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History of Hand Research at UTMB

The biomechanics and basic hand surgery research efforts of the current Division of Hand Surgery in the Department of Orthopaedics and Rehabilitation at the University of Texas Medical Branch in Galveston, Texas began in 1984. The initial efforts were spearheaded by Steven F. Viegas, M.D. and Allen Tencer, Ph.D. utilizing Pressure sensitive Fuji film. The group was soon joined by Dr. Rita Patterson who assumed an increasing roll in and direction of the research efforts following Dr. Tencer’s departure in 1985.  Since then the Hand Surgery Division has continued to be dedicated to furthering knowledge in the area of wrist anatomy, kinematics and kinetics. It has been extremely productive under the direction of Rita Patterson, Ph.D. along with the efforts of a long list medical students, orthopaedic residents, international research fellows, doctorate, and post doctorate students as well as a variety of other collaborators.  This overview of some of the past efforts and our current capabilities is a tribute and a thanks to all those that have previously passed through our laboratory and our lives, who currently share them.  And to those future visitors, colleagues and friends, we look forward to our time together. 

Clarence “Nic” Nicodemous joined us in 1992, first as a doctoral student and subsequently stayed on adding to our expertise in the field of kinematics. Bill Buford, Ph.D. also joined our effort arriving from the Carville Hospital in Louisiana where he had previously worked with Dr. Dan Riordan and Dr. Paul Brand.

Our current capabilities include research in basic anatomy, comparative anatomy, load mechanics (kinetics), kinematics, 3-D image analysis, computer animation and modeling.

The original UTMB medical school building which was built in 1891 and restored in 1994  is the location of a wonderful anatomy lab on its top floor, which offers ample access to both fresh and embalmed cadaver specimens with the assistance and continued support of  the Anatomy Department.  Much of our detailed dissection is carried out in the Orthopaedic Biomechanics Lab in Rebecca Sealy Hospital.  Previous anatomy studies have among other things identified two distinct types of carpal morphology of the wrist most evident by different shapes of the lunate, of which the Type 1 lunate has a single distal surface which articulates with the capitate while the Type 2 lunate has two distinct distal surfaces one facet articulating with the capitate and the other with the hamate (Figure 1). Anatomy dissections and sections through the wrist demonstrate the differences between these two basic patterns of carpal morphology (Figure 2, Figure 3, Figure 4, Figure 5). These differences in some cases can be seen on radiographs (Figure 6) but are not always easily or reliably identified.  Anatomy studies have also identified that the most common location of degenerative changes in the wrist was identified to be at the proximal pole of the hamate (Figure 7) which was found to have a strong correlation with the presence of the type 2 lunate.

The Biomechanics laboratory also has the capabilities to study the particular properties of the ligaments which include precise measurements of the dimensions of a ligament (Figure 8) and testing of specific mechanical properties of the ligaments (Figure 9). With this strong interest in the anatomy of the human wrist, studies of variability and comparative anatomy (Figure 10) have been conducted and continue. 

Specific programming has been developed at UTMB for edge identification and contouring to allow the accurate and quantifiable reproduction and study of three dimensional models of the skeletal anatomy based on two dimensional CT scans. This process begins with an individual CT scan (Figure 11) which is analyzed by an automated edge identification and contouring program (Figure 12). Individual contours of the bone are assembled (Figure 13) and surface tiling programs with color and shading capabilities allow for the construction of a three dimensional image of a bone such as the scaphoid (Figure 14) or the entire wrist which can be seen from any perspective, such as the dorsal view (Figure 15) or the carpal tunnel view (Figure 16).

Pressure sensitive Fuji film has been utilized to study the contact areas and pressures with in the wrist joint in a variety of conditions including the normal wrist in various positions under various magnitudes of load and/or load paths, various ligament injuries,  fracture patterns and various types of surgical procedures.  The Fuji pressure sensitive film has increasing red coloration with increasing load (Figure 17). A dorsal opening in the dorsal wrist capsule is made and an external marker is affixed to the dorsal radius. The Fuji film transducer can be made with the two components of the film (Figure 18) and placed in to the wrist joint. The wrist can then be loaded resulting in red coloration on the pressure sensitive film at the external marker and under the scaphoid and lunate where they would contact and load the radius. This pressure sensitive film is then analyzed to give area and pressure data. This data can be utilized to show the changing pattern of contact on the radius (Figure 19) which compares on the left, a pressure sensitive film print of a normal wrist in one position and load where most of the red imprint is located in an area between the lunate and the radius, while on the right side of the figure most of the red imprint has shifted to the scaphoid fossa where the same wrist was used in the same position and with the same magnitude of load the only difference being a scapholunate dissociation was surgically simulated. The pressure sensitive film studies have always, as in this case, revealed that the areas of increased load coincide with where we see joint space narrowing and arthritis develop in the clinical conditions that are simulated such as on the x-ray in Figure 20 where the arrow points to the joint surface which coincides with that so-called SLAC wrist (scapholunate advance collapse). Other pressure film studies have included the study of the proximal pole fracture of the scaphoid where Fuji film imprints again show a good correlation between increased load and the development of arthritis. Figure 21 shows increased load (red coloration) between the distal scaphoid fragment and the radial styloid which coincides with the area where degenerative changes are seen in a long standing scaphoid non-union of the proximal pole (Figure 22). The pressure sensitive film studies have also shown a good correlation between a decrease or no change in load and absence of arthritic changes. Figure 23 shows decreased or no change in load (red coloration) under the proximal pole of the scaphoid and the lunate where the joint space between the proximal pole of the scaphoid and the radius, and between the lunate and the radius are maintained and do not develop degenerative changes, even in a long standing non-union of the proximal pole of the scaphoid (Figure 24) .

Over more recent years there has been an increased interest and efforts mounted to study the kinematics of the wrist and its individual carpal bones. This is accomplished by a combination of CT imaging and reconstruction, with motion analysis systems.   Under fluoroscopic control triad video reflective pins are placed in the specific bones which are targeted for study (Figure 25).  Tendons are dissected  free to allow loading and motion of the wrist. The upper extremity is mounted to an apparatus which allows passive or indirect active mobilization of the wrist (Figure 26). The wrist is mobilized and six cameras of the motion analysis system track the external pin markers attached to the targeted bones while the wrist is going through its range of motion. Before and after motion analysis CT scans are obtained with the triad pins in place. Individual CT scans, some of which include the triad pins (Figure 27) are utilized to reconstruct the individual carpal bones along with the video reflective balls of each individual triad pin (Figure 28). This allows the visualization of instantaneous screw axes (Figure 29), the equivalent of time lapse progressive and changing positions of one bone relative to another fixed bone (Figure 30) and with the analysis of the images, the proximity of the subchondral bone between two bones within given ranges (Figure 31), which is an indirect and noninvasive way to analyze the inferred contact, can be mapped. This is an alternative to using pressure sensitive film (Figure 32) which has the added benefit of being able to noninvasively and simultaneously demonstrate the proximity mappings (areas of inferred contact) in the radiocarpal joint (Figure 33), midcarpal joint (Figure 34) carpometacarpal joints (Figure 35), distal radioulnar joint (Figure 36) and virtually any other within the reconstructed image.

All of these resources can be utilized to study an area such as the scaphotrapeziotrapezoid joint. We can document the skeletal variations such as the presence or absence of and interfacet ridge on the distal articular surface of the scaphoid, study the anatomy of the associated ligaments to hypothesis the relationship of the soft tissue ligamentous anatomy and the skeletal morphology with its impact on and constraints to the motions of that joint (Figure 37) and test and demonstrate the kinematics of that joint. (Figure 38 and Figure 39). This has been done with the STT joint and what the skeletal and ligamentous anatomy suggested was the motion is constrained to an axis of rotation which runs essentially perpendicular to the orientation of the interfacet ridge which aligns with the scaphotrapeziotrapezoid ligament attachment on the scaphoid and scaphocapitate ligament and this motion plane is the same whether the wrist as a whole is moving in flexion extension or radioulnar deviation.

Many other studies are on going and still more are targeted for future times and visitors who wish to participate in research in the field of the hand, wrist, forearm and elbow and to share in our enthusiasm and enjoyment in research.

Past Fellows

Amir Alemohammad, MD.

Naoya Yazaki, M.D., May 2006 - Dec 2007
Nagoya University, Japan.

Geetinder Goyal, M.D., May 2005 - May 2006
Punjab University, Chandigarh, India.

Mitsuhiko Nanno, M.D., Ph.D., March 2005 - March 2006
Department of Orthopaedic Surgery, Nippon Medical School, Tamanagayama Hospital, Tokyo, Japan.

Akira Iwamoto, M.D., July 11, 2004 - July 27, 2005
Department of Orthopaedic Surgery, Dokkyo University School of Medicine, Tochigi, Japan.

Shukuki Koh, M.D. Sept 4, 2003 - Aug 31, 2005
Department of Hand Surgery, Nagoya University School of Medicine, Nogoya, Japan

Soya Nagao M.D., July 15, 2002 - Sept. 15, 2003
Department of Orthopaedic Surgery, Present Nihon Univ. School of Medicine, Tokyo, Japan.

Ryo Yoshida, M.D.,
St. Marianna University School of Medicine, Kawasaki, Japan.

Hiromichi Mitsuyasu, M.D.,
Kyushu University, Fukuoka, Japan.

Muhammad Jawaid Meraj, M.D., Clinical Hand Surgery Fellowship, July 18, 2001 - Aug. 24, 2001
Chief Resident Orthopaedics, Division of Surgery, The Aga Khan University Hospital, Stadium Road, Karachi, Pakistan

Maria Angelica Orellana, M.D.
University of Buenos Aires, Buenos Aires, Argentina.

Maged El-shennawy, M.D., Sept. 29, 1999 – Sept. 2001
Department of Orthopaedic Surgery, Mansoura University Hospital, El-Mansoura, Egypt.

Denju Osada, M.D.,  April 3, 2000 - Nov. 30, 2000
Dokkyo University School of Medicine, Tochigi, Japan.

Koji Nakamura M.D., Sept. 15, 1998 – March 2000
Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan.

Hisao Moritomo M.D.,  June 11, 1998 – July 6, 1999
Department of Orthopaedic Surgery, Kansai Rosai Hospital, Amagasaki City, Japan.

Johan Carel Goslings M.D., Ph.D., October 1, 1998 – Dec. 31, 1990
Surgical Resident Academic Medical Centre, Amsterdam, The Netherlands.

Satoshi Yamaguchi M.D., Sept. 1, 1996 – Sept. 31, 1998
Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan.
Dr. Yamaguchi  has opened a new private clinic in Tokyo. 

Andre Ayalla Rodrigues, M.D., Oct. 15, 1998 – Nov. 25, 1998
Auxiliary Professor at the Faculdade de Ciencias Medicas-Universidade de Pernambuco (discipline of orthopedic), Brazil.

Emiko Horii, M.D., Feb., 1994
Department of Orthopaedics at Nagoya University, Nagoya Japan.

Conferences and Awards

The 58th Annual Meeting of the American Society for Surgery of the Hand, Chicago, Illinois, Sept.  18 - 20, 2003. 

Award for Best Scientific Content: "Three-Dimensional Description of  Ligamentous Attachments around the Lunate," Soya Nagao MD, William L. Buford Jr. PhD, Clark R. Andersen BS, Rita M. Patterson, PhD, Munir A. Shah MD, Steven F. Viegas MD

The 55th Annual Meeting of the American Society for Surgery of the Hand, Seattle, WA, October 5 - 8, 2000. 

Award for Best Scientific Content: "The Second through Fifth Carpometacarpal Joints: Anatomy and Kinematics Analysis," Nakamura, K., Viegas, S.F., El-Shennawy, M., Patterson, R., and Elder, K.

Emanuel B. Kaplan Award for "anatomical excellence in surgery of the hand": "The Scaphotrapeziotrapezoid Joint: An Anatomy, Radiographic and Kinematic Study,"  Moritomo, H., Nakamura, K., Viegas, S.F., Patterson, R., and Elder, K.

The 54th Annual Meeting of the American Society for Surgery of the Hand, Boston, MA, September 2-4, 1999

Award for Best Scientific Content: "The STT Joint-Anatomic, Radiographic and Kinematic Study," a joint collaboration with Moritomo, H. Viegas, S.F., Patterson, R.M., Elder, K., Nakamura, K., and DaSilva, M.F.

The 52th Annual Meeting of the American Society for Surgery of the Hand, Denver, CO, September 1997.

Award for Best Scientific Content: "The Pisotriquetral Joint: Anatomy and Kinematics," Yamaguchi, S., Beppu, M., Viegas, S.F., and Patterson, R.M.

Award for Best Layout and Presentation: Scientific exhibit entitled "Telemedicine Hand Clinic."

The 49th Annual Meeting of the American Society for Surgery of the Hand, Cincinnati, OH, October 1994.

Award for Best Scientific Content: "Kinematic Analysis and Dynamic Visualization of the Carpus," Nicodemus, C.L., Viegas, S.F., Elder, K.W., and Patterson, R.M.

Selected Publications

1. Viegas, S.F., Patterson, R.M., Tencer, A., Peterson, P., Roefs, J., and Choi, S., "The Effects of Various Load Paths and Different Loads on the Load Transfer Characteristics of the Wrist," J. Hand Surgery, 14A:458-465, May 1989.

2. Viegas, S.F., Rimoldi, R., and Patterson, R.M., "A Modified Technique of Intramedullary Fixation for Wrist Arthrodesis, "J. Hand Surgery, 14A:618-623, 1989.

3. Viegas, S.F., Patterson, R.M., Peterson, P.D., Pogue, D.J., Jenkins, D.K., Sweo, T.D., and Hokanson, J.A., "The Evaluation of the Biomechanical Efficacy of Limited Intercarpal Fusions for the Treatment of Scapho-Lunate Dissociation," J. Hand Surgery, 15A(1):120-128, January 1990.

4. Viegas, S.F., Patterson, R.M., Peterson, P.D., Pogue, D.J., Jenkins, D.K., Sweo, T.D., and Hokanson, J.A., "Ulnar Sided Perilunate Instability: An Anatomic, Biomechanic, and Clinical Study," J. Hand Surgery, 15A(2):120-128, March 1990.

5. Viegas, S.F., Wagner, K., Patterson, R.M., and Peterson, P.D., "The Medial (Hamate) Facet of the Lunate," J. Hand Surgery, 15A:564-571, 1990.

6. Viegas, S.F., Pogue, D.J., Patterson, R.M., and Peterson, P.D., "The Effects of Radioulnar Instability on the Wrist:  A Biomechanical Study," J. Hand Surgery, 15(5):728-732, September 1990.

7. Pogue, D.J., Viegas, S.F., Patterson, R.M., Peterson, P.D., Jenkins, D.K., Sweo, T.D., and Hokanson, J.A., "The Effects of Distal Radius Fracture Malunion on Wrist Joint Mechanics," J. Hand Surgery, 15(5):721-727, September 1990.

8. Viegas, S.F., Patterson, R.M., Peterson, P.D., Crossley, M., and Foster, R.A., "The Silicone Scaphoid:  A Biomechanical Study," J. Hand Surgery, 16(1):91-97, 1991.

9. Daum, W.J., Patterson, R.M., Cartwright, T.J., and Viegas, S.F., "Comparison of Cortical and Cancellous Screw Pull-Out Strengths About the Posterior Column and Sacro-Iliac Joint," J. Orthopaedic Trauma, 5(1):34-37, 1991.

10. Viegas, S.F., Patterson, R.M., Hillman, G.R., Peterson, P.D., Crossley, M., and Foster, R.A., "The Simulated Scaphoid Proximal Pole Fracture: A Biomechanical Study," J. Hand Surg., 16A:495-500,1991.

11. Viegas, S.F., Patterson, R.M., Todd, P., and McCarty, P., "Load Transfer Characteristics of the Midcarpal Joint," J. Hand Surgery, 18A:14-18, January 1993.

12. Viegas S.F., Hillman, G., Elder, K. Stoner, D., and Patterson, R.M., "Measurement of Carpal Bone Geometry by Computer Analysis of 3-D CT Images," J. Hand Surgery, 18A(2): 341-349, March 1993.

13. Viegas, S.F., Patterson, R.M., Hokanson, J.A., and Davis, J., "Wrist Anatomy: Incidence, Distribution and Correlation of Anatomy, Tears and Arthritis," J. Hand Surgery, 18A:463-475, May 1993.

14. Tagare, H.D., Elder, K.W., Stoner, D.M., Patterson, R.M., Nicodemus, C.L., Viegas, S.F., and Hillman, G.R., "Location and Geometric Description of Carpal Bones in CT Images," Annals of Biomedical Engr. 21:715-726, 1993.

15. Viegas, S.F., Patterson, R.M., and Ward, K., "Extrinsic Wrist Ligaments in the Pathomechanics of Ulnar Translation Instability," J. Hand Surgery, 20A(2):312-318, March 1995.

16. Patterson, R.M., Viegas, S.F., Elder, K., and Buford, W.L., Jr., "Quantification of Anatomic, Geometric, and Load Transfer Characteristics of the Wrist Joint," J. Arthroplasty, 6(1):13-19, January 1995.

17. Patterson, R.M. and Viegas, S.F., Biomechanics of the Wrist, J. Hand Therapy, 8(2):97-105, June/April 1995.

18. Patterson, R.M., Elder, K.W., Viegas, S.F., and Buford, W.L., Jr., "Carpal Bone Anatomy Measured by Computer Analysis of 3D Reconstructions of CT Images," J. Hand Surgery, 20A(6):923-929, November 1995.

19. Patterson, R.M., Nicodemus, C.L., Viegas, S.F., Elder, K.W., and Rosenblatt, J., "Normal Wrist Kinematics and the Analysis of the Effect of Various Dynamic External Fixators for Treatment of Distal Radius Fractures," Hand Clinics, 13(1):129-142, February, 1997.

20. Viegas, S.F., and Patterson, R.M., "Load Mechanics of the Wrist," Hand Clinics13(1):109-128, February, 1997.

21. Patterson, R.M., Nicodemus, C.L., Viegas, S.F., Elder, K.W., and Rosenblatt, J., "High Speed, Three Dimensional Kinematic Analysis of the Normal Wrist," J. Hand Surg., 23A(3):446-453, May 1998.

22. Yamaguchi, S., Viegas, S.F., and Patterson, R.M., "Anatomic Study of the Pisotriquetral Joint: Ligament Anatomy and Cartilaginous Change," J. Hand Surgery, 23A(4):600-606, July 1998.

23. Peh, W.C.G., Patterson, R.M., Viegas, S.F., Hokanson, J.A., and Gilula, L.,"Radiographic-Anatomic Correlation at Different Wrist Articulations," J. Hand Surgery, 24A(4):777-780, July 1999.
    Viegas, S.F., Yamaguchi, S., Boyd, N.L., and Patterson, R.M., "The Dorsal Ligaments of the Wrist: Anatomy, Mechanical Properties, and Function," J. Hand Surgery, 24A (3): 456-458, May 1999.