibrocartilage complex (TFCC) is currently assessed by inference using the hook test. Using dry arthroscopic techniques, the primary author observed that many patients with painful distal radioulnar joint (DRUJ) instability and a positive hook test had an intact foveal insertion. This study was performed to determine whether a positive hook test is a reliable index of a tear of the foveal insertion. Technique The hook test is performed using a probe to elevate the TFCC off the ulna head toward the articular surface of the lunate. In this study, the hook test was considered positive if the TFCC could be elevated to bridge more than 80% of the space between the TFCC and the articular surface of the lunate. Patients and Methods A retrospective study was performed using the medical records and arthroscopic videos of 113 patients who had clinical signs of DRUJ instability and underwent arthroscopic surgery performed by the primary author in 2020. It was documented whether the hook test was positive or negative, whether the foveal insertion was intact, abnormal or absent, and whether there were peripheral (dorsal or volar) tears of the TFCC. Sensitivity and specificity were calculated using arthroscopic findings as the reference standard. Results The sensitivity of the hook test was found to be 100%, and the specificity was 7.0%. The positive predictive value for foveal pathology was found to be 12.3% and the negative predictive value 100%. The diagnostic accuracy of the hook test in determining the presence of foveal tears was found to be 17.7%. The diagnostic accuracy of the hook test in determining the presence of a TFCC abnormality was 99.1%. Conclusions A positive hook test is indicative of a tear of the TFCC, but it is not anatomically specific for a tear of the foveal insertion. To reliably assess the foveal insertion, it must be visualized and probed using dry arthroscopic techniques.

The Top-Hat Flap: A New Technique for Segmental Nailbed Reconstruction.

SUMMARY: The finger or thumb tip was used as a homodigital neurovascular island flap ('top-hat flap') to reconstruct 28 segmental defects of the distal phalanx, nailbed or pulp over a 7-year period with a minimum follow-up of 12 months. All flaps survived and all fractures united. 75% of patients achieved full range-of-motion at the distal interphalangeal joint, 71% achieved 2-point discrimination <6mm and 92% returned to their preinjury unrestricted job less than 3 months after injury. The average digit AMA5 impairment score was 19%. The top-hat flap is an option for the treatment of complex injuries of the finger or thumb tip where there is a segmental defect in the nailbed, distal phalanx or pulp and a neurovascularly intact finger or thumb tip.

Arthroscopic Bone Graft and Internal Fixation of Non-Union of the Proximal Pole of the Scaphoid: Surgical Technique and Outcomes.

Background Fractures of the proximal pole of the scaphoid have been associated with delayed union, non-union, and avascular necrosis. This has been attributed to avascularity of the proximal pole of the scaphoid. While proximal pole non-unions can be successfully treated using open techniques, there is little information in the literature regarding arthroscopic bone graft and internal fixation of proximal pole non-unions. Description of Technique After insertion of a 1.2-mm radiolunate K-wire, the scaphoid non-union was arthroscopically excised, bone grafted with iliac crest cancellous bone, and internally fixed with 3 × 1.2 mm K-wires. Patients and Methods This is a retrospective study of patients who had arthroscopic bone graft of non-union of the proximal pole of the scaphoid between 2009 and 2021. Results There were 30 cases in this study; 29 cases united. The one case that did not unite was caused by inadequate fixation of the proximal pole. The size of the proximal pole did not influence the outcome. Conclusion Arthroscopic bone graft and internal fixation is a reliable technique for the treatment of non-union of the proximal pole of the scaphoid.

Dry Arthroscopy Distal Radioulnar Joint and Foveal Insertion: Surgical Technique.

Background Arthroscopy of the distal radioulnar joint is considered to be difficult to perform. At this time the integrity of the foveal insertion is indirectly evaluated with a hook test. If a hook test is positive it is inferred that the foveal insertion is torn or incompetent. Description of Technique The ideal way to evaluate the foveal insertion is by direct visualization and probing. In order to do this, arthroscopic examination of the distal radioulnar joint and foveal insertion is required. The article describes how to reliably perform "dry" arthroscopy of the distal radioulnar joint and foveal insertion using a 1.9 mm arthroscope to accurately assess the triangular fibrocartilage complex and foveal insertion. Patient and Methods A total of 169 dry DRUJ arthroscopies were performed by the primary author between January 2018 and February 2021. Results Using this technique, the foveal insertion was successfully visualized in 168 cases (99%). Conclusion Dry arthroscopy of the DRUJ is a reliable technique to evaluate the integrity of the foveal insertion.

Outcome of primary tendon grafts for open Zone 3 extensor tendon injuries.

Open injuries of the extensor mechanism in Zone 3 (dorsum of the proximal interphalangeal joint) have poor outcomes. We retrospectively analysed the outcomes of treating 19 Zone 3 extensor tendon injuries in 17 patients. The treatment comprised wound excision and debridement, primary tendon graft to reconstruct the damaged/missing extensor tendon, skeletal fixation when required, local flaps to vascularize the zone of injury and immediate short arc motion therapy. Using the criteria defined by Geldmacher et al., the outcome was predicted to be poor in nine, satisfactory in seven and good in three cases. In this study the outcomes were excellent in 10, good in six and satisfactory in three cases. Mean range of motion was 75° (range 25°-115°) at the proximal interphalangeal joint. We conclude that using the protocol described there should no longer be the perception of a dismal outcome for these complex Zone 3 extensor tendon injuries.Level of evidence: IV.

Flexor Pollicis Longus Rupture in a Scaphoid Nonunion: A Case Report.

Background Flexor pollicis longus (FPL) tendon rupture is a rare complication of scaphoid nonunion. Case Description A fit active 70-year-old woman ruptured her FPL when it abraded on a painless 50-year-old scaphoid nonunion. She had asymptomatic scaphoid nonunion advanced collapse (SNAC) arthritis. At surgery, the sharp mobile volar scaphoid osteophytes were excised and the volar wrist capsule was repaired. A vascularized fat flap based on a perforator of the radial artery was used to augment the volar wrist capsule repair and to create a smooth gliding surface for the FPL. The ruptured FPL tendon was reconstructed with a palmaris longus graft. Literature Review Complete rupture of the FPL tendon secondary to scaphoid nonunion is a rare complication. It can be easily misdiagnosed because the original injury may be unrecognized or forgotten. A consensus regarding the optimal surgical management has not been reached. Clinical Relevance The objective of surgery in this case was to restore FPL function and prevent a recurrent rupture. The asymptomatic SNAC arthritis was not treated. No further wrist surgery was required. The patient was asymptomatic with a functioning FPL tendon 4 years after surgery.