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Background Previous study demonstrated that distal radioulnar joint (DRUJ) plays a biomechanical role in extension and flexion of the wrist and suggested that fixation of the DRUJ could lead to loss of motion of the wrist. Little is known about the pre- and postoperative range of motion (ROM) after the Sauvé–Kapandji (S-K) and Darrach procedures without tendon rupture. To understand the accurate ROM of the wrist after the S-K and Darrach procedures, enrollment of patients without subcutaneous extensor tendon rupture is needed. Purpose This study aimed to investigate the pre- and postoperative ROM after the S-K and Darrach procedures without subcutaneous extensor tendon rupture in patients with rheumatoid arthritis (RA) and osteoarthritis (OA). Methods This retrospective study included 36 patients who underwent the S-K procedure and 10 patients who underwent the Darrach procedure for distal radioulnar joint disorders without extensor tendon rupture. Pre- and postoperative ROMs after the S-K and Darrach procedures were assessed 1 year after the surgery. Results In the S-K procedure, the mean postoperative ROM of the wrist flexion (40 degrees) was significantly lower than the mean preoperative ROM (49 degrees). In wrist extension, there were no significant differences between the mean preoperative ROM (51 degrees) and postoperative ROM (51 degrees). In the Darrach procedure, the mean postoperative ROM of the wrist flexion and extension increased compared with the mean preoperative ROM; however, there were no significant differences. Conclusion In the S-K procedure, preoperative ROM of the wrist flexion decreased postoperatively. This study provides information about the accurate ROM after the S-K and Darrach procedures. Level of Evidence This is a Level IV, therapeutic study.

Background The triangular fibrocartilage complex (TFCC) lesions are frequently implicated as a cause of ulnar wrist pain following impact and loading injuries. The objective of this study was to describe the clinical outcomes following TFCC lesion repair with the arthroscopic outside-in technique. Description of Technique We inserted a 21-gauge needle with 4–0 nylon loop perpendicular to the injured triangular fibrocartilage (TFC). We held two 4–0 nylon loops with mosquito forceps, drew them once out of the joint through a 4 to 5 portal, and put both sides through each loop. After that, we pulled out the 21-gauge needles and performed outside-in sutures after making a small incision and tying directly over the capsule. Patients and Methods Twenty-one wrists who underwent arthroscopic capsular repair were included. Arthroscopic findings were evaluated, and we used a distal radioulnar joint (DRUJ) evaluation system to monitor relief of pain, forearm rotation range of motion, and DRUJ stability postoperatively. Results Simple ulnar avulsion (Palmer 1B, Atzei Class 1) was recognized in ten wrists. A combination of the 1B tear with a horizontal TFC tear was noted in five wrists; and ulnar avulsion extending to the dorsal half of the TFC was identified in six wrists, including complete dorsal avulsion of the TFC from the capsule. There are significantly better results in the cases whose preoperative periods were 15 months or less. Conclusion The outside-in TFC repair technique produced excellent clinical results for peripheral detachment of the TFC in cases without severe DRUJ instability and with a preoperative period less than 15 months.

Background Isolated ulnar head fracture is a rare entity, and the restriction of range of motion in the wrist is rarely reported. Case Description We report two cases of conservatively treated ulnar head malunion with restricted supination and pronation. The increased tension of the volar portion of the triangular fibrocartilage complex was observed, and the surgical treatment significantly improved the range of motion. Literature Review There are a few reports on isolated ulnar head fracture. Other causes of restricted supination and pronation of the wrist are mostly due to the interposition of soft tissues or loose bodies. Clinical Relevance Malunion after ulnar head fracture can cause restriction of wrist supination and pronation. Surgical intervention may be considered if restricted range of motion remains after conservative treatment.

Background There has been clinical question in the treatment of ulnar styloid fracture with distal radius fracture, surgical fixation of the styloid fragment, or ignorance of the fragment. We examined relationship between size of the ulnar styloid fracture and distal radioulnar joint (DRUJ) stability biomechanically to answer the above clinical question. Methods Changes in the dorsopalmar stiffness of the DRUJ after experimentally simulating in four types of ulnar styloid fractures were examined in cadavers. After tip, middle, base-horizontal, and base-oblique type of styloid fractures were made sequentially, changes in dorsopalmar DRUJ stiffness were measured using the MTS machine in the intact wrist, for each fracture, at 60 degrees pronation, neutral, and 60 degrees supination, respectively. Additional cutting of the radioulnar ligament (RUL) at the fovea was also simulated with the base-horizontal fracture. Results The tip and middle type fractures did not demonstrate significant loss of stiffness compared with the intact. The base-horizontal fracture demonstrated only significant loss of stiffness in the dorsal direction (radius palmar; ulnar dorsal) with forearm in neutral rotation. The base-oblique fracture demonstrated significant loss of dorsopalmar stiffness of the DRUJ. Additional section of the RUL with the base-horizontal fracture induced significant loss of stiffness of the DRUJ compared with the intact. Conclusions Because the RUL originates from the fovea as well as from the base of the ulnar styloid, these results suggest that DRUJ instability closely correlates with how much of the bony fragment includes the originating portions of the RUL. The findings further suggest that larger base-oblique and base-horizontal fragments with resultant DRUJ instability must be reattached, but that even base-horizontal fragment as well as tip and middle ulnar styloid fragment can be ignored when there is no instability.

Background Peripheral triangular fibrocartilage complex (TFCC) tears may induce instability of the distal radioulnar joint (DRUJ). In this biomechanical study, simulated peripheral tears of the TFCC were examined on the stability of the DRUJ. Restabilization effect of the DRUJ by ulnar shortening and direct repair of those injuries were sequentially examined. Method The DRUJ stiffness was measured in intact, simulated two types of peripheral tears (ulnar and extended ulnodorsal) at three forearm positions: neutral, 60° pronation and 60° supination in 8 fresh frozen cadaver specimens. After the tears were sutured with stitches or after simulated ulnar shortening of 3 mm, the DRUJ stiffness was again measured. Results The ulnar and ulnodorsal TFCC tears decreased the DRUJ stiffness significantly compared with the intact in all forearm positions. When ulnar shortening was done for the ulnar tear, the DRUJ stiffness increased significantly in the neutral and 60° pronated positions. When the ulnar TFCC tear was repaired, the DRUJ stiffness increased significantly in all forearm positions. DRUJ stiffness did not increase either with ulnar shortening or repair in ulnodorsal tear of the TFCC, however. Conclusion The simulated TFCC tears indicated significant loss of DRUJ stiffness. Direct repair or ulnar shortening was effective only on treatment of the ulnar tear of the TFCC in this study.

Background The number of available wrist scoring systems is limited; some of them do not include forearm rotation criteria. Purpose To describe a new electronic wrist clinical score and to present a new patient's generated wrist evaluation criterion, the subjective wrist value (SWV). Materials and Methods A new electronic wrist clinical score, the Lyon wrist score (LWS) including wrist VAS pain and function, active range of motion and strength was built into an excel file. VAS flexion-extension pain and function were evaluated independently from pronation-supination pain and function. A new patient's generated wrist evaluation criterion, SWV was described. Results The LWS is available in two versions, standard and full (the latter including forearm rotation strength). Both standard and full LWS are displayed into an automatically generated diamond-shaped graph providing a comprehensive visual display of the clinical status of most osteoarticular wrist disorders. The graph also includes SWV. The LWS, combined with SWV into a graph that may be directly exported to a PowerPoint presentation, provide a new practical and comprehensive tool for following/comparing wrist osteoarticular clinical status/outcomes. Both standard and full LWS charts are available in colored versions on a related website for free download. Conclusion A comprehensive updated electronic display of osteoarticular wrist clinical status including forearm rotation criteria is provided and displayed into a graph which may be exported as such into a PowerPoint presentation for clinical analysis/comparisons. Level of Evidence Level II.

We treated an extremely rare case of osteoid osteoma of the pisiform. Pisiform hypertrophy caused persistent pain and ulnar nerve irritation at Guyon's canal after the initial trauma. The re-enlargement of the pisiform attracted our attention allowing us to ultimately diagnose the condition as osteoid osteoma and treat the patient with a successful clinical result.

Purpose Changes in the shape of the triangular fibrocartilage complex (TFCC) during radial–ulnar deviation were studied using “cine-mode” magnetic resonance imaging (MRI) in 10 right wrists of healthy volunteers, 5 wrists of TFCC tear, and 5 wrists of ulnar styloid nonunion. Subjects and Methods The wrist was fixed in a custom acrylic device, which only allows radial and ulnar deviation. Coronal MR images of nine radial–ulnar deviated positions (every 5 degree from 15 degrees radial deviation to 25 degrees ulnar deviation) were obtained in volunteers and patients. Cine-mode MRI was assembled and was output to MPEG video to observe. Results Cine MRI demonstrated the ulnar side of the TFCC was elongated by average 15 mm in 15 degrees of radial deviation and shortened by average 8 mm in 25 degrees of ulnar deviation in all normal TFCC subjects. Distal portion of the triangular fibrocartilage (TFC) was compressed during radial–ulnar deviation in 10 healthy volunteers and in 3 patients, but proximal portion of the TFC was stable throughout the motion. In contrast, the wavy deformities on the disc in ulnar deviation were observed in three patients with horizontal tear inside the TFCC. In nonunion of the ulnar styloid process, the fragment was snapped in maximum ulnar deviated position or elongation of the space between the styloid fragment and ulna was seen. Conclusion This study indicated normal and abnormal changes in the shape of the TFCC during radial–ulnar deviation motion on cine MRI. The abnormal dynamic changes of the TFCC may be seen in ulnar deviated position in patients, which are related to positive ulnocarpal stress test with the wrist forced ulnar deviated.

Background Since 1998, we treated 25 wrists with foveal detachment of the triangular fibrocartilage complex (TFCC) by our original reattachment technique using a half-slip of the extensor carpi ulnaris (ECU) tendon with a very small titanium interference screw. We examine the clinical outcome of this procedure with a minimum of 2 years follow-up. Patients and Methods There were 25 wrists of 24 patients (16 right, 7 left, 1 bilateral, mean age, 34.8 years) with a minimum follow-up of 2 years (range 2–7 years, average 3.1). There was a neutral ulnar variance in 19 wrists and positive in 6. In the positive-variance wrists, an ulnar shortening was performed to prevent ulnar abutment before the reattachment. The diagnosis of a TFCC injury was done by arthrogram, magnetic resonance imaging (MRI), and distal radioulnar (DRUJ) arthroscopy. The clinical outcome was evaluated using our original DRUJ evaluating system. Technique A distally based ECU half-slip was harvested, introduced into the TFCC, sutured to the remnant of the TFCC, and pulled out through a 2.5-mm bone tunnel at the center of the fovea. The ECU half-slip was subsequently anchored to the ulnar fovea with a small titanium interference screw. Results At the final follow-up, 21 wrists had no pain, 3 wrists indicated mild pain, and 1 wrist severe pain. One patient had a loss of supination by 30 degrees. The DRUJ was stable in 22 wrists, moderately unstable in 2 wrists, and severely unstable in 1 wrist. There were 21 excellent, 2 good, 1 fair, and 1 poor results. Conclusions Anatomic reattachment of the TFCC to the ulnar fovea using an ECU half-slip tendon is a promising procedure. This technique is effective for severe DRUJ instability due to chronic foveal avulsion of the TFCC.

PURPOSE Magnetic resonance (MR) imaging offers the highest sensitivity for detecting bone necrosis. We evaluated osteonecrosis in rabbit models by calculating the percentage of fat to (fat + water) [F/(F+W)] on MR spectroscopy (MRS) and compared MR spectroscopy and imaging findings with corresponding histological results. METHODS To model the natural course of articular osteonecrosis, we removed the fourth tarsal bone in 45 rabbits, froze it for 5 min in liquid nitrogen to produce complete cellular necrosis, and then replaced the bone into the knee joint. We performed Carr-Purcell-Meiboom-Gill proton spectroscopic imaging to assess necrotic bone at 3 days and one, 2, 3, 4, 8, 12, 16, and 20 weeks after osteonecrosis and calculated the percentage of F/(F+W) of each bone. We also performed conventional T1- and T2-weighted imaging and compared all data to histological findings to analyze the natural course of necrosis. RESULTS T1-weighted MR imaging demonstrated obvious low signal intensity at 2 to 8 weeks and recovery at 12 to 20 weeks, whereas T2-weighted imaging demonstrated inconsistent intensities throughout the period. The postoperative percentage of F/(F+W) measured using line scan MRS decreased to 8.88% at 3 weeks, 6.22% at 8 weeks, and 34.40% at 20 weeks results that were mostly consistent with MR imaging findings. Histological findings demonstrated complete absence of osteocyte nuclei and loss of osteoid-osteogenesis at 3 to 8 weeks. Recovery of bone marrow was identified as an increase in the area of fat after 12 weeks. CONCLUSION Osteonecrosis delineated by T1-weighted MR imaging demonstrated fat content in the bone marrow that correlated with histology. The present MRS modality can be used to calculate the percentage of F/(F+W) of osteonecrosis to enable objective assessment of recovery and quantification of osteonecrosis to provide a numerical value for osteonecrosis.

Background Recently, arthroscopic Bankart repairs have become much more popular than open repairs for the treatment of recurrent anterior shoulder instability. However, it is unclear whether the modern arthroscopic Bankart repairs using suture anchors could restore equivalent stability to open repairs. We conducted a meta-analysis to compare arthroscopic Bankart repairs using suture anchors and open repairs in regard to clinical outcomes. Methods A literature review was performed according to the PRISMA guidelines. PubMed was searched from January 1966 to January 2017. Studies were identified using the terms ‘anterior shoulder dislocation’ or ‘recurrent anterior shoulder dislocation’ and ‘Bankart repair’. The search yielded 36 publications. After reading the full-text articles, we included four randomized controlled trials and five retrospective studies that compared arthroscopic and open repairs using suture anchors. Results No significant differences were found between the two procedures in frank re-dislocation and revision surgery due to recurrence. However, the overall recurrent instability including not only re-dislocation but also subluxation and apprehension was significantly higher in arthroscopic repairs than in open repairs, while a significantly higher Rowe score and lower loss of external rotation at 90° of abduction were observed following arthroscopic repairs compared to open repairs. Conclusions Modern arthroscopic Bankart repairs using suture anchors provide an equivalent outcome compared to open repairs in terms of apparent re-dislocation, but overall recurrent instability including subluxation or apprehension was still significantly higher in arthroscopic repairs than in open repairs.

Ulnar shortening osteotomy often is indicated for treatment of injuries to the triangular fibrocartilage complex (TFCC). However, the effect of ulnar shortening osteotomy on the changes in shape of the TFCC is unclear. In our study, quantitative evaluations were performed using MRI to clarify the effect of ulnar shortening on triangular fibrocartilage (TFC) thickness attributable to disc regeneration of the TFC and TFC angle attributable to the suspension effect of ulnar shortening on the TFC. The purposes of this study were (1) to compare preoperative and postoperative TFC thickness and TFC angle on MR images to quantitatively evaluate the effect of ulnar shortening osteotomy on disc regeneration and the suspension effect on the TFC; and (2) to assess whether changes in TFC thickness and TFC angle correlated with the Mayo wrist score. Between 1995 and 2008, 256 patients underwent ulnar shortening osteotomy for TFCC injuries. The minimum followup was 24 months (mean, 51 months; range, 24–210 months). A total of 79 patients (31%) with complete followup including preoperative and postoperative MR images and the Mayo wrist score was included in this retrospective study. Evaluation of the postoperative MR images and the Mayo wrist score were performed at the final followup. The remaining 177 patients did not undergo postoperative MRI, or they had a previous fracture, large tears of the disc proper, or were lost to followup. Two orthopaedists, one of whom performed the surgeries, measured the TFC thickness and the TFC angle on coronal MR images before and after surgery for each patient. Correlations of the percent change in the TFC thickness and the magnitude of TFC angle change with age, sex, postoperative MR images, extent of ulnar shortening, preoperative ulnar variance, and postoperative Mayo wrist score were assessed. Stepwise regression analysis showed a correlation between the percent change in TFC thickness and preoperative ulnar variance (R2 = 0.21; β = −0.33; 95% CI, −0.11 to 0.01; p = 0.01) and between the magnitude of change in the TFC angle and the extent of ulnar shortening (R2 = 0.18; β = −0.29; 95% CI, −5.8 to 0.29; p = 0.03). The Mayo wrist score was not correlated with the percent change in TFC thickness or the magnitude of change in the TFC angle. These results suggest that, in patients with TFCC injury with a smaller preoperative ulnar variance, a high residual potential for regeneration in the disc proper was seen after ulnar shortening osteotomy, and correlated with the extent of ulnar shortening and the suspension effect on TFC. However, there was no correlation between disc regeneration or the suspension effect on TFC and the Mayo wrist score. Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Severe arthritis or derangement of the distal radioulnar joint (DRUJ) leads to instability of the DRUJ, and the subluxation of the ulna causes pain on motion, loss of grip strength, and a restriction of forearm rotation.1 A variety of surgical procedures have been described to treat these.2 In 1912, Darrach described a resection of the ulnar head.3 Although this procedure could successfully restore forearm rotation, serious postoperative complications frequently occurred, such as a further loss of grip strength or pain over the proximal ulnar stump.4,5,6 As an alternative solution, Sauve and Kapandji described a distal radioulnar arthrodesis combined with an intentional pseudarthrosis of the distal ulna.7 Some reports of this technique have shown superior results both clinically and radiographically,8,9,10,11 and hence the Sauve-Kapandji (S-K) procedure has almost replaced Darrach's as the most common resection arthroplasty for the treatment of DRUJ dysfunction. The conventional S-K procedure is contraindicated, however, in patients with extremely poor bone quality, which is often seen in patients with advanced-stage rheumatoid arthritis (RA). Since 1994, we have modified the S-K procedure for the treatment of patients with a severely damaged DRUJ. This modification involves rotating the resected ulnar segment 90° and inserting it into the DRUJ to form a bridge between the eroded ulnar head and the decorticated ulnar notch of the radius to provide ulnar support as well as to maintain the radioulnar width of the wrist (Fig. 1). The extensor carpi ulnaris (ECU) tendon sheath attachment into the ulnar head and shaft is preserved, providing a dynamic stabilizing effect on the proximal stump. Fig. 1 Surgical procedure of the modified Sauve-Kapandji procedure. The resected ulnar segment is rotated 90° and inserted in the curetted distal radio-ulnar joint in existing form to bridge the thinned ulnar head and the sigmoid notch using ... The purpose of this study is to review the radiographic findings following the modified S-K procedure to assess its effectiveness at maintaining the radioulnar width of the wrist, controlling ulnar translocation, and maintaining the pseudarthrosis space.

Skeletal fracture healing involves a variety of cellular and molecular events; however, the mechanisms behind these processes are not fully understood. In the current study, we investigated the potential involvement of the signal transducer and activator of transcription 1 (STAT1), a critical regulator for both osteoclastogenesis and osteoblast differentiation, in skeletal fracture healing. We used a fracture model and a cortical defect model in mice, and found that fracture callus remodeling and membranous ossification are highly accelerated in STAT1-deficient mice. Additionally, we found that STAT1 suppresses Osterix transcript levels and Osterix promoter activity in vitro, indicating the suppression of Osterix transcription as one of the mechanisms behind the inhibitory effect of STAT1 on osteoblast differentiation. Furthermore, we found that fludarabine, a potent STAT1 inhibitor, significantly increases bone formation in a heterotopic ossification model. These results reveal previously unknown functions of STAT1 in skeletal homeostasis and may have important clinical implications for the treatment of skeletal bone fracture.

Summary Objective Two lateral wedged insoles were compared: one with, and the other without, subtalar strapping. Methods Twenty-one patients (age 58–83, mean 72) with medial knee osteoarthritis (OA) were enrolled. Thirty-seven knees in the patients were divided into three groups based on the Kellgren and Lawrence OA grading system; grades 2 (cases=20), 3 (cases=11), and 4 (cases=6). The subjects were tested during walking barefoot and during walking with a silicon rubber lateral wedged insole with elevation of 10mm attached to a barefoot. Gait analysis was performed on a 10m walkway for each subject under three different walking conditions; barefoot, wearing a conventional insole, and a subtalar strapping insole. Peak knee varus moment during gait was measured under each condition, and compared between the three conditions and between the OA grades. Results On the whole (cases=37), the peak varus moment was significantly reduced by wearing either of the insoles, compared to walking barefoot. The reduction was more obvious with the strapping insole (−13%, P P P =0.0048 and 0.005, respectively). However, no significant difference was detected in severe OA patients (grade 4) between the two types of insoles ( P =0.4). Conclusions Both lateral wedged insoles significantly reduced the peak medial compartment load during gait. The subtalar strapping insole had a greater effect than the conventional insole, particularly in patients with moderate medial knee OA.

Purpose To detect the earlier changes of the skeletal muscle of rats after peripheral nerve injury by measuring the apparent diffusion coefficient (ADC) on diffusion MR spectroscopy. Materials and Methods The posterior tibial nerve was transected in six rats (nerve transection group) and was only dissected in six rats (control group). At one, three, five, seven, 14, and 28 days after the surgery, both the T2 value and the ADC of gastrocnemius muscle were measured using a line-scan diffusion spectrum on a 1.5T clinical MR imager on both groups. Results In the nerve transection group, the T2 ratio compared to the contralateral side increased gradually over four weeks after the transection, while the ADC ratio increased right after the surgery and began to decrease at five days. Four weeks after the transection, the ADC ratio returned to normal while the T2 ratio stayed at a high value. The control group indicated an almost constant T2 and ADC ratio during the experimental periods. Conclusion The ADC of the skeletal muscle increased quickly after the transection of the dominant peripheral nerve and was detectable one day after the surgery. Diffusion MRI can be a useful tool for early detection of peripheral nerve injury instead of T2-weighted MRI or electromyography (EMG). J. Magn. Reson. Imaging 2007. © 2007 Wiley-Liss, Inc.

Background The biomechanical properties of the capitohamate (CH) ligament are equivalent to those of the scapholunate (SL) interosseous ligament. We reconstructed the SL ligament using the CH bone-ligament-bone substitute for chronic injury of the SL ligament. Patients and Methods Beginning in 2008, 15 wrists of 14 patients with an average age of 38 years underwent this procedure with a minimum follow-up of 2 years. Thirteen wrists had an SL joint gap more than 3 mm, and two had a complete SL ligament disruption with a severe dorsal intercalated segment instability (DISI) deformity. Kirschner wires (K-wires) were removed 8 weeks after the surgery, then active ROM exercise began. Pain (on visual analog scale [VAS]), wrist motion (angle), radiographic characteristics, such as SL gap (mm) and SL angle, and Modified Mayo Wrist Score (MMWS) were evaluated. Technique The SL joint was reduced by manipulation or with the use of joysticks, then temporary fixed with K-wires. A dorsal trough was then made between the scaphoid and the lunate. The proximal half of the CH ligament was harvested with attached bone from the capitate and hamate (CH bone-ligament-bone), inset into the SL trough, and fixed firmly with 1.2-mm diameter titanium screws in the scaphoid and lunate, respectively. Results The VAS improved from 77 preoperatively to 12 postoperatively. The average wrist extension/flexion was 74°/60°. There was no ossification of the reconstructed SL at the final follow-up. The SL gap improved from an average of 4.8 mm to an average of 2.1 mm, and the SL angle changed from 67° to 55°. The MMWS improved to 82 points postoperatively from a preoperative average of 47 with eight excellent, five good, and two fair results.