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1.  Distal capitate shortening with capitometacarpal fusion for management of the early stages of Kienböck’s disease with neutral ulnar variance: case series 
Background
The aim of surgical management of Kienböck’s disease has been proposed to slow the progressive osteonecrosis and secondary carpal damage. The aim of this case series was to evaluate the results of a new technique, combining distal capitate shortening with capitometacarpal fusion for the treatment of Kienböck’s disease (Lichtman stage II or stage IIIA) in neutral ulnar variance patients.
Methods
From 2009 to 2012, 12 patients (mean age: 25 ± 7.6 years) were enrolled in this series. Radiological and clinical evaluations using the modified Mayo wrist scoring system were performed both pre-operatively and 12 months post-operatively. In addition, values of the scapho-capitate angle were evaluated both pre-operatively and 12 months post-operatively. The mean follow-up was 20.7 ± 11.2 months. Statistical analysis was performed for comparisons between pre-operative and post-operative findings with the use of paired sample T test, Pearson’s correlation, independent sample T test, and Spearman’s rho correlation. Statistical significance was determined to be present at p <0.05.
Results
All patients achieved bony union at the fusion site within a mean period of 11.5 ± 2.4 weeks. Regarding wrist pain, grip strength, total wrist arc of motion, practicing daily activities in a normal pattern, and the total modified Mayo wrist score, there were statistically significant differences between the pre-operative and post-operative results. For the differential arc of motion, the only non-significant results were at the ulnar/radial deviation range (p = 0.262). The mean pre-operative scapho-capitate angle was 29.75 ± 3.44 while the mean post-operative value was 33.67 ± 4.77 (p < 0.001). Both pre-operative and post-operative scapho-capitate angle values were positively correlated to post-operative pain, ulnar/radial deviation, and final score (p = 0.001, 0.027, 0.021 and p = 0.001, 0.004, 0.002, respectively). Other parameters had no correlation to this angle.
Post-operative MRI (at 12 months follow-up) demonstrated better lunate revascularization in four patients; one of them was diagnosed as having Lichtman stage IIIA Kienböck’s disease. There were no patient-reported complications at the end of follow-up.
Conclusions
Distal capitate shortening combined with capitometacarpal fusion represents a new reliable method in the treatment of early stages of Kienböck’s disease with neutral ulnar variance.
doi:10.1186/s13018-014-0086-3
PMCID: PMC4195980  PMID: 25304759
Kienböck’s disease; Capitate shortening; Capitometacarpal fusion; Neutral ulnar variance; Scapho-capitate angle; Miniplate
2.  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
3.  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
4.  A new treatment strategy for Kienböck’s disease: combination of bone marrow transfusion, low-intensity pulsed ultrasound therapy, and external fixation 
Journal of Orthopaedic Science  2012;18(2):230-237.
Background
The purpose of this study was to investigate the midterm clinical and radiographic outcomes of this new treatment for Kienböck’s disease.
Methods
We applied a new method involving drilling, bone marrow transfusion, external fixation, and low-intensity pulsed ultrasound for patients with Kienböck’s disease. Between 2000 and 2006, the treatment was performed in 18 patients (10 men and 8 women; 9 right wrists and 9 left wrists). The preoperative Lichtman stages were stage II in 4 cases, stage IIIa in 11 cases, and stage IIIb in 3 cases. The mean age at surgery was 44.9 years (range 16–68 years), and the mean follow-up period was 63 months (range 28–125 months). The overall results were evaluated using the Mayo wrist score and Nakamura scoring system for Kienböck’s disease. Magnetic resonance imaging (MRI) was performed for all patients.
Results
Wrist pain improved to no pain in 13 patients, mild pain in 4 patients, and moderate pain in 1 patient. The average wrist flexion–extension arc was 100° and averaged 120 % of the preoperative value. The average grip strength increased from 50 to 85 % relative to the unaffected side. On roentgenograms, the carpal height ratio (change from 0.53 to 0.51) and the Stahl index (change from 0.38 to 0.32) decreased slightly. On MRI, fatty marrow was recovered in 11 patients (61 %) on proton density-weighted images.
Conclusions
This method can be used as a less-invasive surgical treatment alternative for Kienböck’s disease. At an average follow-up period of 6 years, this new treatment has been shown to be a reliable and durable procedure for patients with Lichtman stage II or stage III Kienböck’s disease. Caution should be exercised for patients with a fragmented lunate because of the risk of collapse and nonunion of the lunate.
doi:10.1007/s00776-012-0332-7
PMCID: PMC3607713  PMID: 23114859
5.  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
6.  Distal radius definitive epiphysiodesis for management of Kienböck´s disease in skeletally immature patients 
International Orthopaedics  2012;36(10):2101-2105.
Purpose
Kienböck’s disease is an unusual pathology with unknown aetiology within the pediatric population. Several treatment options have been described in the literature; however, there are neither large series nor homogeneous studies that have clarified which treatment is best. The aim of this study was to describe five cases in which definitive distal radius epiphysiodesis was performed as an alternative method to the classic distal radius shortening osteotomy in skeletally immature patients with Kienböck’s disease.
Methods
The clinical charts and radiographs of four patients (five wrists) diagnosed as having Kienböck’s disease and treated by definitive distal radius epiphysiodesis were reviewed.
Results
All patients were symptomatically free with full range of motion at 4.25 months (range, three to six months) after surgery. In all cases, shortening of the distal radius was achieved (p = 0.032).
Conclusions
This new technique is a simple, effective, and minimally invasive procedure with low morbidity and good clinical and radiological outcomes.
doi:10.1007/s00264-012-1597-3
PMCID: PMC3460097  PMID: 22829120
7.  Proximal Row Carpectomy for Coexisting Kienböck's Disease and Giant Intraosseous Ganglion of the Scaphoid: A Case Report and Review of the Literature 
Case Reports in Orthopedics  2014;2014:834063.
The etiologies of Keinböck's disease and intraosseous ganglion remain unknown. Both entities are rare and the coexistence of these two pathologies in the same patient and hand is even less frequent. We report the case of a 40-year-old man with a longstanding history of martial arts practice (karate) who developed an avascular necrosis of the lunate concomitant with a giant intraosseous ganglion of the scaphoid bone successfully managed by proximal row carpectomy. We review the literature of these two diseases.
doi:10.1155/2014/834063
PMCID: PMC4235236  PMID: 25530898
8.  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
9.  Ulnar variance and the role of joint levelling procedure for Kienböck's disease 
International Orthopaedics  2003;27(4):240-243.
Forty patients with Kienböck's disease were reviewed to determine the relationship between ulnar variance and the development of Kienböck's disease in a Japanese cohort. The joint levelling procedures designed to correct ulnar variance were evaluated in 11 patients after a mean of 9.7 years following surgery. The mean ulnar variance was 0.50±1.67 in patients with Kienböck's disease and 0.56±1.76 in a control group. The onset of wrist symptoms in a younger age group was noticed after sports injuries, whereas older patients had no distinct history of trauma. Joint levelling procedures produced good clinical results, but carpal height ratio, Stahl's index and radioscaphoid angle were not improved, as evidenced radiographically. Our study suggests that in a Japanese cohort ulnar minus variance is not an important factor in the aetiology of Kienböck's disease. Although joint levelling procedures improved the clinical results, they did not reverse lunate collapse or carpal alignment.
doi:10.1007/s00264-003-0466-5
PMCID: PMC3458477  PMID: 12827300
10.  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
11.  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
12.  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
13.  Changes in Patterns of Scaphoid and Lunate Motion During Functional Arcs of Wrist Motion Induced by Ligament Division 
The Journal of hand surgery  2005;30(6):1156-1160.
Purpose:
To determine the in vitro motion of the scaphoid and lunate during wrist circumduction and wrist dart-throw motions and to see how these motions change after the ligamentous stabilizers of the scaphoid and lunate are sectioned in a manner simulating scapholunate instability.
Methods:
Twenty-one fresh-frozen cadaver forearms were moved through a dart-throw motion and a circumduction motion using a wrist joint simulator. Scaphoid and lunate motion were measured with the wrist ligaments intact and after sectioning of the scapholunate interosseous ligament, the scaphotrapezium ligament, and the radioscaphocapitate ligament.
Results:
In the intact wrist the scaphoid and lunate moved more during circumduction than during the dart-throw motion. With ligamentous sectioning the scaphoid flexed more and the lunate extended more during both the circumduction and dart-throw motions. During the circumduction motion both before and after sectioning the global motion of the scaphoid was greater than that of the lunate. After sectioning the scaphoid motion increased and the lunate motion decreased.
Conclusions:
The scaphoid and lunate motions were observed to change remarkably after ligamentous sectioning. The observed changes in carpal motion correlate with the clinical observation that after ligamentous injury arthritic changes occur in the radioscaphoid joint and not in the radiolunate joint. Analysis of the injured wrist in positions that combine flexion-extension and radial-ulnar deviation may allow noninvasive diagnosis of specific wrist ligament injuries.
doi:10.1016/j.jhsa.2005.08.005
PMCID: PMC1986800  PMID: 16344171
Carpal motion; wrist circumduction motion; wrist dart-throw motion; kinematics; scapholunate interosseous ligament; scaphoid; lunate
14.  Open perilunate injury with lunate revascularization after complete ligamentous avulsion 
Journal of Surgical Case Reports  2014;2014(5):rju041.
Perilunate dislocations are a devastating injury to the carpus that carry a guarded long-term prognosis. Mayfield type 4 perilunate dislocations are rare, high-energy injuries that carry a risk for avascular necrosis (AVN) of the lunate. When AVN ensues and the carpus collapses, primary treatment with a proximal row carpectomy or arthrodesis has been advocated. This case reports a successful clinical result and revascularization of an extruded lunate with open reduction and internal fixation. This type 4, Gustilo grade 1 open perilunate dislocation exhibited complete avulsion of all lunate ligamentous attachments. Management included open reduction and internal fixation as well as carpal tunnel release through a combined dorsal and volar approach. Despite concerns for lunate AVN due to complete disruption of lunate vascularity, a 10-month postoperative clinical and radiographic examination demonstrated no pain with activities of daily living as well as a revascularized lunate.
doi:10.1093/jscr/rju041
PMCID: PMC4017232  PMID: 24876511
15.  Arthroscopic Dorsal Capsulo-Ligamentous Repair in the Treatment of Chronic Scapho-Lunate Ligament Tears 
Journal of Wrist Surgery  2013;2(2):141-148.
Introduction Scapholunate ligament injuries usually result due to a fall on the outstretched hand leading to scapholunate instability. The natural history of untreated scapholunate instability remains controversial and usually results in late arthritic changes- the so-called “SLAC” wrist. The advent of wrist arthroscopy helps in early diagnosis and treatment of these serious injuries. In selected cases with reducible scapholunate instability (Garcia-Elias stages 2, 3 and 4) we propose a new “all arthroscopic dorsal capsulo- ligamentous repair” with the added advantage of early rehabilitation and prevention of post-operative stiffness.
Material and Methods We report the results of our series of 57 consecutive patients suffering from chronic wrist pain refractory to conservative measures. All patients underwent a thorough clinical examination in addition to a standard set of radiographs and MRI exam; and they were treated by an all-arthroscopic dorsal capsulo-ligamentous repair under loco-regional anesthesia on an ambulatory basis. All patients were available for follow-up at regular intervals during the post-operative period. At follow-up, the wrist ROM in all directions, the grip strength, DASH questionnaire and pain relief based on the VAS were recorded for both- the operated and contra-lateral sides.
Results There were 34 males & 23 females with a mean age of 38.72 ± 11.33 years (range 17–63 years). The dominant side was involved in 52 cases. The mean time since injury was 9.42 ± 6.33 months (range 3–24 months) and the mean follow-up was 30.74 ± 7.05 months (range 18–43 months). The mean range of motion improved in all directions. The mean difference between the post- and pre-operative extension was 14.03° (SEM = 1.27°; p < 0.001); while the mean difference between the post-and pre-operative flexion was 11.14° (SEM = 1.3°; p < 0.0001) with flexion and radial deviation reaching 84.3% and 95.72% respectively of the unaffected wrist. The mean difference for the VAS score was -5.46 (SEM = 0.19; p < 0.0001). The mean post-operative grip strength of the affected side was 38.42 ± 10.27 kg (range 20–60 kg) as compared with mean pre-operative grip strength of 24.07 ± 10.51 kg (range 8–40 kg) (p < 0.0001). The mean post-operative grip strength of the operated side was 93.4% of the unaffected side. The DISI was corrected in all cases on post-operative radiographs. The mean difference between the post-and pre-operative SL angles was −8.95° (SEM = 1.28°; p < 0.0001). The mean post-operative DASH score was 8.3 ± 7.82 as compared with mean pre-operative DASH score of 46.04 ± 16.57 (p < 0.0001). There was a negative co-relation between the overall DASH score and the post-operative correction of the DISI deformity with a lower DASH score associated with increasing SL angles.
Discussion The dorsal portion of the scapholunate ligament is critical for the stability scapholunate articulation, largely due to its attachment to the dorsal capsule. We have recently conducted a multi-centric anatomical study with international collaboration demonstrating the critical importance of this dorsal scapholunate complex. The all arthroscopic capsulo-ligamentous repair technique provides reliable results in addition to avoiding postoperative stiffness. The overall results at a mean follow-up period of more than 2 years in our series of young, active patients appear to be encouraging.
doi:10.1055/s-0033-1341582
PMCID: PMC3699260  PMID: 24436807
scapholunate ligament; chronic scapholunate injury; dorsal capsuloplasty; wrist arthroscopy
16.  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
17.  Biomechanical Evaluation of the Ligamentous Stabilizers of the Scaphoid and Lunate: Part III 
The Journal of hand surgery  2007;32(3):297-309.
Purpose:
This study continued our previous investigations of the ligaments stabilizing the scaphoid and lunate in which we examined the scapholunate interosseous ligament, the radioscaphocapitate, and the scaphotrapezial ligament. In this current study, we examined the effects of sectioning the dorsal radiocarpal ligament, dorsal intercarpal ligament, scapholunate interosseous ligament, radioscaphocapitate, and scaphotrapezial ligaments. In the current study, the scapholunate interosseous ligament, radioscaphocapitate, and scaphotrapezial ligaments were sectioned in a different order than performed previously.
Methods:
Three sets of 8 cadaver wrists were tested in a wrist joint motion simulator. In each set of wrists, only 3 of the 5 ligaments were cut in specific sequences. Each wrist was moved in continuous cycles of flexion-extension and radial-ulnar deviation. Kinematic data for the scaphoid and lunate were recorded for each wrist in the intact state, after the 3 ligaments were sectioned in various sequences and after the wrist was moved through 1,000 cycles of motion.
Results:
Dividing the dorsal intercarpal or scaphotrapezial ligaments did not alter the motion of the scaphoid or lunate. Dividing the dorsal radiocarpal ligament alone caused a slight statistical increase in lunate radial deviation. Dividing the scapholunate interosseous ligament after first dividing the dorsal intercarpal, dorsal radiocarpal, or scaphotrapezial ligaments caused large increases in scaphoid flexion and lunate extension.
Conclusions:
Based on these findings, we concluded that the scapholunate interosseous ligament is the primary stabilizer and that the other ligaments are secondary stabilizers of the scapholunate articulation. Dividing the dorsal radiocarpal, dorsal intercarpal, or scaphotrapezial ligaments after cutting the scapholunate interosseous ligament produces further changes in scapholunate instability or results in changes in the kinematics for a larger portion of the wrist motion cycle.
doi:10.1016/j.jhsa.2006.10.024
PMCID: PMC2062528  PMID: 17336835
Scapholunate instability; wrist; biomechanics
18.  Long-Term Outcomes of Proximal Row Carpectomy: A Systematic Review of the Literature 
Journal of Wrist Surgery  2012;1(2):141-148.
Purpose Proximal row carpectomy is a well-established technique for the management of wrist arthritis; however, patient selection and long-term durability of proximal row carpectomy is still a matter of controversy. Hence, we conducted a systematic review of the English literature to determine the best evidence on long-term outcomes following proximal row carpectomy.
Methods A MEDLINE search using the term “proximal row carpectomy” was performed. A total of 192 studies were identified. All studies with 10 or more years of follow-up were included in the review. Data extracted included patient demographics, indications for surgery, previous surgery, outcome assessment, and information on complications and failures.
Results A total of 147 patients from six studies met the inclusion criteria and were included in the study. The majority of patients were male and involved in manual labor. There was no significant difference between the preoperative and long-term postoperative motion. The weighted mean for postoperative grip strength was 68.4% compared with the contralateral side. Disabilities of the arm, shoulder, and hand; patient-rated wrist examination; and Mayo wrist scores were comparable to those reported for four-corner arthrodesis. There were 21 failures (14.3%) requiring re-operation. Failures were not associated with a specific preoperative diagnosis but distributed among patients with Kienböck disease, scaphoid nonunion advanced collapse, and scapholunate advanced collapse arthritis.
Conclusions This systematic review confirms the long-term durability of proximal row carpectomy when used for the treatment of wrist arthritis. Although radiocapitate arthritis develops over time in most patients, the clinical significance of this finding is undetermined and does not necessarily correlate with failure of proximal row carpectomy. Poorer long-term outcomes are likely to result in patients engaged in heavy manual labor, whereas better outcomes may be obtained in patients undergoing proximal row carpectomy for trauma or earlier-stage Kienböck disease.
doi:10.1055/s-0032-1329547
PMCID: PMC3658690  PMID: 24179718
proximal row carpectomy; outcomes; wrist; arthritis
19.  Long-term outcomes for Kienböck's disease 
Hand (New York, N.Y.)  2012;8(1):23-26.
Background
The precise etiology of Kienböck's disease is unclear. Controversy exists regarding the appropriate treatment modality. The present study sought to investigate and compare surgical and nonsurgical treatment outcomes of patients suffering from Kienböck's disease in the province of Newfoundland and Labrador (NL), Canada.
Methods
The present study was a retrospective analysis of 66 patients. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Student's t test was used to assess differences in outcomes between treatment groups. One-way ANOVA was used to assess differences in primary outcome in time since first assessed in an effort to examine progression over time. Pearson correlation was used to assess for correlation between primary outcome and age at diagnosis.
Results
The average age was 38.6 ± 11.4 (18–70) years; Four patients were excluded due to inaccessible imaging. Of the remaining patients, 44 were treated conservatively, while 18 were treated surgically. The DASH scores for the surgical group were 23.7 ± 24.5 (0.9–82.8) and nonsurgical group were 20.0 ± 20.1 (1.7–81). As expected, the surgical group was mainly comprised of late-stage Kienböck's. When both groups were compared, there was no significant difference in the DASH scores. There were no difference in DASH scores within groups according to time since first diagnosed (<5 years; between 5 and 10 years; and >10 years). A positive correlation was found between age at diagnosis and DASH score (r = 0.42, p = 0.007), despite treatment modality. This finding remained significant after accounting for confounding factors (p = 0.029).
Conclusion
The DASH score for the surgical group was 23.7 ± 24.5 (0.9–82.8) and nonsurgical group was 20.0 ± 20.1 (1.7–81). No significant difference in DASH scores was found between surgically and nonsurgically treated patients. A positive association was found between the age at diagnosis of Kienböck's and DASH score, which suggests that patients diagnosed and treated later in life tend not to do as well.
doi:10.1007/s11552-012-9470-9
PMCID: PMC3574490  PMID: 24426889
Kienböck's disease; Surgical treatment; Nonsurgical treatment; DASH; Long-term outcomes
20.  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
21.  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
22.  Wrist Joint Reconstruction With a Vascularized Fibula Free Flap Following Giant Cell Tumor Excision in the Distal Radius 
Eplasty  2010;10:e38.
Objective: Multiple therapeutic modalities exist for giant cell tumors (GCT) in the distal radius. The majority of GCTs are amenable to curettage, with the expanded lesions requiring a more radical approach. This case report examines the technique of managing a GCT that has extended beyond the boundaries of the cortex and into local tissues. The decision to use arthroplasty versus arthrodesis and the proximal fibular head as a vascularized free flap is discussed in reference to a patient requiring a proximal row carpectomy (PRC) secondary to tumor invasion. Methods: A 47-year-old woman with GCT in the right distal radius presented with decreased range of motion secondary to pain. Confirmation of the GCT was made with radiographic imaging and biopsy. The extensive invasion of the lesion required en bloc tumor resection with PRC and subsequent arthroplasty. Results: Treatment involved resection of tumor and PRC with arthroplasty using the proximal head of the fibula and reattachment of the radioscaphocapitate and ulnar carpal ligaments. Success was measured on functionality of the joint, viability of the flap, and the absence of tumor recurrence and pain. Conclusion: This case presents an example of successful excision of a GCT in the distal radius with a PRC and arthroplasty using a vascularized fibula free flap autograft. The patient remained pain-free, had no evidence of tumor recurrence, demonstrated 50% range of motion in the wrist, and 80% preoperative strength as expected following PRC.
PMCID: PMC2875920  PMID: 20505792
23.  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
24.  The carpal stretch test 
Canadian Journal of Surgery  1998;41(2):119-125.
Objective
To compare the sensitivity of traditional motion studies, bone scintigraphy and radiocarpal arthrography to a “carpal stretch test,” for evaluation of dynamic dissociative carpal instability.
Design
Experimental study comparing the results of the tests to the findings of arthroscopy, the “gold standard.”
Setting
A university hospital-based upper extremity practice.
Patients
Six patients with chronic wrist pain, arthroscopically confirmed proximal row ligamentous disruption and radiographs not suggestive of proximal row instability.
Interventions
The carpal stretch test: both affected and unaffected wrists were subjected to the same testing, wherein the wrist was suspended from finger traps for 10 minutes by a 4.5-kg weight. Standardized posteroanterior radiographs were taken of the suspended wrists.
Main outcome measures
Disruption of Gilula’s arcs I and II, and sensitivity of the carpal stretch test compared with other investigations.
Main results
Step deformities ranging from 2.5 to 6 mm (average 3.7 mm) were recorded in the affected wrists and 0 to 4 mm (average 1.5 mm) in the “unaffected” wrists. The test was more sensitive than traditional radiography, arthrography and scintigraphy in defining both presence and site of proximal carpal row ligamentous tears and was almost as sensitive as arthroscopy.
Conclusion
In patients with chronic wrist pain and dynamic dissociative wrist instability, the carpal stretch test may prove to be a valuable screening tool for detecting ligamentous tears of the proximal carpal row.
PMCID: PMC3949824  PMID: 9575994
25.  Isolated volar surgical approach for the treatment of perilunate and lunate dislocations 
Indian Journal of Orthopaedics  2014;48(3):301-305.
Background:
Volar and/or dorsal surgical approaches are used for surgical treatment of perilunate and lunate dislocations. There are no accepted approaches for treatment in the literature. We evaluated the functional results of isolated volar surgical approach for the treatment of perilunate and lunate dislocation injuries.
Materials and Methods:
9 patients (6 male and 3 female patients average age 34.5 ± 3.6 years) diagnosed with perilunate or lunate dislocations between January 2000 and January 2009 were involved in the study. The reduction was performed through isolated volar surgical approach and K-wire fixation, fracture stabilization with volar ligament repair was performed. Range of wrist joint motion, fracture healing, carpal stability, grip strength, return to work were evaluated and also direct radiographs were taken routinely at each control. The scapholunate interval and the scapholunate angle were evaluated radiographically. Evaluations of the clinical results were done using the DASH, VAS and Modified Mayo Wrist Scores.
Results:
The physical rehabilitation was started at 6th week, after the K-wires were removed. The average followup was 18.2 months (range 12-28 months). At the final followup, the average flexion extension arc was 105.0 ± 9.6° (74.6% of the other side), the average rotation arc was 138.8 ± 7.8° (81.5% of the other side) and the average radioulnar arc was 56.1 ± 9.9° (86.4% of the other side). The grip strength was 0.55 bar; 83.2% that the uninjured arm. According to the Mayo Modified Wrist score, the functional result was excellent in five patients and good in four and the average DASH score was 22.8. The scapholunate interval was 2.1 mm and scapholunate angle was 51°.
Conclusion:
The clinical and radiological results of the isolated volar surgical approach were satisfactory. The dorsal approach was not needed for reduction of dislocations during operations. Our results showed that an isolated volar approach was adequate.
doi:10.4103/0019-5413.132523
PMCID: PMC4052031  PMID: 24932038
Carpal instability; lunate dislocation; perilunate dislocation; volar surgical approach

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