Two-stage treatment of neglected perilunate wrist dislocations

INTRODUCTION: The treatment of neglected perilunate dislocations of the wrist remains a complex challenge for surgeons. To address this issue, hand surgeons have several options in their arsenal: open reduction, lunate excision, proximal row carpectomy, arthrodesis, and arthroplasty. Open reduction appears to be an attractive approach, as it allows restoring normal wrist anatomy with preserving the possibility of future procedures in case of failure. However, there is no consensus among contemporary surgeons regarding the acceptable time interval between injury and surgery. Likewise, opinions differ on the technique of reduction itself. CASE DESCRIPTION: The treatment of 8 patients aged 24 to 42 years with neglected perilunate dislocations was analyzed. The interval between injury and surgery ranged from 1.5 to 19 months. The first stage involved application of an Ilizarov external fixator for gradual preoperative distraction of the wrist joint. After 2–4 weeks, the Ilizarov external fixator was removed, and open reduction followed by fixation with wires was performed. At the second stage, in three cases, scaphoid osteosynthesis with a screw and free bone grafting were additionally performed. In all cases, gradual distraction enabled progressive soft tissue elongation without ischemic or neurological complications. At the second stage, all perilunate dislocations were successfully reduced via open approach. Functional outcomes were assessed 6 to 60 months after open reduction using the Mayo wrist score. Hand function improved in 6 patients (60–80 points) and was fully restored in 2 patients with a 1.5-month injury duration (100 points). In patients (3) with scaphoid pseudarthrosis, bone union was achieved. In the long-term follow-up, 3 patients developed radiological signs of post-traumatic wrist osteoarthritis, including partial resorption of the lunate, capitate, and hamate in 2 cases. CONCLUSION: Preliminary wrist joint distraction facilitated and simplified the performance of open reduction of neglected perilunate dislocations of the carpal bones. The functional outcome in our patients depended on the time elapsed since injury and the presence of associated carpal fractures. The question of a time limit after injury for which open reduction remains a justifiable option remains unresolved.