Effect of Pisiform Excision or Pisotriquetral Arthrodesis as a Treatment for Pisotriquetral Arthritis: A Biomechanical Study (2022)


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The Journal of Hand Surgery

Volume 38, Issue 10,

October 2013

, Pages 1913-1918


To determine whether flexor carpi ulnaris (FCU) forces and tendon displacements change after pisotriquetral arthrodesis or after pisiform excision.

(Video) Evaluation & Management of arthritis of the Wrist and Hand: Michael Baskies, MD


Nine cadaver wrists were moved through 4 variations of a dart throw motion, each having an oblique plane of motion, but with different ranges of motion and different antagonistic forces. The FCU tendon force and movement were measured in the intact wrist, following pisotriquetral arthrodesis, and following pisiform excision. Changes in force and tendon movement were compared using a repeated measures analysis of variance.


After excision of the pisiform, a significantly greater FCU force was required during the 2 variations of the dart throw motion having a larger range of motion and during the smaller motion having a larger antagonistic force. Pisotriquetral arthrodesis did not cause a significant increase in the peak FCU force. Excision of the pisiform caused the FCU tendon to significantly retract during all wrist motions as compared to the intact wrist or after pisotriquetral arthrodesis.


Greater FCU forces are required to move the wrist when the pisiform with its moment arm function has been removed. This occurs during large oblique plane wrist motions and also in a smaller motion when greater antagonistic forces are applied. Excision of the pisiform also allows the FCU to move proximally, again because its moment arm function has been eliminated.

Clinical relevance

Excision of the pisiform requires greater FCU forces during large wrist motions and during motions that include large gripping forces such that excision may be a concern in high-demand patients with pisotriquetral arthritis. Although pisotriquetral arthrodesis does not alter the mechanical advantage of the FCU, its use in high-demand patients with pisotriquetral osteoarthritis cannot yet be recommended until the effects of that arthrodesis on midcarpal kinematics are further clarified.

Section snippets


Nine fresh-frozen right cadaver wrists (average, 68 years; 5 female, 4 male) were tested in a wrist joint motion simulator13 by pulling on 5 wrist flexor and extensor tendons to cause wrist motion under computer control (Fig.1). Each wrist was thawed the previous day and prepared for testing by dissecting 3 wrist extensors (extensor carpi ulnaris, extensor carpi radialis brevis, and extensor carpi radialis longis) and 2 wrist flexors (FCU and flexor carpi radialis). The flexor and extensor


After excision of the pisiform, a significantly greater FCU force (Table1, Fig.2) was required to move thewrist during both of the larger wrist motions (P<.002) and during the smaller wrist motion with a larger antagonistic force (P < .001) compared to the intact wrist. In the smaller wrist motion with the smaller antagonistic force, there was not a significant difference in the FCU force between pisiform excision and the intact wrist (P > .99).

There was no significant difference in the


During high-demand wrist activities, such as in competitive sports or in heavy manual tasks, greater wrist tendon forces are required. The purpose of this study was to determine whether greater FCU forces might be required in simulated low-demand and high-demand activities with pisiform excision. We differentiated between low-demand and high-demand activities by changing the amount of the force resisting (antagonistic to) a wrist motion.

In the simulated low-demand patient (lower antagonistic

References (17)

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Cited by (10)

  • Pisiformectomy in advanced pisotriquetral joint arthritis: A retrospective study of 12 wrists with a mean follow-up of 7.5 years

    2019, Hand Surgery and Rehabilitation

    Trail et al. [4], in a case series of 12 patients (mean age of 31 years), reported significantly decreased grip strength (86% of the contralateral wrist). O’Keefe et al. [9], in a biomechanical study, found greater FCU excursion in extreme range of motion after pisiformectomy and while carrying heavy loads because the pisiform acts as a pulley. Increasing the FCU excursion leads to decreased FCU force during these tasks.

    Pisiformectomy is the gold standard treatment for pisotriquetral arthritis resistant to conservative treatment. We evaluated the long-term clinical and functional outcomes after pisiformectomy in resistant pisotriquetral arthritis cases. We retrospectively evaluated 11 patients (12 wrists), mean age of 59 years (49–69) treated by pisiformectomy using a standardized surgical technique. Pisiformectomy was performed for primary osteoarthritis in 10 cases, for post-traumatic osteoarthritis in 1 case and for pisotriquetral instability in 1 case. The clinical and functional evaluation was carried out by an independent examiner. Mean time to review was 90 months (63–151). Pain on a Visual Analog Scale (/10) decreased significantly to 1.1 from 6.8 preoperatively. Mean range of motion was 79° in flexion, 61.5° in extension, 18° in ulnar deviation and 36° in radial deviation. Mean grip strength of the operated wrist was 86% of the non-operated wrist. Functional scores significantly improved with a gain of 40 points for the QuickDASH and 53 points for the PRWE. Based on this long-term follow-up study, pisiformectomy seems to alleviate wrist pain and improve the quality of life in a low-demand population with pisotriquetral osteoarthritis resistant to conservative treatment. When compared to the pisotriquetral arthrodesis, pisiformectomy is easier to perform, allows quicker mobilization of the wrist and leads to good functional outcomes.

    La pisiformectomie représente la solution chirurgicale la plus utilisée en cas d’échec d’un traitement médical bien conduit dans l’arthrose piso-triquétrale. L’objectif de cette étude était d’évaluer les résultats cliniques et fonctionnels à long terme de cette technique. Il s’agit d’une étude rétrospective monocentrique portant sur 11 patients (12 poignets), d’âge moyen 59 ans (49–69), opérés d’une pisiformectomie selon la même technique chirurgicale. Dans 10 cas, l’étiologie était l’arthrose piso-triquétrale essentielle. Il y avait un cas d’arthrose post-traumatique et une instabilité de l’articulation piso-triquétrale. Une évaluation clinique et fonctionnelle a été réalisée par un examinateur indépendant. Le recul moyen à la révision était de 90 mois (63–151). On retrouvait une amélioration significative de la douleur avec une évaluation visuelle analogique moyenne évaluée à 1,1/10 (versus 6,8/10 en préopératoire). Les mobilités moyennes du poignet étaient de 79°, 61,5°, 18° et 36° en flexion, en extension, en inclinaison ulnaire et en inclinaison radiale respectivement. La force de poigne était de 86% par rapport au côté opposé. Les scores fonctionnels étaient également améliorés significativement avec un gain de 40 points pour le QuickDASH et 53 points pour le PRWE. Au vu de cette étude au recul important, la pisiformectomie semble apporter l’indolence et améliorer le confort de vie chez les patients porteurs d’une arthrose piso-triquétrale avancée. En comparaison à l’arthrodèse piso-triquétrale, principale alternative chirurgicale, la pisiformectomie a l’avantage de la simplicité de réalisation, mais également des suites opératoires rapides permettant de maintenir les mobilités articulaires du poignet.

  • Management of Pisotriquetral Instability

    2018, Journal of Hand Surgery

    It is well-described to be an effective pain-relieving operation with minimal associated functional deficit. O’Keefe et al20 published a biomechanical comparison of pisiformectomy versus pisotriquetral arthrodesis by moving 9 cadaver wrists through variations of a dart-throwing motion. The main difference between cadaver wrists after pisiformectomy and pisotriquetral arthrodesis was the FCU force needed to flex the wrist when the wrist was in extension.

    Pisotriquetral instability is an often-overlooked condition that can lead to ulnar-sided wrist pain and dysfunction. Various case series and biomechanical studies have been published regarding the diagnosis and treatment of this condition. We review current methods for examining, diagnosing, and treating pisotriquetral instability.

  • Distal radius joint surface reconstruction using a pedicle pisiform osteochondral transfer

    2015, Journal of Hand Surgery

    However, graft harvesting was particularly difficult, and all of the patients complained of temporary donor site pain. A biomechanical study in cadavers demonstrated that a significantly greater FCU force was required to move the wrist after excision of the pisiform,21 and a slight, but not clinically significant, decrease in wrist flexion strength after excision of the pisiform has also been reported.22 In contrast, in a follow-up of more than 30 years, excision of the pisiform provided complete pain relief in almost all of the painful pisotriquetral joints with no loss of wrist motion or strength.23

    Treatment of a large articular cartilage defect in the distal radius poses a significant challenge to hand surgeons. To reduce the development of secondary degenerative arthritis, restoration of the articular surface is preferable. Pedicle pisiform transfer has been reported as a useful treatment option for Kienböck’s disease. We describe a surgical technique involving vascularized pisiform transfer for large cartilage defects after intra-articular distal radius fractures and highlight the vascular supply of the pisiform.

    (Video) Hand and Wrist Arthritis - ABOS Orthopedic Surgery Board Exam Review
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Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.


Can the pisiform bone be removed? ›

Surgery is the only definitive treatment for persistent symptoms. The usual indication is pain and consequent functional difficulties. The operation involves removal of the pisiform bone. The function of the tendon is not altered by its removal.

What is Pisotriquetral arthritis? ›

Pisotriquetral (PT) osteoarthritis (OA) and enthesopathy of the flexor carpi ulnaris (FCU) are pathologies of the hypothenar eminence which both often remain undiagnosed, but can cause ulnar wrist pain. This study determined the prevalence of these pathologies in an older donor population.

How is pisiform pain treated? ›

Treatment for pisotriquetral arthritis

Conservative treatment of pisotriquetral arthritis consists of local injections of steroid into the pisotriquetral joint along with nonsteroidal anti-inflammatory drugs (NSAIDs) and a protective splint.

What is Pisiformectomy? ›

Conclusions Pisiformectomy is a surgery used sparingly in cases with refractory pain associated with arthrosis of the pisotriquetral joint or enthesopathy of the flexor carpi ulnaris/pisiform interface.

How long does it take for pisiform bone to heal? ›

Most patients with a pisiform fracture can be treated with cast immobilization for 4 to 6 weeks. Conservative management for non-displaced triquetrum body fractures or dorsal chip fractures involves a short arm cast for 4 to 6 weeks.

Do you need your pisiform bone? ›

The pisiform bone may provide mechanical stability to the ulnar column of the wrist by preventing triquetral subluxation. Thus, surgical excision of the pisiform might cause loss of function to the wrist.


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