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1.  Pyrocarbon Interposition Wrist Arthroplasty in the Treatment of Failed Wrist Procedures 
Journal of Wrist Surgery  2012;1(1):31-38.
Treatment of failures after prior wrist surgeries with major articular destruction is challenging. In most cases, total wrist fusion is the only possible salvage procedure. We propose a new interposition arthroplasty with a pyrocarbon implant called Amandys.
A total of 16 patients, 14 men and 2 women, with a mean age of 56 years were operated on for a failure of wrist surgery performed previously, with an average time lapse of 12 years. The prior surgeries were partial wrist arthrodesis in seven cases, silicone implant interpositions in five cases, advanced Kienböck disease (Lichtman IV) treatment in two cases, proximal row carpectomy in one case, and an isolated scaphoidectomy in one case. A prospective study with clinical and radiological evaluation was performed with a mean follow-up of 24 months (6 to 41 months).
Pain and function showed significant improvement. The mean pain score decreased from 7 of 10 to 4 of 10, postoperatively. The mean grip strength was 19 kg (53% of the contralateral side), and the mean range of motion in flexion extension was 68 degrees. Mean strength and range of motion did not change significantly with the operation. The mean QuickDASH (Disability Arm Shoulder and Hand) score decreased from 59 of 100 to 39 of 100. The mean Patient-Rated Wrist Evaluation decreased from 57 of 100 to 33. Two patients (12.5%) required revision for implant repositioning. No dislocation or subsidence of the implant was noted.
Pyrocarbon interposition arthroplasty is a new option for treatment of advanced wrist destruction. Preliminary short-term results suggest that it may be a reliable alternative to total wrist fusion. The level of evidence of this study is IV (therapeutic case series).
doi:10.1055/s-0032-1323641
PMCID: PMC3658666  PMID: 23904977
wrist arthroplasty; pyrocarbon implant; wrist osteoarthritis; interposition; failure
2.  Comparison between proximal row carpectomy and four‐corner fusion for treating osteoarthrosis following carpal trauma: a prospective randomized study 
Clinics  2011;66(1):51-55.
OBJECTIVE:
To compare the functional results of carpectomy and four‐corner fusion surgical procedures for treating osteoarthrosis following carpal trauma.
METHODS:
In this prospective randomized study, 20 patients underwent proximal row carpectomy or four‐corner fusion to treat wrist arthritis and their functional results were compared. The midcarpal joint was free of lesions in all patients.
RESULTS:
Both proximal row carpectomy and four‐corner fusion reduced the pain. All patients had a decreased range of motion after surgery. The differences between groups were not statistically significant.
CONCLUSIONS:
Functional results of the two procedures were similar as both reduced pain in patients with scapholunate advanced collapse/scaphoid non‐union advanced collapse (SLAC/SNAC) wrist without degenerative changes in the midcarpal joint.
doi:10.1590/S1807-59322011000100010
PMCID: PMC3044580  PMID: 21437436
Arthritis; Degenerative; Wrist injuries; Carpal bones; Arthrodesis; Wrist joint
3.  Unicameral bone cyst of the lunate in an adult: case report 
We report a case of a symptomatic unicameral (simple) bone cyst of the lunate in a 42-year- old woman. The lesion was treated with curettage and cancellous autogenous iliac bone grafting. At five years of follow-up the wrist was pain free, there were no limitations of motion, and the radiographs showed complete obliteration of the cavity. To the best of our knowledge, no other unicameral bone cyst of the lunate has been reported in an adult. Cysts with significant cavities at the carpal bones in an adult should be approached cautiously, as they may require early curettage and bone grafting for healing, before collapse and degenerative changes occur.
doi:10.1186/1749-799X-5-79
PMCID: PMC2984580  PMID: 21034505
4.  Decision Making for Partial Carpal Fusions 
Journal of Wrist Surgery  2012;1(2):103-114.
Limited wrist fusions are effective surgical procedures for providing pain relief while preserving motion of the wrist in patients with localized arthritis of the carpus. In deciding which motion-preserving procedure to perform, the etiology of the arthritis, which joints are involved, and which are spared should be determined. The main principle is to fuse the involved joints and to allow motion through the uninvolved joints. In this article, we discuss the various traumatic and nontraumatic conditions causing arthritis of the wrist and the treatment options for those conditions. Common indications for limited wrist fusions include scapholunate advanced collapse and scaphoid nonunion advanced collapse. Options for treating these conditions include three- and four-corner fusions as well as a proximal row carpectomy. This paper discusses which procedures are the most appropriate as well as the outcomes of these procedures. If the basic principles of limited wrist fusions are adhered to, a good outcome can be obtained. The authors' surgical technique and decision-making processes are discussed.
doi:10.1055/s-0032-1329548
PMCID: PMC3658677  PMID: 24179713
carpal fusion; wrist salvage; SLAC wrist; SNAC wrist; Kienböck disease
5.  Congenital bipartite lunate presenting as a misdiagnosed lunate fracture: a case report 
Introduction
A rare case of congenital bipartite lunate in a child is reported. Carpal variants are very uncommon as independent entities, with only three previous reports of this condition in the English literature.
Case presentation
An 11-year-old Caucasian boy presented with pain in the left wrist after a fall. Radiographs in the emergency department demonstrated a lunate that was divided into palmar and dorsal parts, causing a misdiagnosis of fractured lunate. Magnetic resonance imaging was then used to differentiate between the two diagnoses.
Conclusion
Very few cases of bipartite lunate have been reported in the literature, and unless awareness is raised about congenital anomalies such as this variant, confusion may arise.
doi:10.1186/1752-1947-5-102
PMCID: PMC3064648  PMID: 21401931
6.  Scaphocapitolunate Arthrodesis and Radial Styloidectomy: A Treatment Option for Posttraumatic Degenerative Wrist Disease 
Journal of Wrist Surgery  2012;1(2):115-122.
Longstanding scaphoid nonunion, scaphoid malunion, and chronic scapholunate dissociation result in malalignment of the carpal bones, progressive carpal collapse, instability, and osteoarthritis of the wrist. The most commonly used procedures to treat scaphoid nonunion advanced collapse (SNAC) and scapholunate advanced collapse (SLAC) wrists are the four-corner fusion (4CF) and the proximal row carpectomy (PRC). Here we describe a different treatment option: radial styloidectomy and scaphocapitolunate (SCL) arthrodesis. This treatment option is chosen in an effort to maintain the joint contact surface and load transmission across the radiocarpal joint. Twenty patients were treated by the senior author (DLF) with this method with a mean follow-up of 4.6 years. Pain decreased in all patients, and 13 patients were pain-free postoperatively. The average Disabilities of the Arm, Shoulder, and Hand (DASH) scores decreased from 44 preoperatively to 23 postoperatively. One patient's course was complicated by nonunion, which was successfully treated with revision of the SCL arthrodesis. On follow-up radiographs, no patient had progressive osteoarthritis. This method preserves the normal ulnar-sided joints of the carpus, which are sacrificed during 4CF, and maintains a more physiologic joint surface for radiocarpal load sharing.
doi:10.1055/s-0032-1329592
PMCID: PMC3658680  PMID: 24179714
SNAC; SLAC; scaphocapitolunate; wrist arthrodesis
7.  Concomitant flying lunate and scaphoid 
Devastating perilunate injuries are rare, compromising of less than 10% of wrist injuries. We report a 19-year-old worker man who presented with left wrist pain and swelling after falling from a height. Not only the lunate was seen in middle third of forearm, but also proximal part of the scaphoid was in distal forearm. Open reduction and internal fixation was done via volar approach. He came back after two years with limited motion, pain, and weakness because of static scapholunate dissociation and osteonecrosis of lunate and proximal scaphoid. Despite optimal management, the prognosis of this injury is relatively poor especially if the initial trauma was severe.
doi:10.1093/jscr/2011.11.4
PMCID: PMC3649328
8.  Scaphocapitolunate Arthrodesis and Radial Styloidectomy for Posttraumatic Degenerative Wrist Disease 
Journal of Wrist Surgery  2012;1(1):47-54.
Long-standing scaphoid nonunion, scaphoid malunion, and chronic scapholunate dissociation result in malalignment of the carpal bones, progressive carpal collapse, instability, and osteoarthritis of the wrist. The most commonly used procedures to treat scaphoid nonunion advanced collapse (SNAC) and scapholunate advanced collapse (SLAC) wrists are the four-corner fusion (4CF) and the proximal row carpectomy (PRC). The purpose of this study was to evaluate the clinical outcome of a different treatment modality: radial styloidectomy and scaphocapitolunate (SCL) arthrodesis. This treatment option is chosen in an effort to maintain the joint contact surface and load transmission across the radiocarpal joint. We conducted a retrospective review of 20 patients (average age 62 years, range: 27 to 75 years) treated from 1994 to 2010. Seven patients were treated for SNAC, 12 patients for SLAC wrists, and 1 for degenerative joint disease following a transscapho-transcapitate perilunar dislocation. Sixteen patients had Herbert screw fixation, and four had Spider plate fixation. All patients had autologous bone graft used for the arthrodesis. The mean follow-up was 4.6 years (range: 2 to 9.6 years). Patients were evaluated clinically and radiographically. Nineteen of 20 arthrodeses healed on an average of 9.6 weeks. One patient was reoperated 8 months after the initial operation with salvage of the SCL arthrodesis with a spider plate with an adequate result. The mean active flexion–extension arc was 70 degrees and the radioulnar deviation arc was 23 degrees. Pain decreased in all patients, 13 of whom were pain free postoperatively. The average postoperative disabilities of arm, shoulder, and hand score was 24. Radiographically, neither radiolunate nor radioscaphoid arthritis was noted on follow-up. SCL arthrodesis with radial styloidectomy resulted in an adequate residual range of motion and pain relief. This method preserves the normal ulnar sided joints of the carpus and maintains a more physiologic joint surface for radiocarpal load sharing.
doi:10.1055/s-0032-1323846
PMCID: PMC3658667  PMID: 23904979
scaphocapitolunate; wrist arthrodesis; SNAC; SLAC
9.  Treatment of post-traumatic degenerative changes of the radio-carpal and distal radio-ulnar joints by combining radius, scaphoid, and lunate (RSL) fusion with ulnar head replacement 
Distal radial fractures are a common type of fracture. In the case of intra-articular fractures, they often result in post-traumatic arthrosis. The objective of this study is to describe a novel alternative to the established salvage techniques for the treatment of post-traumatic arthrosis of the radio-carpal and distal radio-ulnar joints (DRUJ). Six patients with radio-carpal and DRUJ arthrosis were treated with a combined radius, scaphoid, and lunate (RSL) arthrodesis and as a Herbert ulnar head prosthesis. Follow-up consisted of both radiographic and functional assessments. Functional measurements were noted both pre- and postoperatively. No non-union or pseudoarthrosis was seen; neither did any of the ulnar head prostheses show loosening. Clinical examination showed an improvement in strength, pain, and range of movement, as well as a decrease in disability. Combining RSL arthrodesis with a Herbert ulnar head prosthesis, which deals with pain while retaining partial wrist movement, can be an alternative to established salvage procedures.
doi:10.1007/s00238-011-0556-3
PMCID: PMC3218278  PMID: 22162910
Wrist; Partial arthrodesis; Endoprosthetics; Post-traumatic arthrosis
10.  The Floating Lunate: Arthroscopic Treatment of Simultaneous Complete Tears of the Scapholunate and Lunotriquetral Ligaments 
Hand (New York, N.Y.)  2008;4(3):250-255.
Carpal instabilities continue to be a controversial topic in hand surgery. Accurate diagnosis of the ligament injuries is usually difficult without an arthroscopic evaluation. Few studies have focused on the diagnosis and proper management of simultaneous scapholunate (SL) and lunotriquetral (LT) ligament tears. This is an uncommon injury that leads to marked disability and chronic wrist pain. This is essentially a “floating lunate” and indicates a severe ligamentous lesion. Thirteen patients (six female and seven male) with complete SL and LT tears and with gross arthroscopic dynamic carpal instability were included in the present study. None of the patients showed radiographic evidence of lunate dislocation. One patient presented acutely and was operated on 3 days after the injury. The average time from the initial injury to the arthroscopy for the other 12 patients was 13.5 months (range 1.5–84 months). All patients underwent arthroscopic debridement of the SL and LT ligaments coupled with percutaneous pinning (two 0.045-in. Kirschner wires) in both joints. At the final follow-up, the average range of motion was 50° of flexion, 54° of extension, 77° of pronation, 80° of supination, 25° of ulnar deviation, and 15° of radial deviation. The average final grip strength was 67% from the non-affected side. All patients had negative shifting tests at final follow-up. Furthermore, there was no evidence of any static or dynamic instability in all the patients except for one patient who developed a volar intercalated segment instability 8 months after the surgery. At the final follow-up, ten patients had no pain, one had mild pain, and two experienced moderate pain.
doi:10.1007/s11552-008-9155-6
PMCID: PMC2724611  PMID: 19104901
Carpal instabilities; Arthroscopy; Ligamentous tears; Lunate instability
11.  Long-term follow-up of callotasis lengthening of the capitate after resection of the lunate for the treatment of stage III lunate necrosis 
The callotasis lengthening technique was used to gradually lengthen the capitate after resection of the lunate in stage IIIa necrosis in 23 patients. Results of ten patients with a follow-up of at least 5 years showed rapid and sufficient callus formation in every patient regardless of age. The callotasis lengthening modification of the Graner II operation provides all advantages and avoids the major inconvenience of the traditional Graner II operation. There was no increased rate of disturbed fracture healing. Results of the DTPA-gadolinium MRI study did not show any significant impairment of vascularization within the region of the capitate bone. With the “intrinsic bone formation,” contrary to every other intercarpal arthrodesis at the wrist, there is no need for an additional bone graft.
doi:10.1007/s11751-009-0069-9
PMCID: PMC2839315  PMID: 20012506
Hand; Wrist; Lunate; Necrosis; Kienböck; Distraction; Osteogenesis; Partial arthrodesis
12.  Long-term follow-up of callotasis lengthening of the capitate after resection of the lunate for the treatment of stage III lunate necrosis 
The callotasis lengthening technique was used to gradually lengthen the capitate after resection of the lunate in stage IIIa necrosis in 23 patients. Results of ten patients with a follow-up of at least 5 years showed rapid and sufficient callus formation in every patient regardless of age. The callotasis lengthening modification of the Graner II operation provides all advantages and avoids the major inconvenience of the traditional Graner II operation. There was no increased rate of disturbed fracture healing. Results of the DTPA-gadolinium MRI study did not show any significant impairment of vascularization within the region of the capitate bone. With the “intrinsic bone formation,” contrary to every other intercarpal arthrodesis at the wrist, there is no need for an additional bone graft.
doi:10.1007/s11751-009-0069-9
PMCID: PMC2839315  PMID: 20012506
Hand; Wrist; Lunate; Necrosis; Kienböck; Distraction; Osteogenesis; Partial arthrodesis
13.  Avascular necrosis of the lunate bone (Kienböck’s disease) secondary to scapholunate ligament tear as a consequence of trauma – a case study 
Summary
Background
Avascular necrosis of the lunate bone (Kienböck’s disease), is a condition in which lunate bone, loses its blood supply, leading to necrosis of the bone.
There is probably no single cause of Kienbock’s disease. Its origin may involve multiple factors, such as the blood supply (arteries), blood drainage (veins), and skeletal variations. Trauma, either isolated or repeated, may possibly be a factor in some cases. This case presented with multifactorial etiology.
Case Report
In the presented case, a patient with negative ulnar variant had injured her right wrist and presented at an orthopedic clinic due to nonspecific pain 6 months later. An arthro-MRI examination revealed necrosis of the lunate bone, scapholunate ligament tear and coexisting TFCC (triangular fibrocartilage complex) tear.
Conclusions
Early diagnosis and treatment can prevent progression of necrotic lesions and bone collapse. MRI examination seems to be the key diagnostic method in the early stage of the Kienböck’s disease with negative x-ray and CT images. Arthro-MRI examination also allows us to identify the underlying ligamentous injury. In cases of traumatic etiology, an additional CT test enables stating the final diagnosis.
doi:10.12659/PJR.890027
PMCID: PMC3921098  PMID: 24523832
Kienböck’s disease; scapholunate ligament; MR/CT arthrography
14.  In Vivo Kinematics of the Scaphoid, Lunate, Capitate, and Third Metacarpal in Extreme Wrist Flexion and Extension 
The Journal of hand surgery  2012;38(2):278-288.
Purpose
Insights into the complexity of active in vivo carpal motion have recently been gained using 3D imaging; however kinematics during extremes of motion have not been elucidated. The purpose of this study was to determine motion of the carpus during extremes of wrist flexion and extension.
Methods
Computed tomography scans of 12 healthy wrists were obtained in neutral-grip, extreme loaded flexion, and extreme loaded extension. Three-dimensional bone surfaces and 6-degree-of-freedom kinematics were obtained for the radius and carpal bones. The flexion and extension rotation from neutral-grip to extreme flexion and extreme extension of the scaphoid and lunate was expressed as a percentage of capitate flexion and extension and then compared to previous studies of active wrist flexion and extension. We also tested the hypothesis that the capitate and third metacarpal function as a single rigid body. Finally, joint space metrics at the radiocarpal and midcarpal joints were used to describe arthrokinematics.
Results
In extreme flexion, the scaphoid and lunate flexed 70% and 46% of the amount the capitate flexed, respectively. In extreme extension, the scaphoid extended 74% and the lunate extended 42% of the amount the capitates extended, respectively. The third metacarpal extended 4° farther than the capitate in extreme extension. The joint contact area decreased at the radiocarpal joint during extreme flexion. The radioscaphoid joint contact center moved onto the radial styloid and volar ridge of the radius in extreme flexion from a more proximal and ulnar location in neutral.
Conclusions
The contributions of the scaphoid and lunate to capitate rotation were approximately 25% less in extreme extension compared to wrist motion through an active range of motion. More than half the motion of the carpus when the wrist was loaded in extension occured at the midcarpal joint.
Clinical Relevance
These findings highlight the difference in kinematics of the carpus during at the extremes of wrist motion, which occur during activities and injuries, and give insight into the possible etiologies of the scaphoid fractures, interosseous ligament injuries, and carpometacarpal bossing.
doi:10.1016/j.jhsa.2012.10.035
PMCID: PMC3557539  PMID: 23266007
Carpal; Kinematics; Lunate; Passive; Scaphoid
15.  Vaughan-Jackson-like syndrome as an unusual presentation of Kienböck's disease: a case report 
Introduction
Kienböck's disease is a condition of osteonecrosis of the lunate bone in the hand, and most patients present with a painful and sometimes swollen wrist with a limited range of motion in the affected wrist. Vaughan-Jackson syndrome is characterized by the disruption of the digital extensor tendons, beginning on the ulnar side with the extensor digiti minimi and extensor digitorum communis tendon of the small finger. It is most commonly associated with rheumatoid arthritis. We describe a case of a patient with an unusual presentation of Kienböck's disease with symptoms similar to those of Vaughan-Jackson syndrome.
Case presentation
A 40-year-old man of Indian ethnic origin with no known history of trauma presented to our clinic with a ten-day history of an inability to extend his right little and ring fingers with associated pain in his right wrist. He was being treated with long-term steroids but had no other significant medical history. His examination revealed an inability to extend the metacarpal and phalangeal joints of the right ring and little fingers with localized tenderness over the lunate bone. Spontaneous disruption of the extensor tendons was diagnosed clinically and, after radiological investigation, was confirmed to be secondary to dorsal extrusion of the fragmented lunate bone. The patient underwent surgical repair of the tendons and had a full recovery afterward.
Conclusion
Kienböck's disease, though rare, is an important cause of spontaneous extensor tendon rupture. The original description of Vaughan-Jackson syndrome was of rupture of the extensor tendons of the little and ring fingers caused by attrition at an arthritic inferior radioulnar joint. We describe a case of a patient with Kienböck's disease that first appeared to be a Vaughan-Jackson-like syndrome.
doi:10.1186/1752-1947-5-325
PMCID: PMC3158122  PMID: 21787412
16.  Tendon Interposition and Ligament Reconstruction with ECRL Tendon in the Late Stages of Kienböck's Disease: A Cadaver Study 
The Scientific World Journal  2013;2013:416246.
Background. The optimal surgical treatment for Kienböck's disease with stages IIIB and IV remains controversial. A cadaver study was carried out to evaluate the use of coiled extensor carpi radialis longus tendon for tendon interposition and a strip obtained from the same tendon for ligament reconstruction in the late stages of Kienböck's disease. Methods. Coiled extensor carpi radialis longus tendon was used to fill the cavity of the excised lunate, and a strip obtained from this tendon was sutured onto itself after passing through the scaphoid and the triquetrum acting as a ligament to preserve proximal row integrity. Biomechanical tests were carried out in order to evaluate this new ligamentous reconstruction. Results. It was biomechanically confirmed that the procedure was effective against axial compression and distributed the upcoming mechanical stress to the distal row. Conclusion. Extensor carpi radialis longus tendon has not been used for tendon interposition and ligament reconstruction in the treatment of this disease before. In view of the biomechanical data, the procedure seems to be effective for the stabilization of scaphoid and carpal bones.
doi:10.1155/2013/416246
PMCID: PMC3628666  PMID: 23606814
17.  Orientations of wrist axes of rotation influence torque required to hold the hand against gravity: A simulation study of the nonimpaired and surgically salvaged wrist 
Journal of biomechanics  2012;46(1):192-196.
The wrist is a complex kinematic link connecting the forearm and hand. The kinematic design of the wrist is permanently altered during surgical salvage procedures, such as proximal row carpectomy (PRC) and scaphoid-excision four-corner fusion (SE4CF), which have the unintended consequence of long-term functional impairments to both the wrist and hand. We developed simulations of the nonimpaired, PRC, and SE4CF wrists to evaluate if surgically altered wrist kinematics contribute to functional impairments. Specifically, as a step toward understanding the connection between kinematics and function, we examined the torque necessary to statically maintain functional postures. All simulations included only bone geometry and joint kinematics; soft tissues were excluded. Our simulations demonstrate that the torque necessary to maintain a functional posture is influenced by the orientations of the flexion and deviation axes of rotation relative to each other and the anatomical planes of the radius. The magnitude of torque required to hold the hand against gravity decreased in simulations of the PRC wrist compared to the nonimpaired wrist. In contrast, the torque required increased relative to the nonimpaired wrist in simulations of the SE4CF wrist. These divergent results are directly related to how motion is coupled between the flexion–extension and deviation axes of rotation. This study highlights that, even without considering the effects of soft tissues, changing the kinematic design of the wrist influences function; therefore, kinematics should be considered when surgically redesigning the wrist.
doi:10.1016/j.jbiomech.2012.10.035
PMCID: PMC3593346  PMID: 23199898
Wrist; Kinematics; Computer simulation; Proximal row carpectomy; Four-corner fusion
18.  Biomechanical Evaluation of Ligamentous Stabilizers of the Scaphoid and Lunate 
The Journal of hand surgery  2002;27(6):991-1002.
This study evaluated the effects of sectioning the scapholunate interosseous ligament, radioscaphocapitate ligament, and scaphotrapezial ligament on the kinematics of the scaphoid and lunate. Eight cadaver upper extremities were placed in a wrist joint simulator and moved in continuous cycles of flexion-extension and radial-ulnar deviation. Positional data of the scaphoid and lunate were obtained in the intact state, after the scapholunate ligament was cut; after the scapholunate and scaphotrapezial ligaments were cut; after the scapholunate, scaphotrapezial, and radioscaphocapitate ligaments were cut; and after all 3 ligaments were cut and the specimen was placed through an additional 1,000 cycles of flexion-extension. Cutting the scapholunate ligament caused changes in scaphoid and lunate motion during flexion-extension, but not radial-ulnar deviation. Additional sectioning of the scaphotrapezial ligament followed by the radioscaphocapitate ligament caused further kinematic changes in these carpal bones. One thousand cycles of motion after all 3 ligaments were sectioned caused additional kinematic changes in the scaphoid and lunate. The scapholunate ligament appears to be the primary stabilizer between the scaphoid and lunate. The radioscaphocapitate and scaphotrapezial ligaments are secondary restraints. Repetitive cyclic motion after ligament sectioning appears to have additional deleterious effects on carpal kinematics.
doi:10.1053/jhsu.2002.35878
PMCID: PMC1986797  PMID: 12457349
Carpal instability; scaphoid; lunate; kinematics
19.  DISTAL RADIUS HEMIARTHROPLASTY COMBINED WITH PROXIMAL ROW CARPECTOMY: CASE REPORT 
The Iowa Orthopaedic Journal  2010;30:168-173.
Severe wrist arthritis is most commonly treated by complete wrist arthrodesis,1-3 which provides predictable pain relief but the loss of motion may reduce ease of function.4 In selected patients, motion preserving surgical options, including limited intercarpal fusion, proximal row carpec-tomy (PRC), and total wrist arthroplasty (TWA) are considered. However, limited fusion and PRC are typically possible only in less severe cases in which there are some articular surfaces showing minimal degeneration that can be retained.5
TWA is an option for patients who have lower activity demands and specific needs or desires to maintain some wrist motion.1,3 Recent utility and decision analysis studies6,7 demonstrate that arthroplasty is associated with higher qualify adjusted life year (QALY) than arthrodesis in patients with rheumatoid arthritis. Despite these positive aspects of TWA, the procedure is not as widely accepted as hip, knee, or shoulder arthroplasfy. Early implants had problems related to both materials and design, with breakage, loosening and joint imbalance being common complications.8 Newer generation implants are improved with more predictable early function, less joint imbalance, and rare breakage, but distal component loosening remains a substantial problem. Thus, patients with poor bone stock and those with high activity demands are typically not candidates for TWA, and all patients are advised to restrict activities to reduce the risk of implant loosening.9,10
A new motion preserving procedure has recently been used at our institution in selected patients with severe arthritis who do not qualify for TWA but request an alternative to complete wrist fusion. In this procedure, a distal radius implant arthroplasty is combined with a PRC. The distal radius component of a Universal 2 (UNI 2) total wrist arthroplasty system (Integra life Sciences, Plainsboro, NJ) is used. To our knowledge, there have been no previous publications on this tech-nique. We report our first two cases which have shown a satisfactory early outcome for pain relief and functional wrist motion.
PMCID: PMC2958290  PMID: 21045991
20.  Stress injury of the lunate in tennis players: a case series and related biomechanical considerations 
British Journal of Sports Medicine  2007;41(11):812-815.
Objective
To investigate clinical and imaging differential diagnosis and tennis stroke biomechanics potentially involved in lunate stress injury pathogenesis.
Methods
The present report describes five competitive tennis players with overuse‐related dorsal wrist pain assessed by magnetic resonance imaging.
Results
Magnetic resonance imaging revealed the presence of lunate stress injury. All players were treated conservatively, with symptom resolution and complete functional recovery achieved at 14 weeks.
Conclusions
Lunate stress injuries should be considered in the differential diagnosis of overuse‐related dorsal wrist pain in tennis players.
doi:10.1136/bjsm.2007.036806
PMCID: PMC2465273  PMID: 17957020
21.  Arthroplasty of the lunate using bone marrow mesenchymal stromal cells 
International Orthopaedics  2010;35(3):379-387.
Mesenchymal stromal cells have the potential to differentiate into a variety of mesenchymal tissues such as bone, cartilage and ligaments. The potential for the regeneration of bone with cartilage coverage has still not been achieved. We evaluated the ability of bone marrow mesenchymal stromal cells to regenerate osteochondral defects in the cavity of the lunate in an animal model. Autologous mesenchymal stromal cells were harvested from the iliac crest of New Zealand white rabbits and expanded in vitro. Total lunate excision was performed in 24 animals and the isolated cells were loaded onto scaffolds. Cell-free scaffolds were implanted in the lunate space of the right wrists of all animals, and the left lunate spaces were filled with predifferentiated, cell-loaded scaffolds. Radiographic and histological analyses were performed after two, six and 12 weeks. In addition, the animals were injected with a fluorescent agent every five days, starting at day 30. After two and six weeks there was no radiographic evidence of ossification, whereas after 12 weeks all animals showed radiographic evidence of ossification. Histological sections showed increasing evidence of cartilage-like cell formation at the edges and new bone tissue in the centre of the newly formed tissue in all groups. The histological examinations showed that bone tissue was located around the newly incorporated vascularisation. This study demonstrated that newly formed vascularisation is necessary for the regeneration of bone tissue with cell-loaded scaffolds.
doi:10.1007/s00264-010-0997-5
PMCID: PMC3047649  PMID: 20349357
22.  Midcarpal Hemiarthroplasty for Wrist Arthritis: Rationale and Early Results 
Journal of Wrist Surgery  2012;1(1):61-68.
Midcarpal hemiarthroplasty is a novel motion-preserving treatment for radiocarpal arthritis and is an alternative to current procedures that provide pain relief at the expense of wrist biomechanics and natural motion. It is indicated primarily in active patients with a well-preserved distal row and debilitating arthritic symptoms. By resurfacing the proximal carpal row, midcarpal arthroplasty relieves pain while preserving the midcarpal articulation and the anatomic center of wrist rotation. This technique has theoretical advantages when compared with current treatment options (i.e., arthrodesis and total wrist arthroplasty) since it provides coupled wrist motion, preserves radial length, is technically simple, and avoids the inherent risks of nonunion and distal component failure. The KinematX midcarpal hemiarthroplasty has an anatomic design and does not disrupt the integrity of the wrist ligaments. We have implanted this prosthesis in nine patients with promising early results. The indications for surgery were as follows: scapholunate advanced collapse wrist (three), posttraumatic osteoarthritis (three), inflammatory arthritis (two), and Keinböck disease (one). Prospective data has been collected and the results are preliminary given the infancy of the procedure. The mean follow-up was 30.9 weeks (range: 16 to 56 weeks). The mean Mayo wrist score increased from 31.9 preoperatively to 58.8 (p < 0.05) and the mean DASH score improved significantly from 47.8 preoperatively to 28.7 (p < 0.05). There was a trend toward increased motion but statistical significance was not reached. Two patients required manipulation for wrist stiffness. There was no evidence of prosthetic loosening or capitolunate narrowing. The procedure is simple (average surgical time was 49 minutes) and maintains coupled wrist motion through preservation of the midcarpal articulation. The preliminary data show that it appears safe but considerably longer follow-up is required before conclusions can be drawn as to its durability, reliability, and overall success. The level of evidence for this study is therapeutic level IV (case series).
doi:10.1055/s-0032-1323644
PMCID: PMC3658668  PMID: 23904981
arthritis; arthroplasty; hemiarthroplasty; KinematX; outcomes; treatment; wrist arthritis; wrist arthroplasty; wrist hemiarthroplasty
23.  Wrist fusion versus limited carpal fusion in advanced kienbock's disease 
International Orthopaedics  2005;29(6):355-358.
We treated 18 patients with advanced Kienbock's disease surgically. Six had total wrist fusions and 12 had limited carpal fusions. The average age was 39.6 yrs and the average follow up was 61.8 months and 66.8 months respectively. The visual analogue pain scores, the patient satisfaction scores and the SF 12 were better in the total wrist fusion group. The DASH (Disabilities of the Arm, Shoulder and Hand) scores, the range of movement and the grip strengths were better in the limited carpal fusions group but this was not statistically significant. Four patients with limited carpal fusions had a non-union that required revising. We believe that total wrist fusion should be offered earlier to patients with advanced stages of the disease, as there are less surgical failures, more satisfied patients, better post operative pain scores and consistent long-term results with less potential for further deterioration with time as compared to other treatment methods.
doi:10.1007/s00264-005-0013-7
PMCID: PMC2231587  PMID: 16205959
24.  Isolated Dorsal Dislocation of the Lunate 
Lunate dislocations are well described in the volar direction as part of the perilunate dislocation, sometimes together with fractures of the other carpal bones or distal radius, as described by the anatomical studies of Mayfield [1]. It is a result of disruption of the complex inter-carpal and radiocarpal ligaments that hold the well conforming carpus in their normal position. Given the strength of these structures a significant trauma is required to cause them to fail.
However, we present a case of a patient who not only presented with relatively trivial trauma that resulted in a lunate dislocation, but it was also in the dorsal direction and not associated with any fracture or neurological compromise. In addition, she presented several days after her injury.
We treated her with closed manipulation and percutaneous K-wire fixation followed by a short period of immobilisation in a Plaster-of-Paris cast, with rapid return to full duties at work.
As many volar lunate dislocations may be missed at presentation, we suggest that in patients with relatively trivial trauma there should also be a suspicion of the lunate dislocating dorsally, which may be treated successfully without the aggressive open surgery usually required in volar perilunate dislocations.
doi:10.2174/1874325001206010531
PMCID: PMC3522489  PMID: 23248723
Carpus; dislocation; dorsal; ligament rupture; lunate; perilunate.
25.  Scaphoid and lunate translation in the intact wrist and following ligament resection: A cadaver study 
The Journal of hand surgery  2011;36(2):291-298.
Purpose
The two purposes of this study were a) to determine the amount of scaphoid and lunate translation that occurs in normal cadaver wrists during wrist motion and b) to quantify the change in ulnar translation when specific dorsal and volar wrist ligaments were sectioned.
Methods
The scaphoid and lunate motion of 37 cadaver wrists were measured during wrist radioulnar deviation and flexion-extension motions using a wrist joint motion simulator. The location of centroids of the bones were quantified during each motion in the intact wrists and after sectioning either two dorsal ligaments along with the scapholunate interosseous ligament or two volar ligaments and the scapholunate interosseous ligament.
Results
In the intact wrist the scaphoid and lunate statistically translated radially with wrist ulnar deviation. With wrist flexion the scaphoid moved volarly and the lunate dorsally. After sectioning either the dorsal or volar ligaments, the scaphoid moved radially. After sectioning the dorsal or volar ligaments, the lunate statistically moved ulnarly and volarly.
Conclusion
These results indicate that measureable changes in the scaphoid and lunate translation occur with wrist motion and change with ligament sectioning. However, for the ligaments that were sectioned, these changes are small and an attempt to clinically measure these translations of the scaphoid and lunate radiographically may be limited. The results support the conclusion that ulnar translocation does not occur unless multiple ligaments are sectioned. Injury of more than the scapholunate interosseous ligament along with either the dorsal intercarpal and dorsal radiocarpal or the radioscaphocapitate and scaphotrapezial ligaments are needed to have large amounts of volar and ulnar translation.
doi:10.1016/j.jhsa.2010.11.023
PMCID: PMC3044914  PMID: 21276893
Scaphoid translation; lunate translation

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