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Scaphoid-trapezium-trapezoid fusion in the treatment of chronic scapholunate instability
Vol. l1A, No.4 July 1986
6. Epner RA, Bowers WH, Guilford WB: Ulnar variance. The effect of wrist positioning and roentgen filming technique. J HAND SURG 7:298-305, 1982 7. Palmer AK, Glisson RR, Werner FW: Ulnar variance determination. J HAND SURG 7:376-9, 1982 8. Palmer AK, Levinsohn EM, Kuzma GR: Arthrography of the wrist. J HAND SURG 8:15-23, 1983 9. Mikic ZOJ: Arthrography of the wrist joint. J Bone Joint Surg [Am] 66:371-8, 1984 10. Platt H: Colles' fracture. Surg Gynecol Obstet 60:5424, 1935 11. Michaelis LS: Locking wrist. Lancet, :229-33, 1940 12. Mino DE, Palmer AK, Levinsohn EM: The role of radiography and computerized tomography in the diagnosis of subluxation and dislocation of the distal radio-ulna joint. J HAND SURG 8:23-31, 1983
Disk lesion of wrist joint
13. Hoegen K, Reske W: Veriinderungen an der dreieckigen Bandscheibe des distalen Radio-UlnargeIenkes. Z Orthop 87:525-32, 1956 14. Palmer AK, Dobyns JH, Linscheid RL: Management of posttraumatic instability of the wrist secondary to ligament wrist. J HAND SURG 3:507-32, 1978 15. Albert SM, Wohl MA, Rechtman AM: Treatment of the disrupted radio-ulnar joint. J Bone Joint Surg 7: 1373-81, 1963 16. De Palma AF: Management of fractures and dislocations. Philadelphia, 1970, WB Saunders Co, pp 931-4 17. Imbriglia JE, Boland DS: Tears of the articular disc of the triangular fibrocartilage complex: Results of excision of the articular disc. J HAND SURG 8:620, 1983
Scaphoid-trapezium-trapezoid fusion in the treatment of chronic scapholunate instability Limited intercarpal arthrodesis for chronic scapholunate instability has been the subject of several recent publications. We have followed nine patients, who had scapho-trapezio-trapezoidal (S-T -T) fusion for scapholunate instability. All nine patients were re-examined recently after an average follow-up period of 19 months (range, 12 to 25 months). Six of the nine patients believ~d that their symptoms were significantly improved. The postoperative range of wrist motion (ROM) was decreased in all directions of motion. The pinch strength averaged 86% on the treated side and the grip strength averaged 74% of the unoperated side. Review of follow-up x-ray films showed radiographic evidence of union in eight of nine patients. We conclude that, with careful patient selection and close attention to operative detail, S-T-T fusion can be an effective treatment for scapholunate instability. However, the results are not uniformly predictable, and neither range of motion nor strength is normal after the procedure. (J HAND SURG llA:497-502, 1986.)
James F. Eckenrode, M.D., Dean S. Louis, M.D., and Thomas L. Greene, M.D., Ann Arbor, Mich.
Chronic wrist pain secondary to scapholunate instability has proved to be difficult to treat. Since the condition was first recognized and discussed by Destoe in 1925, many nonoperative and surgical From the Orthopaedic Hand Service, Department of Surgery, Uni· versity of Michigan Hospitals, Ann Arbor, Mich. Received for publication April 29, 1985; accepted in revised form Sept. 16, 1985. Reprint requests: Dean S. Louis, M.D., C4500 Outpatient, University Hospital, 1405 E. Ann St., Ann Arbor, MI 48109.
approaches to the problem have been suggested. These have included massage, I prolonged immobilization, 2 exercises,3 proximal row carpectomy,4.5 silicone rubber replacement arthroplasty,6 repair and/or reinforcement of the intercarpal and radiocarpal ligaments,1-9 and various combinations of radiocarpal or intercarpal fusions.3, 10. II In 1967 Peterson and Lipscomb l2 reported various limited intercarpal arthrodeses performed on eight patients who had different diagnoses. These diagnoses included one case of scapho-trapezio-trapezoidal (S-T-T) THE JOURNAL OF HAND SURGERY
497
498
The Journal of HAND SURGERY
Eckenrode, Louis, and Greene
Table I. Patient data
Patient
AgelSex
Length of follow-up (mo)
M.L. C. H. P. G. G. C.
23/F 17/F 181M 4l!M
22 19 13 25
W.H. E. G.
331M 381M
18 12
C. M. R. K.
52/M 321M
17 17
P. R.
361M
18
Symptoms at follow-up
Scapholunate angle (degrees) (preopl postop)
Grip strength (pounds) (operl nonoper)
Pinch strength (pounds) (operl nonoper)
Motion (degrees) (operlnonoper) Extension
Radial
Ulnar
60/80
24123 35/30 30/38
20/40 40/80 50/60 26/80
20/45 45/60 60/80 26/65
30/36 18/35 10130 5135
15/32 22/45 32/50 20/35
90190 85170
851120 751110
28/30 24/30
52170 65170
45/90 30/60
26/38 20/30
30/45
55/45 55/60
22/95 1051125
4121 30/37
12/68 54170
32/60 60170
7140 14122
26/45 32/35
-165
1101110
30/33
45/65
65/65
14/31
25/36
Flexion Unimproved None None Minimal pain Unimproved Minimal pain Unimproved Minimal pain None
75/50 -160 85/45 70/60
fusion for painful "scaphoid subluxation" with a 16year-follow-up and an excellent clinical result. However, the patient did have a subsequent radiocarpal fusion after she sustained an additional injury. In 1980 Watson and Hempton l3 reported a series of 13 patients who had been treated with S-T-T fusion. Four of these patients had a diagnosis of "rotary subluxation of the scaphoid," and all four had excellent clinical results at follow-up at 5, 6, and 8 months, and 6 years. In 1982 Kleinman et aL 14 reported a series of 12 patients who were treated for chronic rotatory subluxation of the scaphoid by S-T-T fusion. Nine of the 12 patients had good results (defined as no postoperative pain and return to work) at follow-up of 3 to 28 months. This article reports our experience with this procedure at the University of Michigan Hospitals. Nine patients are included in the study, and all of the patients had postoperative follow-up of at least 1 year. Material and methods
Nine patients had S-T-T fusion for treatment of chronic scapholunate instability at the University of Michigan Hospitals between March 1982 and June 1983. All of the patients' operations were performed by the two senior authors (D. S. L. and T. L. G.). The ages of the nine patients ranged from 17 to 52 years at the time of the surgery. There were seven male and two female patients. The mechanism of injury was forced extension in seven patients; one patient implicated repetitive occupational trauma, and one denied any history of trauma. The dominant hand was involved in only two of the nine patients. The duration of symp-
25/65 45/45 1151115
9116
10120
toms before the operation ranged from 3 months to 6 years, with a mean of 18 months. The most common preoperative symptom was pain, although some patients also complained of clicking of the wrist or a feeling of instability. All patients in the study were interviewed and reexamined recently by one of us after an average followup period of 19 months (range, 12 to 25 months). Wrist motion was measured in all four cardinal directions of motion, with the shaft of the radius and the third metacarpal as reference points. Strength was tested with the Jamar Dynamometer* at all five positions of grip width. Key pinch strength was measured with the Preston pinch meter. t Preoperative and postoperative radiographs were reviewed at the time of the follow-up. Scapholunate angles were measured on lateral radiographs in the manner described by Linscheid et aL 15 Surgical technique
All of the operations were performed via a dorsoradial approach, under tourniquet hemostasis. We followed the technique of S-T-T fusion described by Watson and Hempton I3 and later modified by Kleinman et aL 14 We used an extended longitudinal approach, as we have found the transverse approach to be too confining. Bone graft material was harvested from the ipsilateral distal radius through an extension of the same incision. Two or more Kirschner wires were used to percutaneously transfix the scaphoid to the capitate and
*Jamar Dynamometer, Asimow Engineering Co., Los Angeles, CA. tPreston pinch meters, J. A. Preston Corp., N.Y., NY.
Vo\. IIA, No . 4
Scaphoid-trapezium-trapezoid fusion
July 1986
lunate, maintaining a reduced position. Our objective was to restore the scapholunate angle to a normal range of 45° to 60°. No wires were passed across the S-T-T fusion site. At the completion of the procedure the patients' wrists were placed in a well-padded short arm-thumb spica cast. Immobilization was maintained for 6 weeks or until radiographic evidence of bony union was obtained. After the casts were removed the patients were allowed to gradually resume activities as their symptoms abated.
499
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,
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Results The results of the study are summarized in Table l. Six of the nine patients believed that their symptoms were significantly improved. Three of these six patients did have occasional pains with excessive or strenuous activity, such as racquet sports or weight lifting. Six patients returned to their previous employment, two patients changed to less strenuous occupations , and one patient was unemployed. The postoperative range of motion (ROM) was measured for each patient in palmar flexion, extension, radial deviation , and ulnar deviation. The unoperated side was used as a reference to what was "normal" for each patient. The postoperative ROM (with values for the unoperated wrist in parentheses) averaged 45° (69°) extension, 40° (67°) palmar flexion, 25° (39°) ulnar deviation, and 14° (35°) radial deviation (Fig. 1). None of the patients believed that the decreased ROM was a hindrance in any leisure or occupational activity. Grip strength was measured with the Jamar Dynamometer in all five positions of grip width, and the unoperated side was again used as a control. The grip strength at all grip widths was decreased on the operated side (Fig. 2). For all nine patients the grip strength measured at the middle position of the dynamometer averaged 74% of the strength of the unoperated side. If only the six patients without postoperative pain are included, the grip strength averaged 85% of the unoperated side. Key pinch was measured with the Preston pinch meter and compared to the unoperated side. Pinch strength averaged 86% of the unoperated side in all patients and 91 % in the six patients without postoperative pain (Fig. 2). A review of the follow-up x-ray films showed radiographic evidence of bony union of the S-T -T joints in eight of nine patients. Follow-up x-ray films of one patient (C. M.) showed no evidence of bony union despite immobilization of 8 weeks. That patient continued to have pain and subsequently had a silicone
Fig. 1. The range of wrist motion in the operated and nonoperated sides. Measurements were made using the shafts of the radius and third metacarpal as references (average of all nine patients).
rubber trapezium implant at another institution, which did not relieve his symptoms. Another patient (G. C.) had apparent extension of the fusion to include the capitate. This patient reported excellent relief of pain but his ROM, particularly palmar flexion and extension, decreased more than in those patients whose fusion did not include the capitate. The postoperative scapholunate angle that was measured on standard lateral radiographs averaged 61 0, with a range of 45° to 90°. The patient who had the greatest number of symptoms postoperatively (W. H.) had a scapholunate angle of 90°. Discussion Although the French surgeon Destot described the lesion early in this century, widespread recognition of scapholunate instability or rotatory subluxation of the scaphoid as a cause of chronic wrist pain has been relatively recent. 7. 9, 15, 16 We believe the first description of the entity in the American literature dates from 1932, in a case report of a closed reduction of a scapholunate dislocation by F. T. Andrews. 17 After a successful
500
The Journal of HAND SURGERY
Eckenrode, Louis, and Greene
KEY CIperIIhId
•
--CIperIIhId
30
20
10
2
3
GRIP
4
5
PINCH
Fig. 2. Grip strength and pinch strength of operated and non operated sides (average values for all nine patients).
closed reduction of a palmar dislocation of scaphoid and lunate, he reported that "the hand was x-rayed and the bones found to be in perfect alignment, although an unusual space remained between the semilunar and scaphoid." The significance of this finding was apparently not appreciated, and Dr.. Andrews goes on to state that "[the patient] was allowed to return to his home feeling much improved, with no apparent deformity of the wrist joint." No further follow-up was noted. Two years later, in another case report, 18 B. F. Buzby described the treatment of a 47-year-old man for a palmar dislocation of the scaphoid, which he sustained in .an automobile accident. After closed reduction and 4 weeks' immobilization, the patient continued to have "pain on certain movements in rotation of the wrist . . .. " Photographs of x-ray films that were taken at the time of follow-up are included in the article and show a definite widening of the scapholunate cartilage space. Again, at the time this was not appreciated and the text of the report states that the follow-up films "appear like the x-rays of a normal wrist." In 1949 Vaughn-Jackson 2 and RusseIP simultaneously reported several cases of rotary subluxation of the scaphoid. Subsequent to these early reports, several case reports and small series had been published. The detailed anatomic and kinematic studies of Taleisn;.k, 19 Mayfield,20 Kauer,zl and Linscheid et al. 15 further amplified our understanding of the pathomechanics of these intriguing problems. Current evidence suggests that scapholunate instability or rotary scaphoid sublux-
ation represents a rupture of the palmar scapholunate ligament. Rotation of the proximal pole of the scaphoid occurs around the radio-scapho-capitate ligament, thereby widening the distance between the proximal pole'of the scaphoid and the lunate. The scaphoid then rotates into a plane perpendicular to the axis of the palm. Mayfield et al. 22 have shown biomechanical evidence that this injury represents the first stage of a spectrum of ligamentous injuries that result from a hyperextension force on the wrist and culminate in a lunate or perilunate dislocation if a force of sufficient magnitude and direction is applied. . Efforts to maintain anatomic reduction of the scaphoid by closed means after rotatory subluxation have been generally unsuccessful. Closed or open reduction with Kirschner wire fixation has met with only limited success,23 and other proposed surgical procedures, including implant arthroplasty, ligamentous reconstruction, and proximal row carpectomy, are either disabling, cosmetically displeasing, or restrict the patient's ability to perform. S-T-T fusion, as described originally by Peterson and Lipscomb l2 and expanded upon by others, 13. 14 represents an alternative approach to this difficult problem. However, previous studies suffer from a lack of longterm follow-up. Only one of four patients in the Watson and Hempton l3 study and six of the twelve patients in the study by Kleinman et al. 14 were followed for as long as 1 year. Follow-up of our nine patients was at least 1 year
Vol. IIA, No.4 July 1986
Scaphoid-trapezium-trapezoid fusion
501
Fig. 3. X-ray films of the symptomatic wrist of G. C. A, Preoperative anterior-posterior view shows prominent scapholunate gap. 8, Preoperative lateral views shows dorsal subluxation of proximal pole of scaphoid and resultant scapholunate angle of approximately 90°. C, Postoperative view shows scaphoid reduced and held in position with two Kir&chner wires . D, Anterior-posterior view at 8-month follow-up shows successful fusion and maintenance of scapholunate reduction.
and averaged 19 months. Further long-term studies are definitely needed to evaluate the possible development of degenerative changes in the carpus secondary to altered intercarpal kinematics. In the short-term study reported here, 33% of the results were considered to be unsatisfactory. We believe that the enthusiasm reported by other authors for this procedure should be tempered by the knowledge that complications may occur. In one patient (C. M.), the fusion was unsuccessful and a nonunion of the fusion mass resulted. The patient's pain has persisted despite a trapezium implant that was subsequently performed at another institution. Another patient (W. H.) had a successful fusion, but postoperative radiographs
showed a scapholunate angle of 90° and the patient continued to compfain of pain postoperatively. A third patient (M. L.) continued to complain of wrist pain postoperatively despite a successful fusion in good position as shown by radiographs. She has subsequently had an extended intercarpal fusion but continues to have significant and disabling pain in the wrist. Fig. 3 shows the radiographs of a representative case. None of the patients had any complaints that referred to their decreased range of wrist motion. Recent studies 24 . 25 confirmed that a range of motion of 5° extension to 30° flexion and 10° radial deviation to 15° ulnar deviation is sufficient to perform most occupations and virtually all activities of daily living.
S02
Eckenrode, Louis, and Greene
Conclusion
Although neither ROM nor strength is normal after the S-T-T fusion, patients are able to return to work .and perform activities of daily living without pain or the feeling of wrist instability. We believe that this procedure is less disabling and also more cosmetically pleasing than more extensive intercarpal or radiocarpal procedures. We conclude that careful patient selection is extremely important. There should be no evidence of degenerative arthritis of the intracarpal or radiocarpal joints. With these precautions and close attention to operative detail, S-T-T fusion can be an effective treatment for chronic wrist pain secondary to scapholunate instability. The limitation of motion that occurs is within a functional range for most activities of daily living. Further long-term follow-up is needed to determine whether this limitation of motion may result in symptomatic degenerative arthritis of the radiocarpal and remaining intercarpal joints. REFERENCES L Destot E: (translated by R. B. Atkinson FRB): Injuries of the wrist-A radiological study. London, 1925, Ernest Benn Ltd, pp 56-68 2. Vaugh-Jackson OJ: Case of recurrent subluxation of the carpal scaphoid. J Bone Joint Surg [Br) 31:532-3 , 1949 3. Russell TB: Intracarpal dislocation and fracture-dislocation: A review of 59 cases. J Bone Joint Surg [Br) 31 :524-31, 1949 4. Jorgenson EC: Proximal-row carpectomy. J Bone Joint Surg [Am) 51:1104-11, 1969 5. Inglis AE, Jones EC: Proximal-row carpectomy for diseases of the proximal row. J Bone Joint Surg [Am) 59:460-3, 1979 6. Eiken 0: Implant arthroplasty of the scapho-trapezial joint. Scand J Plast Reconstr Surg 13:461-8, 1979 7. Howard FM, Fahey T, Wojik E: Rotary subluxation of the navicular. Clin Orthop 104:134-9, 1974. 8. Gerard FM: Post-traumatic carpal instability in a young child. J Bone Joint Surg [Am) 62:131-3, 1980
The Journal of HAND SURGERY
9. Dobyns JH, Linscheid RL, Chao EYS, Weber ER, Swanson GE: Traumatic instability of the wrist. Instructional course lectures AAOS, vol 24, St. Louis, 1975 10. Taleisnik J: Subtotal arthrodesis of the wrist joint. Clin Orthop 187:81-8, 1984 II . Ricklin P: L'arthrodese radiocarplenne partielle. Am Cir 30:909-11, 1976 12. Peterson HA, Lipscomb PR : Intercarpal arthrodesis . Arch Surg 95 :127-34, 1967 13. Watson HK, Hempton RF: Limited wrist arthrodesis: The triscaphoid joint. J HAND SURG 5:320-7, 1980 14. Kleinman WB, Steichen JB, Strickland JW: Management of chronic rotary subluxation of the scaphoid by scaphotrapezium-trapezoid arthrodesis. J HAND SURG 7: 125-36, 1982 15 . Linschied RL, Dobyns JH, Beabout JW, Bryan RS: Traumatic instability of the wrist: Diagnosis, classification, and biomechanics. J Bone Joint Surg [Am) 54:1612-32, 1972 16. Armstrong GWD: Rotational subluxation of the scaphoid . Can J Surg 11:306-14, 1968 17. Andrews FT: A dislocation of the carpal bones-the scaphoid and semilunar: Report of a case. Michigan medicine 31 :269-71, 1932 18. Buzby BF: Isolated radial dislocation of the carpal scaphoid. Ann Surg 100:553-4, 1934 19. Taleisnik J: The ligaments of the wrist. J HAND SURG 1:110-18, 1976 20. Mayfield JK: Mechanism of .carpal injuries. Clin Orthop 149:45-54, 1980 21. Kauer JMG: The interdependence of carpal articulation chains. Acta Anat 88:481-501, 1976 22. Mayfield JK, Johnson RP, Kilcoyne RK: Carpal dislocation: Pathomechanics and progressive perilunar instability. J HAND SURG 5:226-41, 1980 23. Green DP: Carpal dislocations . In Green DP, editor: Operative hand surgery. New York, 1982, Churchill Livingston Inc pp 718-23 24. Brumfield R, Nickel V, Nickel E: Joint motion in wrist flexion and extension. South Med J 59:909-10, 1966 25 . Palmer AK, Werner FW, Murphy D, Glisson R: Functional wrist motion: A biomechanical study. J HAND SURG lOA: 39-46 , 1985
6. Epner RA, Bowers WH, Guilford WB: Ulnar variance. The effect of wrist positioning and roentgen filming technique. J HAND SURG 7:298-305, 1982 7. Palmer AK, Glisson RR, Werner FW: Ulnar variance determination. J HAND SURG 7:376-9, 1982 8. Palmer AK, Levinsohn EM, Kuzma GR: Arthrography of the wrist. J HAND SURG 8:15-23, 1983 9. Mikic ZOJ: Arthrography of the wrist joint. J Bone Joint Surg [Am] 66:371-8, 1984 10. Platt H: Colles' fracture. Surg Gynecol Obstet 60:5424, 1935 11. Michaelis LS: Locking wrist. Lancet, :229-33, 1940 12. Mino DE, Palmer AK, Levinsohn EM: The role of radiography and computerized tomography in the diagnosis of subluxation and dislocation of the distal radio-ulna joint. J HAND SURG 8:23-31, 1983
Disk lesion of wrist joint
13. Hoegen K, Reske W: Veriinderungen an der dreieckigen Bandscheibe des distalen Radio-UlnargeIenkes. Z Orthop 87:525-32, 1956 14. Palmer AK, Dobyns JH, Linscheid RL: Management of posttraumatic instability of the wrist secondary to ligament wrist. J HAND SURG 3:507-32, 1978 15. Albert SM, Wohl MA, Rechtman AM: Treatment of the disrupted radio-ulnar joint. J Bone Joint Surg 7: 1373-81, 1963 16. De Palma AF: Management of fractures and dislocations. Philadelphia, 1970, WB Saunders Co, pp 931-4 17. Imbriglia JE, Boland DS: Tears of the articular disc of the triangular fibrocartilage complex: Results of excision of the articular disc. J HAND SURG 8:620, 1983
Scaphoid-trapezium-trapezoid fusion in the treatment of chronic scapholunate instability Limited intercarpal arthrodesis for chronic scapholunate instability has been the subject of several recent publications. We have followed nine patients, who had scapho-trapezio-trapezoidal (S-T -T) fusion for scapholunate instability. All nine patients were re-examined recently after an average follow-up period of 19 months (range, 12 to 25 months). Six of the nine patients believ~d that their symptoms were significantly improved. The postoperative range of wrist motion (ROM) was decreased in all directions of motion. The pinch strength averaged 86% on the treated side and the grip strength averaged 74% of the unoperated side. Review of follow-up x-ray films showed radiographic evidence of union in eight of nine patients. We conclude that, with careful patient selection and close attention to operative detail, S-T-T fusion can be an effective treatment for scapholunate instability. However, the results are not uniformly predictable, and neither range of motion nor strength is normal after the procedure. (J HAND SURG llA:497-502, 1986.)
James F. Eckenrode, M.D., Dean S. Louis, M.D., and Thomas L. Greene, M.D., Ann Arbor, Mich.
Chronic wrist pain secondary to scapholunate instability has proved to be difficult to treat. Since the condition was first recognized and discussed by Destoe in 1925, many nonoperative and surgical From the Orthopaedic Hand Service, Department of Surgery, Uni· versity of Michigan Hospitals, Ann Arbor, Mich. Received for publication April 29, 1985; accepted in revised form Sept. 16, 1985. Reprint requests: Dean S. Louis, M.D., C4500 Outpatient, University Hospital, 1405 E. Ann St., Ann Arbor, MI 48109.
approaches to the problem have been suggested. These have included massage, I prolonged immobilization, 2 exercises,3 proximal row carpectomy,4.5 silicone rubber replacement arthroplasty,6 repair and/or reinforcement of the intercarpal and radiocarpal ligaments,1-9 and various combinations of radiocarpal or intercarpal fusions.3, 10. II In 1967 Peterson and Lipscomb l2 reported various limited intercarpal arthrodeses performed on eight patients who had different diagnoses. These diagnoses included one case of scapho-trapezio-trapezoidal (S-T-T) THE JOURNAL OF HAND SURGERY
497
498
The Journal of HAND SURGERY
Eckenrode, Louis, and Greene
Table I. Patient data
Patient
AgelSex
Length of follow-up (mo)
M.L. C. H. P. G. G. C.
23/F 17/F 181M 4l!M
22 19 13 25
W.H. E. G.
331M 381M
18 12
C. M. R. K.
52/M 321M
17 17
P. R.
361M
18
Symptoms at follow-up
Scapholunate angle (degrees) (preopl postop)
Grip strength (pounds) (operl nonoper)
Pinch strength (pounds) (operl nonoper)
Motion (degrees) (operlnonoper) Extension
Radial
Ulnar
60/80
24123 35/30 30/38
20/40 40/80 50/60 26/80
20/45 45/60 60/80 26/65
30/36 18/35 10130 5135
15/32 22/45 32/50 20/35
90190 85170
851120 751110
28/30 24/30
52170 65170
45/90 30/60
26/38 20/30
30/45
55/45 55/60
22/95 1051125
4121 30/37
12/68 54170
32/60 60170
7140 14122
26/45 32/35
-165
1101110
30/33
45/65
65/65
14/31
25/36
Flexion Unimproved None None Minimal pain Unimproved Minimal pain Unimproved Minimal pain None
75/50 -160 85/45 70/60
fusion for painful "scaphoid subluxation" with a 16year-follow-up and an excellent clinical result. However, the patient did have a subsequent radiocarpal fusion after she sustained an additional injury. In 1980 Watson and Hempton l3 reported a series of 13 patients who had been treated with S-T-T fusion. Four of these patients had a diagnosis of "rotary subluxation of the scaphoid," and all four had excellent clinical results at follow-up at 5, 6, and 8 months, and 6 years. In 1982 Kleinman et aL 14 reported a series of 12 patients who were treated for chronic rotatory subluxation of the scaphoid by S-T-T fusion. Nine of the 12 patients had good results (defined as no postoperative pain and return to work) at follow-up of 3 to 28 months. This article reports our experience with this procedure at the University of Michigan Hospitals. Nine patients are included in the study, and all of the patients had postoperative follow-up of at least 1 year. Material and methods
Nine patients had S-T-T fusion for treatment of chronic scapholunate instability at the University of Michigan Hospitals between March 1982 and June 1983. All of the patients' operations were performed by the two senior authors (D. S. L. and T. L. G.). The ages of the nine patients ranged from 17 to 52 years at the time of the surgery. There were seven male and two female patients. The mechanism of injury was forced extension in seven patients; one patient implicated repetitive occupational trauma, and one denied any history of trauma. The dominant hand was involved in only two of the nine patients. The duration of symp-
25/65 45/45 1151115
9116
10120
toms before the operation ranged from 3 months to 6 years, with a mean of 18 months. The most common preoperative symptom was pain, although some patients also complained of clicking of the wrist or a feeling of instability. All patients in the study were interviewed and reexamined recently by one of us after an average followup period of 19 months (range, 12 to 25 months). Wrist motion was measured in all four cardinal directions of motion, with the shaft of the radius and the third metacarpal as reference points. Strength was tested with the Jamar Dynamometer* at all five positions of grip width. Key pinch strength was measured with the Preston pinch meter. t Preoperative and postoperative radiographs were reviewed at the time of the follow-up. Scapholunate angles were measured on lateral radiographs in the manner described by Linscheid et aL 15 Surgical technique
All of the operations were performed via a dorsoradial approach, under tourniquet hemostasis. We followed the technique of S-T-T fusion described by Watson and Hempton I3 and later modified by Kleinman et aL 14 We used an extended longitudinal approach, as we have found the transverse approach to be too confining. Bone graft material was harvested from the ipsilateral distal radius through an extension of the same incision. Two or more Kirschner wires were used to percutaneously transfix the scaphoid to the capitate and
*Jamar Dynamometer, Asimow Engineering Co., Los Angeles, CA. tPreston pinch meters, J. A. Preston Corp., N.Y., NY.
Vo\. IIA, No . 4
Scaphoid-trapezium-trapezoid fusion
July 1986
lunate, maintaining a reduced position. Our objective was to restore the scapholunate angle to a normal range of 45° to 60°. No wires were passed across the S-T-T fusion site. At the completion of the procedure the patients' wrists were placed in a well-padded short arm-thumb spica cast. Immobilization was maintained for 6 weeks or until radiographic evidence of bony union was obtained. After the casts were removed the patients were allowed to gradually resume activities as their symptoms abated.
499
\,,-,' \
,
\
\
\
\
\
,,
\
,
\
\
\
\
\
Results The results of the study are summarized in Table l. Six of the nine patients believed that their symptoms were significantly improved. Three of these six patients did have occasional pains with excessive or strenuous activity, such as racquet sports or weight lifting. Six patients returned to their previous employment, two patients changed to less strenuous occupations , and one patient was unemployed. The postoperative range of motion (ROM) was measured for each patient in palmar flexion, extension, radial deviation , and ulnar deviation. The unoperated side was used as a reference to what was "normal" for each patient. The postoperative ROM (with values for the unoperated wrist in parentheses) averaged 45° (69°) extension, 40° (67°) palmar flexion, 25° (39°) ulnar deviation, and 14° (35°) radial deviation (Fig. 1). None of the patients believed that the decreased ROM was a hindrance in any leisure or occupational activity. Grip strength was measured with the Jamar Dynamometer in all five positions of grip width, and the unoperated side was again used as a control. The grip strength at all grip widths was decreased on the operated side (Fig. 2). For all nine patients the grip strength measured at the middle position of the dynamometer averaged 74% of the strength of the unoperated side. If only the six patients without postoperative pain are included, the grip strength averaged 85% of the unoperated side. Key pinch was measured with the Preston pinch meter and compared to the unoperated side. Pinch strength averaged 86% of the unoperated side in all patients and 91 % in the six patients without postoperative pain (Fig. 2). A review of the follow-up x-ray films showed radiographic evidence of bony union of the S-T -T joints in eight of nine patients. Follow-up x-ray films of one patient (C. M.) showed no evidence of bony union despite immobilization of 8 weeks. That patient continued to have pain and subsequently had a silicone
Fig. 1. The range of wrist motion in the operated and nonoperated sides. Measurements were made using the shafts of the radius and third metacarpal as references (average of all nine patients).
rubber trapezium implant at another institution, which did not relieve his symptoms. Another patient (G. C.) had apparent extension of the fusion to include the capitate. This patient reported excellent relief of pain but his ROM, particularly palmar flexion and extension, decreased more than in those patients whose fusion did not include the capitate. The postoperative scapholunate angle that was measured on standard lateral radiographs averaged 61 0, with a range of 45° to 90°. The patient who had the greatest number of symptoms postoperatively (W. H.) had a scapholunate angle of 90°. Discussion Although the French surgeon Destot described the lesion early in this century, widespread recognition of scapholunate instability or rotatory subluxation of the scaphoid as a cause of chronic wrist pain has been relatively recent. 7. 9, 15, 16 We believe the first description of the entity in the American literature dates from 1932, in a case report of a closed reduction of a scapholunate dislocation by F. T. Andrews. 17 After a successful
500
The Journal of HAND SURGERY
Eckenrode, Louis, and Greene
KEY CIperIIhId
•
--CIperIIhId
30
20
10
2
3
GRIP
4
5
PINCH
Fig. 2. Grip strength and pinch strength of operated and non operated sides (average values for all nine patients).
closed reduction of a palmar dislocation of scaphoid and lunate, he reported that "the hand was x-rayed and the bones found to be in perfect alignment, although an unusual space remained between the semilunar and scaphoid." The significance of this finding was apparently not appreciated, and Dr.. Andrews goes on to state that "[the patient] was allowed to return to his home feeling much improved, with no apparent deformity of the wrist joint." No further follow-up was noted. Two years later, in another case report, 18 B. F. Buzby described the treatment of a 47-year-old man for a palmar dislocation of the scaphoid, which he sustained in .an automobile accident. After closed reduction and 4 weeks' immobilization, the patient continued to have "pain on certain movements in rotation of the wrist . . .. " Photographs of x-ray films that were taken at the time of follow-up are included in the article and show a definite widening of the scapholunate cartilage space. Again, at the time this was not appreciated and the text of the report states that the follow-up films "appear like the x-rays of a normal wrist." In 1949 Vaughn-Jackson 2 and RusseIP simultaneously reported several cases of rotary subluxation of the scaphoid. Subsequent to these early reports, several case reports and small series had been published. The detailed anatomic and kinematic studies of Taleisn;.k, 19 Mayfield,20 Kauer,zl and Linscheid et al. 15 further amplified our understanding of the pathomechanics of these intriguing problems. Current evidence suggests that scapholunate instability or rotary scaphoid sublux-
ation represents a rupture of the palmar scapholunate ligament. Rotation of the proximal pole of the scaphoid occurs around the radio-scapho-capitate ligament, thereby widening the distance between the proximal pole'of the scaphoid and the lunate. The scaphoid then rotates into a plane perpendicular to the axis of the palm. Mayfield et al. 22 have shown biomechanical evidence that this injury represents the first stage of a spectrum of ligamentous injuries that result from a hyperextension force on the wrist and culminate in a lunate or perilunate dislocation if a force of sufficient magnitude and direction is applied. . Efforts to maintain anatomic reduction of the scaphoid by closed means after rotatory subluxation have been generally unsuccessful. Closed or open reduction with Kirschner wire fixation has met with only limited success,23 and other proposed surgical procedures, including implant arthroplasty, ligamentous reconstruction, and proximal row carpectomy, are either disabling, cosmetically displeasing, or restrict the patient's ability to perform. S-T-T fusion, as described originally by Peterson and Lipscomb l2 and expanded upon by others, 13. 14 represents an alternative approach to this difficult problem. However, previous studies suffer from a lack of longterm follow-up. Only one of four patients in the Watson and Hempton l3 study and six of the twelve patients in the study by Kleinman et al. 14 were followed for as long as 1 year. Follow-up of our nine patients was at least 1 year
Vol. IIA, No.4 July 1986
Scaphoid-trapezium-trapezoid fusion
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Fig. 3. X-ray films of the symptomatic wrist of G. C. A, Preoperative anterior-posterior view shows prominent scapholunate gap. 8, Preoperative lateral views shows dorsal subluxation of proximal pole of scaphoid and resultant scapholunate angle of approximately 90°. C, Postoperative view shows scaphoid reduced and held in position with two Kir&chner wires . D, Anterior-posterior view at 8-month follow-up shows successful fusion and maintenance of scapholunate reduction.
and averaged 19 months. Further long-term studies are definitely needed to evaluate the possible development of degenerative changes in the carpus secondary to altered intercarpal kinematics. In the short-term study reported here, 33% of the results were considered to be unsatisfactory. We believe that the enthusiasm reported by other authors for this procedure should be tempered by the knowledge that complications may occur. In one patient (C. M.), the fusion was unsuccessful and a nonunion of the fusion mass resulted. The patient's pain has persisted despite a trapezium implant that was subsequently performed at another institution. Another patient (W. H.) had a successful fusion, but postoperative radiographs
showed a scapholunate angle of 90° and the patient continued to compfain of pain postoperatively. A third patient (M. L.) continued to complain of wrist pain postoperatively despite a successful fusion in good position as shown by radiographs. She has subsequently had an extended intercarpal fusion but continues to have significant and disabling pain in the wrist. Fig. 3 shows the radiographs of a representative case. None of the patients had any complaints that referred to their decreased range of wrist motion. Recent studies 24 . 25 confirmed that a range of motion of 5° extension to 30° flexion and 10° radial deviation to 15° ulnar deviation is sufficient to perform most occupations and virtually all activities of daily living.
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Eckenrode, Louis, and Greene
Conclusion
Although neither ROM nor strength is normal after the S-T-T fusion, patients are able to return to work .and perform activities of daily living without pain or the feeling of wrist instability. We believe that this procedure is less disabling and also more cosmetically pleasing than more extensive intercarpal or radiocarpal procedures. We conclude that careful patient selection is extremely important. There should be no evidence of degenerative arthritis of the intracarpal or radiocarpal joints. With these precautions and close attention to operative detail, S-T-T fusion can be an effective treatment for chronic wrist pain secondary to scapholunate instability. The limitation of motion that occurs is within a functional range for most activities of daily living. Further long-term follow-up is needed to determine whether this limitation of motion may result in symptomatic degenerative arthritis of the radiocarpal and remaining intercarpal joints. REFERENCES L Destot E: (translated by R. B. Atkinson FRB): Injuries of the wrist-A radiological study. London, 1925, Ernest Benn Ltd, pp 56-68 2. Vaugh-Jackson OJ: Case of recurrent subluxation of the carpal scaphoid. J Bone Joint Surg [Br) 31:532-3 , 1949 3. Russell TB: Intracarpal dislocation and fracture-dislocation: A review of 59 cases. J Bone Joint Surg [Br) 31 :524-31, 1949 4. Jorgenson EC: Proximal-row carpectomy. J Bone Joint Surg [Am) 51:1104-11, 1969 5. Inglis AE, Jones EC: Proximal-row carpectomy for diseases of the proximal row. J Bone Joint Surg [Am) 59:460-3, 1979 6. Eiken 0: Implant arthroplasty of the scapho-trapezial joint. Scand J Plast Reconstr Surg 13:461-8, 1979 7. Howard FM, Fahey T, Wojik E: Rotary subluxation of the navicular. Clin Orthop 104:134-9, 1974. 8. Gerard FM: Post-traumatic carpal instability in a young child. J Bone Joint Surg [Am) 62:131-3, 1980
The Journal of HAND SURGERY
9. Dobyns JH, Linscheid RL, Chao EYS, Weber ER, Swanson GE: Traumatic instability of the wrist. Instructional course lectures AAOS, vol 24, St. Louis, 1975 10. Taleisnik J: Subtotal arthrodesis of the wrist joint. Clin Orthop 187:81-8, 1984 II . Ricklin P: L'arthrodese radiocarplenne partielle. Am Cir 30:909-11, 1976 12. Peterson HA, Lipscomb PR : Intercarpal arthrodesis . Arch Surg 95 :127-34, 1967 13. Watson HK, Hempton RF: Limited wrist arthrodesis: The triscaphoid joint. J HAND SURG 5:320-7, 1980 14. Kleinman WB, Steichen JB, Strickland JW: Management of chronic rotary subluxation of the scaphoid by scaphotrapezium-trapezoid arthrodesis. J HAND SURG 7: 125-36, 1982 15 . Linschied RL, Dobyns JH, Beabout JW, Bryan RS: Traumatic instability of the wrist: Diagnosis, classification, and biomechanics. J Bone Joint Surg [Am) 54:1612-32, 1972 16. Armstrong GWD: Rotational subluxation of the scaphoid . Can J Surg 11:306-14, 1968 17. Andrews FT: A dislocation of the carpal bones-the scaphoid and semilunar: Report of a case. Michigan medicine 31 :269-71, 1932 18. Buzby BF: Isolated radial dislocation of the carpal scaphoid. Ann Surg 100:553-4, 1934 19. Taleisnik J: The ligaments of the wrist. J HAND SURG 1:110-18, 1976 20. Mayfield JK: Mechanism of .carpal injuries. Clin Orthop 149:45-54, 1980 21. Kauer JMG: The interdependence of carpal articulation chains. Acta Anat 88:481-501, 1976 22. Mayfield JK, Johnson RP, Kilcoyne RK: Carpal dislocation: Pathomechanics and progressive perilunar instability. J HAND SURG 5:226-41, 1980 23. Green DP: Carpal dislocations . In Green DP, editor: Operative hand surgery. New York, 1982, Churchill Livingston Inc pp 718-23 24. Brumfield R, Nickel V, Nickel E: Joint motion in wrist flexion and extension. South Med J 59:909-10, 1966 25 . Palmer AK, Werner FW, Murphy D, Glisson R: Functional wrist motion: A biomechanical study. J HAND SURG lOA: 39-46 , 1985