Patient Satisfaction with Pisiform Excision for Pisotriquetral Instability or Arthritis: A Prospective Review

Abstract

Background Pisotriquetral pain and instability is an elusive cause of ulnar-sided wrist pain. Initial treatment of chronic pisotriquetral pathology should involve a trial of nonoperative therapy such as neutral wrist splint, anti-inflammatories, and intra-articular steroid injections. The mainstay of surgical management of pisotriquetral pain is pisiform excision. Purpose This prospective study seeks to understand patient satisfaction after pisiform excision in patients with isolated pisotriquetral pathology. Patients and Methods A consecutive series of nine cases of pisiform excision was performed by the senior surgeon. The primary outcome measure was determined a priori to be the Patient-Rated Wrist Evaluation (PRWE) score. Wrist range of motion, grip strength, and QuickDASH (shortened version of Disabilities of the Arm, Shoulder and Hand) scores were also collected preoperatively and at 3 and 12 months postoperatively as secondary outcome measures. Results There was a very rapid improvement in the PRWE by 3 months, which was maintained at 12 months. The QuickDASH score was slower to improve, with a significant improvement by 12 months. There was no change in grip strength or wrist range of motion at any time point. Conclusion Pisiform excision results in a very rapid improvement of symptoms and should be considered in cases of pisotriquetral instability or arthritis that fail conservative management. Level of Evidence Level IV, case series.

Keywords: patient-reported outcome measures; pisiform arthritis; pisiform excision; pisotriquetral instability.

Fig. 1

Axial and lateral cuts of a CT scan of the wrist illustrating decreased joint space, osteophytes, and subchondral sclerosis of the pisotriquetral joint. Subchondral cysts may also be present.

Fig. 2

Our typical Bruner incision for excision of the pisiform. Care must be taken to identify and protect the ulnar nerve.

Fig. 3

Cadaveric dissection illustrating the course of the ulnar nerve relative to the FCU tendon and pisiform. Note that it is not necessary to dissect the nerve out proximally. a, ulnar artery; n, ulnar nerve; p, pisiform within the flexor carpi ulnaris tendon.

Fig. 4

The FCU tendon is split longitudinally to isolate and excise the pisiform. a, ulnar artery; n, ulnar nerve; p, pisiform within the flexor carpi ulnaris tendon.