Journal of Hand Surgery (European Volume)

There are many good reasons to improve the anatomy of a distal radius fracture, such as early return to function and avoidance of sigmoid notch incongruity or ulnocarpal impaction. It is often feared by patients, and portrayed by some authors of scientific articles and medicolegal reports, that a fracture of the distal radius has a propensity to cause symptomatic osteoarthritis. This article examines some of the current evidence and shares the authors’ experience. Critical questions are asked to direct our observations and guide future research questions. We propose that both clinical experience and a literature analysis do not support the commonly held assumption that untreated distal radial fractures lead to symptomatic osteoarthritis.

Level of evidence: V

Articular malalignment and ulnocarpal impaction can progress to osteoarthritis in the wrist. This may be triggered by tears of the scapholunate ligament (rarely the lunotriquetral ligament) or the foveal lamina of the triangular fibrocartilage complex. In the pre-degenerative stages, radiographic findings are inconclusive, and symptoms may be absent or discrete. Similarly, positive ulnar variance may be associated with symptoms that are at first mild and without radiographic abnormalities. This review presents imaging findings in the early stages before carpal osteoarthritis or impaction syndrome develops. Ligament tears, chondromalacia and focal bone marrow oedema are identified using magnetic resonance imaging as well as magnetic resonance and computed tomography arthrography. Identifying these precursors may allow raise awareness of subtle imaging findings in the wrist that may progress to instability, degeneration or osteoarthritis and allow appropriate patient counselling.

This study describes the patterns and prevalence of advanced osteoarthritis of the wrist. Bilateral wrist radiographs of 1327 patients over the age of 40 years were reviewed. Osteoarthritis was present in 228 (17%) patients (368 wrists). One wrist was affected in 88 (39%) patients and both wrists in 140 (61%). A total of 27 different patterns of wrist osteoarthritis were found. The most common pattern was isolated osteoarthritis of the scaphotrapeziotrapezoidal joint (217 wrists, 59%), followed by isolated osteoarthritis of the radioscaphoid joint (45 wrists, 12%). In 251 (68%) wrists, advanced osteoarthritis was present only in the midcarpal joint, including the scaphotrapeziotrapezoidal joint. In 115 (31%) wrists, advanced arthritis was present in the radiocarpal joint or in both the mid- and radiocarpal joints. This suggests that advanced osteoarthritis of the midcarpal joint without radiocarpal involvement may be more common than previously thought.

Level of evidence: IV

The latest generation of wrist arthroplasties provides good clinical function and pain relief with an acceptable revision/reoperation rate. The procedure is complex and technically demanding, both for the surgeon and the patient. The available implants (with the exception of one) have not been developed or refined in the last decade, which reduces the versatility and ability to adapt to specific patient anatomy, to manage implant/treatment problems and to perform successful revisions. Medical device regulation in Europe has led to a halt in development and a reduction in available implants for niche products such as wrist arthroplasty. To improve long-term outcomes after implantation, surgeons should refine and review their skills, implement improvements, avoid complications reported by experienced colleagues, and expect a learning curve and follow-up surgery. The author reviews the pitfalls and requirements of modern wrist arthroplasty.

Wrist arthrodesis performed to salvage a failed total wrist arthroplasty can be challenging owing to bone loss and poor soft tissue quality. This article focuses on the evidence base and our experience as a tertiary unit in managing this cohort of patients. A systematic and meticulous approach is required to attempt to minimize complications.

Level of evidence: V

Total wrist arthrodesis can be used to treat symptomatic end-stage wrist osteoarthritis after failed conservative treatment. It can also be considered the last-resort option when partial fusion, proximal row carpectomy, denervation or prosthetic arthroplasty is unsuccessful. Currently anatomic pre-contoured low-profile plates with angle stable screws are available with or without inclusion of the carpometacarpal joints. Generally, patients are satisfied after total wrist arthrodesis, although they are not always pain-free, even when wrist flexion and extension remain limited or absent. Complications and reoperations occur frequently, most often due to incomplete bone fusion or hardware-related problems. It is still not known which type of implant is best for degenerative osteoarthritis and if the carpometacarpal joint should be included in the arthrodesis. Future prospective randomized trials may shed more insights on these questions.

Osteoarthritis of the scaphotrapeziotrapezoidal joint is frequent but often pain-free or well tolerated with non-surgical treatment. Surgical options are numerous and none seems to have clear evidence of superiority. In addition to well-established procedures, such as scaphotrapeziotrapezoidal joint arthrodesis, distal scaphoid resection and trapeziectomy, more recent surgical techniques have been reported. These include scaphotrapeziotrapezoidal arthroplasty and arthroscopic treatment. This article provides an overview of the procedures and their outcomes that can be proposed for isolated scaphotrapeziotrapezoidal joint osteoarthritis and when combined with symptomatic osteoarthritis of the thumb carpometacarpal joint or of the radiocarpal and midcarpal joints.

Degenerative wrist conditions, such as scapholunate advanced collapse and scaphoid nonunion advanced collapse, often require salvage procedures to reduce pain and improve function. For early stages of disease, both proximal row carpectomy and scaphoid excision four-corner arthrodesis are viable motion-preserving options. There remains controversy on which technique is superior. Selection is a nuanced decision that requires consideration of patient characteristics and stage of disease. The traditional notion that proximal row carpectomy should be reserved for older individuals with low demands has been challenged; long-term studies in younger populations demonstrate similar patient-reported outcomes, pain relief and survivorship without conversion to total wrist arthrodesis between proximal row carpectomy and four-corner arthrodesis. The existing evidence suggests proximal row carpectomy has advantages of greater range of motion, fewer complications and lower costs. Advancements such as arthroscopic techniques for both procedures show potential, although mastery involves a steep learning curve.

The aim of the study was to investigate the repair strength and the biocompatibility of Alaska pollock-derived gelatin (ApGltn) sheet for nerve repair. Cadaveric digital nerves were repaired with double suture, single suture + ApGltn sheet, single suture + fibrin glue, single suture, ApGltn sheet and fibrin. Maximum failure loads were measured (20 nerves each). Rat sciatic nerves were repaired with double suture, single suture + ApGltn sheet, single suture, ApGltn sheet, fibrin glue and resection (10 nerves each). Macroscopic appearance, muscle weight and histopathological findings were examined 8 weeks postoperatively. The mean failure load of ApGltn sheet (0.39 N) was significantly higher than that of a fibrin (0.05 N), and that of single suture + ApGltn sheet (1.32 N) was significantly higher than that of a single suture alone (0.97 N). Functional and histological assessments showed similar nerve recovery among the suture, ApGltn and fibrin groups. ApGltn sheet has potential for clinical application as an alternative to fibrin.

Neurotomy interrupts the stretch reflex and can be used for the treatment of spasticity. We hypothesized that neurotomy with nerve repair reduces spasticity while preserving motor function due to the preferential recovery of efferent over afferent fibres. This study reports the 1-year outcomes of neurotomy and immediate repair of the musculocutaneous nerve in the proximal arm for treatment of elbow flexor spasticity, comparing these to outcomes in the literature for neurectomy without nerve repair. A total of 10 adult patients with spasticity of the elbow flexors from stroke or traumatic brain injury who had undergone neurotomy and immediate repair of the musculocutaneous nerve were prospectively studied. The results suggest that this procedure effectively reduces elbow flexor spasticity, improves elbow resting position, active elbow extension and is useful for achieving patient goals with effects lasting at least 12 months.

Level of evidence: IV (therapeutic)

We identified individuals born in Norway between 1970 and 2019 with transverse reduction deficiency at or above the wrist (TRDAW) from the Medical Birth Registry of Norway and from the CULA (congenital upper limb anomaly) North Oslo Registry. Infant outcomes and parental factors were compared for 202 individuals with TRDAW to 2,741,013 living individuals without TRDAW born during the same period. We found an overall TRDAW prevalence of 0.74/10,000. Infants with TRDAW had a higher risk for being small for gestational age, an Apgar score <7 and transfer to neonatal intensive care units after delivery. Nine of the infants with TRDAW had associated anomalies, most commonly in the lower limb, and at a higher proportion than the reference population. Other than twin pregnancies, we are unable to identify with certainty any other risk factors for TRDAW.

Level of evidence: I

The distribution of motion between the radiocarpal and midcarpal joints in scapholunate instability is poorly understood. This has potential implications in predicting degenerative changes and in selecting salvage procedures. We studied 19 healthy wrists and 19 wrists with scapholunate instability using dynamic computed tomography during wrist extension to flexion and ulnar to radial deviation. Radiocarpal and midcarpal kinematics of the scaphoid and the lunate were computed. In scapholunate instability, in the radial column, there was increased motion in the radiocarpal joint when the wrist was radially deviating beyond 10° or moving from 70° to 40° extension. In both groups, the capitolunate joint was the dominant articulation in the central column. In scapholunate instability, there was significantly more capitolunate motion during 70° to 30° extension. These changes may predict the development of radioscaphoid arthritis and enable identifying a kinematically abnormal wrist. The motion distribution in scapholunate instability was abnormal beyond 10° of radial deviation and between 70° and 40° of wrist extension.

Level of evidence: III

Total wrist arthroplasty (TWA) aims to restore pain-free motion to diseased joints. One such TWA, the Motec, has demonstrated good results with acceptable complication rates. It has recently been suggested that the metal-on-carbon fibre reinforced poly ether ether ketone (Mo-CFR-PEEK) version of the Motec TWA be implanted instead of the metal-on-metal version. An explant analysis was undertaken on seven Motec Mo-CFR-PEEK TWAs, revised for a variety of reasons, after a mean time of 2 years in vivo. Compared to a new Motec implant, five of the explanted metal heads and three of the CFR-PEEK cups became smoother in vivo, suggesting self-polishing and negative skewness, indicating some material loss in vivo. Two explanted cups showed indentation marks on their rims and one of these was from component impingement with embedded metallic debris. In the short-term, the articulating surfaces of Motec Mo-CFR-PEEK TWAs did not show major damage.

Level of evidence: IV

A cadaveric study showed that vascularized transfer of the articular surface of the ipsilateral first metatarsal head with the lateral collateral ligament could be suitable for reconstruction of the proximal pole of scaphoid and scapholunate ligament. Further study of the technique is recommended.

To address an inconsistency in the nomenclature of the anatomy and compressive syndromes of the deep branch of the radial nerve, we advocate for a single compression syndrome that presents along a spectrum from pain to posterior interosseous nerve palsy.

We report the case of a 15-year-old boy with a de novo chromosomal deletion in the 12q13.13 region, presenting with congenital hand difference. This case emphasizes the clinical significance of recognizing such genetic anomalies and their implications.

In total, 38 patients with cystic dorsal wrist tumours managed with surgical excision were prospectively followed up for 2 years. Tissue was examined histologically after primary surgery and at recurrence. Two distinct tissue types were found: ganglion cyst and synovial cyst.

This study compared the clinical outcomes of tibial-sided digital artery pedicled flap from the second toe versus full-thickness skin grafting to repair great toe defects after wrap-around flap transfers. The pedicled flap resulted in better pain scores and aesthetic outcomes.

Osteoarthritis of the wrist presents complex surgical challenges. A wide variety of surgical options are available when conservative management fails to provide adequate pain relief. Despite advancements in management, such as modifications of partial wrist arthrodesis techniques and increasing use of total wrist replacements, in most scenarios there is no single preferred option. The surgeon’s role is crucial in assessing the patient and creating a bespoke treatment strategy that will provide an optimal outcome. This article presents an approach to management of the degenerate wrist based on current evidence.

Distal radioulnar joint instability is commonly seen after surgical fixation of a distal radial fracture, and surgeons’ ability to reliably determine stability on examination is poor. Debate remains regarding whether to fix the ulnar styloid or reinsert the triangular fibrocartilaginous complex. Four surgeons with Level 5 expertise were asked to respond to questions surrounding this debate.