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Surgical Management of Fixed VISI Deformities
Abigail J Bardwell, DO; Courtney R Carlson Strother, MD; Alexander Y Shin, MD
Mayo Clinic, Rochester, MN
Hypothesis: The reported outcomes of surgical treatment of patients with fixed volar intercalated segment instability (VISI) deformities is sparse and only exists in the forms of case reports or small series. We hypothesized that soft tissue reconstructions (tenodesis with ligament reconstruction) would result in inferior correction of VISI deformities and have poorer outcomes than bony reconstruction (motion sparing procedures: scaphoidectomy + 4 corner fusion, radiolunate fusion, lunotriquetral fusion, proximal row carpectomy [PRC], or total wrist fusions) for patients with symptomatic VISI carpal deformities.
Methods: A retrospective review of all patients who were evaluated for symptomatic fixed VISI deformities between 2000-2021 was performed. Patients with fixed and painful VISI deformity who underwent operative management were included. Medical records, surgical technique, and radiographs were reviewed. Primary outcome was reported pain at final follow up. Secondary outcomes included surgical complications and post-operative correction of radiolunate angle (RL angle) on radiographs.
Results: Twenty-eight patients were identified with fixed painful VISI deformities that underwent surgery, of which 16 (57%) were male. Average age and average follow up was 43.5 and 1.9 years, respectively. The etiology of fixed VISI deformity was prior trauma (n=23, 76.7%), inflammatory conditions (n=3, 10.7%), and other miscellaneous causes (n=4, 14.3%). Surgical management included soft tissue reconstruction, limited carpal or radiocarpal fusions, PRC, and total wrist fusion.
Per surgical group, the total wrist arc of motion, radiographic VISI correction, reports of continued pain, and complications were as follows:
| Procedure (n=30) | Pre-op wrist ROM | Post-op wrist ROM | Pre-op RL angle | Post-up RL angle | Pain at final follow-up | Complications |
| Soft tissue reconstruction (n=12) | 103.8° | 88.1° | -39.8° | -41.0° | 3/12 (25%) | 1 failed -> PRC |
| Motion sparing limited fusion (n=8) | 73.0° | 56.2° | -43.7° | -21.3° | 3/8 (37.5%) | 1 hardware prominence |
| PRC (n=6) | 115.8° | 58.8° | -29.0° | -- | 2/6 (33%) | 2 failed -> total wrist fusion |
| Total wrist fusion (n=4) | 86.3° | -- | -40.5° | -- | 0/4 (0%) | 1 iliac crest infection site, 1 loose hardware |
Summary: In summary, surgical management of VISI deformity remains a challenging problem, with nearly 1/3 of patients reporting continued pain post-operatively regardless of the surgical procedure. Total wrist arthrodesis was the most reliable method of relieving pain, but comes at the sacrifice of wrist motion. Further studies to elucidate the best treatment option for painful VISI deformity are warranted to balance optimal pain relief with sparing wrist motion if possible.
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