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CASE REPORT

Illinois Bone & Joint Institute

University of Illinois Orthopaedic Surgery

I have seen several of these. I have been impressed that my residents have been able to reduce all in the ED under sedation. That removes the urgency for immediate CTR. As an aside I had a patient with single arm function due to polio on his other side, with a handicap under 10 and dislocated an old... Swanson silastic lunate into his carpal tunnel with acute CTS. I have have approached all volarly, including carpal tunnel release, and capsular repair to the radius. I have not gone dorsal or pinned them. I immobilized all for 6 weeks. All did well for the time that I followed them for at least a year, but I am unclear about long term follow-up. They did not present back to our group or in town as we are pretty close with keeping each other informed.I humbly know that long term follow up will ruin early results. I do not fault the 360 approach as it is the time zero kitchen sink approach, and unlikely to cause significant morbidity. No one can say if fell apart because it was under treated.

Thanks for sharing the case There must be another option for initial management,in my humble opinion… Reduction closed (if possible) +\- CTR and planned reconstruction open As Dr Vitale said,there is plenty of articles that shows no need of reconstruction of volar or volar approach,including this gr...eat review from JHS The only benefit volar is to help to reduction,in my opinion I leave 7-9w kw unless reinforcements with Szabo or internal sling-> 4w Nice case Thanks for sharing

The xrays look great Dr. Forsthoefel. Other than doing a CTR, was there any ligamentous repair done via the volar approach. The decision to do a combined volar/dorsal approach versus just a dorsal approach for perllunate fracture dislocations remains controversial. We reviewed the literature seve...ral years ago in the journal of hand surgery, and the body of evidence did not support a volar approach unless needed for carpal tunnel release.

PMID: 25459380

J Hand Surg Am. 2015 Feb;40(2):358-62; quiz 362. Epub 2014 Nov 15.

Perilunate dislocations.

J Hand Surg Am. 2015 Feb;40(2):358-62

Mark A Vitale | Mani Seetharaman | David E Ruchelsman

Agree with comments and the case. Unfortunately, despite a beautiful reduction and perfectly placed K-wires, long term prognosis is guarded and there isn't great evidence or experience that the suture anchor and repair will hold and prevent development of SLAC wrist. Regardless, this is the best o...ption we have at the moment and should probably be performed as it was done here.

There are various ways to approach this injury. I respect all of the various approaches to this injury listed here. I am commenting as I was asked to comment I always tell patients this is a devastating injury and set limited expectations from the outset. That being said I've often had patients ...with surprisingly good results. Through various trauma centers I've been associated with I've treated several dozen of these injuries. That being said results are unpredictable. I've had one college football player I treated on the day of injury with very good post-operative films, great motion, and no pain at 6-9 months that completely fell apart at a year post-surgery requiring a scaphoid excision and four-corner fusion. This patient has acute compression of the median nerve. That has to be addressed with dispatch as 24 hours have already passed and the pressure and potential damage on the nerve from this trauma far exceeds that of simple carpal tunnel syndrome. I would consider an attempt at a closed reduction which if successful will let me address the dislocation electively as long as the median nerve dysfunction resolves with closed reduction. If the closed reduction fails we will need to proceed to the OR today If the closed reduction is successful and the median nerve symptoms resolve with reduction of the lunate this can be treated through a single dorsal approach to repair the SL ligament. If a single dorsal approach is selected careful inspection of Gilula's lines should be used to document the reduction of the lunotriquetral joint . If there is a step at the lunotriquetral joint with disruption of Gilula's proximal line which can not be corrected closed, I have found a volar approach to repair the volar lunotriquetral ligament helps restore that alignment If close reduction fails, or median nerve symptoms are not relieved by a successful closed reduction, a median nerve decompression is warranted urgently. A slight extension of the median nerve incision using a radially based chevron to cross the proximal wrist crease is all the additional exposure needed to reduce the lunate and suture the lunotriquetral ligament. I have found this is the quickest part of the case and does not decrease ultimate wrist motion The scapholunate ligament should be repaired. Traditionally I have done this with suture anchors. Pinning the SL interval the LT interval from the scaphoid to the capitate and from the triquetrum to the capitate each with 2 k wires along with prolonged casting helps the repair heal Although I have not yet done this, based on my experience with SL 360 reconstruction with internal bracing, if a two-incision approach has been done secondary to failure of closed reduction of the lunate or persistent median nerve dysfunction I might support the scapholunate ligament repair with an internal brace construct to allow for earlier mobilization next time I have one of these injuries.

PMID: 27076742 J Orthop. 2016 Sep;13(3):123-6. Epub 2016 Mar 26.

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Clinical outcome of anterior vs posterior approach for cervical spondylotic myelopathy.

OBJECTIVE
- The aim is to demonstrate whether there is clinical difference between posterior vs anterior decompression in cervical spondylotic myelopathy.

METHODS
- Forty-two patient database was obtained from the Centro Medico Nacional de Occidente in Mexico, those who underwent surgical treatment for cervical myelopathy with a mean 1.4 year follow-up.

RESULTS
- Patients were divided; group A (45%) anterior approach and group B (55%) posterior approach, for mJOA, group A had a lower score compare with group B. While in the Nurick score group B got a higher score compare with group A.