Arthroscopic Debridement for Treatment of Chronic Dynamic Scaphoid Instability.

Background There is a paucity of information on minimal surgical intervention for the treatment of chronic dynamic scaphoid instability (CDSI) that will achieve an acceptable mid-term result. Purpose We hypothesize that by following a debride-first-then-wait protocol, some patients with CDSI can be treated with arthroscopic debridement alone and avoid a reconstructive procedure. Patients and Methods We performed a retrospective, longitudinal study from January 2008 to December 2018 of all patients diagnosed with CDSI and treated with arthroscopic debridement of the scapholunate interosseous ligament. In all cases, a debride-first-then-wait protocol was followed that included a predetermined wait period after arthroscopic debridement, giving the patient a chance to experience possible symptom improvement. This approach integrated the patient's perceived wellness into the decision-making process. All wrists that remained symptomatic or experienced recurrence of symptoms were treated with a reconstructive procedure. The wrists were divided into two groups: arthroscopic debridement only (ADO) and reconstructive procedure (RP). Results Seventy-nine wrists (72 patients) of 191 consecutive wrist arthroscopies met the inclusion criteria. The ADO group consisted of 43 wrists (54%). An average of 6.3 years later (range: 2-11 years), these patients remained satisfied with the results of the arthroscopic debridement and did not want further treatment. The RP group included 36 wrists (46%) with 91.7% of reconstructive surgeries occurring within 6 months of the arthroscopy. With a mid-term follow-up, 75% of Geissler grade II ligament tears, 48% of grade III tears, and 39% of grade IV tears were successfully treated with arthroscopic debridement alone and avoided a reconstructive surgery. Conclusion By adopting a debride-first-then-wait protocol, some patients with CDSI can be treated with a more limited intervention, arthroscopic debridement. In this series, 54% of wrists with CDSI avoided a reconstructive surgery for an average of 6.3 years. Type of Study / Level of Evidence Case Series, Level IV.

Dynadesis for Treatment of Dynamic Scaphoid Instability with 20-Year Results.

Background Even though the scapholunate interosseous ligament is the most common wrist ligament injury, its treatment remains a challenge for hand surgeons. We report on a surgical treatment (Dynadesis) for dynamic scaphoid instability (DSI) with a 20-year follow-up period. Description of Technique Dynadesis utilizes antagonist forearm muscles in order to synergistically provide dynamic stabilization to the scaphoid when the wrist is loaded. It is a tendon-to-tendon transfer with the following two components: 1) Dorsal-The extensor carpi radialis longus (ECRL) is passed through a hole in the reduced, distal scaphoid, providing the scaphoid with an independent extension force. 2) Volar-A dynamic checkrein is created by tension-locking the ECRL tendon around the flexor carpi radialis (FCR) tendon. The portion of the FCR distal to the scaphoid tethers and tightens with contracture of the ECRL and FCR muscles. Patients and Methods Twenty patients (21 wrists) were treated with Dynadesis and reevaluated 20 years later (range: 20-27 years). Results Average grip strength improved by 8 kg. The average wrist flexion-extension arc decreased by 3 ° . Wrist X-rays showed no radiocarpal arthritis. On the Mayo wrist score, 81% reported excellent to good results (average: 89). Pain levels improved by 90%, with 76% of patients reporting no pain. All patients (100%) were satisfied with their results and would recommend the procedure. Conclusions Dynadesis is specifically designed for the treatment of DSI. It avoids the eventual complication of osteoarthritis and does not sacrifice wrist motion. A predictable and satisfactory long-term result is obtainable with correct patient selection based on clinical staging and arthroscopic findings.

Subperiosteal Ulnar Nerve Entrapment at the Wrist.

Ulnar nerve entrapment at the wrist can cause debilitating sensory, motor, or sensory and motor deficits in the hand. The sources of compression have been well documented, with ganglions, lipomas, and trauma being common etiological factors. We treated a professional sculptor with intrinsic pain and weakness in her dominant hand because of compression caused by the subperiosteal course of her deep motor branch of the ulnar nerve. The nerve traversed on the radial side of the hook of the hamate and descended into the floor of the palm in the carpal tunnel through the transverse carpal ligament. We present this previously unreported anatomical anomaly and the subsequent operative treatment. Knowledge of this anatomical variation is paramount in avoiding injury to the ulnar nerve when operating the Guyon canal or carpal tunnel, among other hand and wrist surgeries.

Treatment of dynamic scaphoid instability.

BACKGROUND: Chronic wrist pain attributable to scaphoid instability without fixed deformity (dynamic instability) presents a treatment dilemma. The diagnosis usually is delayed, missing the opportunity for direct repair. The intercarpal fusion, tenodesis, and capsulodesis procedures create a fixed deformity. This report presents an outcome study of a new treatment for dynamic scaphoid instability that spanned more than 5 years. METHODS: Arthroscopic evaluation was used to confirm the diagnosis for 105 wrists of 102 patients who had experienced wrist pain for an average of 24.4 months. The treatment for these patients involved transferring two thirds of the extensor carpi radialis longus through the distal pole of the reduced scaphoid volarly to the intact flexor carpi radialis. The postoperative follow-up period averaged 63 months. RESULTS: The average grip strength increased by 65%. The average active wrist extension-flexion increased by 9%, with an average radial deviation loss of 6 degrees. The overall results, as measured by the modified Green and O'Brien clinical wrist scale, were as follows: excellent (49%), good (24%), and fair (26%). Good to excellent results were reported by 85% of the patients. Pain relief was reported by 94% of the patients, and 93% of the patients would recommend the procedure to others. CONCLUSIONS: Scaphoid instability without fixed deformity is a complex problem. Conventional treatments have drawbacks. The new technique produced positive results that are quite promising for the management of dynamic scaphoid instability.

Conservative treatment of carpal tunnel syndrome: an outcome study of adjunct exercises.

We conducted a prospective study to evaluate the effect of a new non-surgical protocol for treating carpal tunnel syndrome (CTS). It incorporates the Carpal Tunnel Decompression Exercise Program (Exercise Program) into conventional non-surgical treatment. Twenty-eight patients (33 hands) met the inclusion criteria and were followed for 18 months. The outcome measurement tools used were the Symptom Severity Scale (SSS) and the Functional Status Scale (FSS). The outcome tools were administered at admission and repeated at 1, 2, and 18 months after admission to the treatment program. Using the adjunct treatment, 80% of the hands in the mild category and 71% in the moderate category were successfully treated without surgery. All patients in the severe category required surgery. The average success rate of our adjunct non-surgical treatment protocol was 67%, a substantial improvement over the 18% to 34% success rate reported nationally for conventional treatment methods. Furthermore, improvement in the outcome of carpal tunnel syndrome by the adjunct non-surgical treatment can result in significant savings in human suffering, medical cost, lost work time, and socioeconomic distress.