Midterm Outcome of Bone-Ligament-Bone Graft and Dorsal Capsulodesis for Chronic Scapholunate Instability

Comparison of Outcomes of Scapholunate Ligament Reconstruction Techniques

Introduction  Injury to the scapholunate interosseous ligament (SLIL) is a common cause of carpal instability, yet surgical management of chronic SLIL disruption remains challenging with no optimal technique identified. Purpose  The purpose of this meta-analysis was to comparatively review the available evidence of clinical, radiographic, and patient-reported outcome measures among popular techniques of SLIL reconstruction (capsulodesis, tenodesis, and bone-tissue-bone graft) to better guide management of SLIL injuries. Methods  A total of 1,172 patients from 42 included studies were assessed. Standardized data extraction and analysis were performed. The mean of postoperative outcome assessments with standard deviation was used to calculate pooled standardized mean difference with 95% confidence interval. Results  Visual Analog Scale (VAS) score for postoperative pain was lowest in bone-tissue-bone patients at 0.9 ( p  = 0.0360). Bone-tissue-bone patients had the highest percentage of "excellent" functional outcomes at 64.5% ( p  < 0.0001). Disabilities of the Arm, Shoulder, and Hand (DASH)/QuickDASH score was best in bone-tissue-bone patients at 9.7 ( p  < 0.0001). Patient-Rated Wrist Evaluation (PRWE) score was best in tenodesis patients at 37.8 ( p  = 0.0255). There were no statistically significant differences in grip strength, range of motion, or radiographic outcomes among the techniques. Conclusion  Existing data demonstrate some benefit of bone-tissue-bone reconstruction over capsulodesis and tenodesis in pain reduction and functional improvement of the injured wrist. No statistically significant differences among radiographic outcomes could be ascertained, possibly attributable to the heterogeneity of procedures. This review provides an updated reference and highlights the need for multicenter trials with longer term follow-up and more standardized outcome measures.

Arthroscopic Capsulodesis for the Treatment of Dynamic Scapholunate Dissociations

Management of scapholunate dissociations remains a significant challenge. Open approaches suffer from a disadvantageous further impairment of the stabilizing local structures. The minimally invasive arthroscopic technique described provides reliable stability of the scapholunate interosseous ligament complex in dynamic lesions. The anatomic key structure is the dorsal capsuloligamentous scapholunate septum, which provides a mechanical connection between the scaphoid, lunate, and dorsal capsule of the wrist. Arthroscopic capsuloplasty aims to tighten and stabilize this complex structure in long term. This approach preserves the adjacent structures, namely the secondary wrist stabilizers and their neuromuscular feedback loops. With a certain degree of experience in wrist arthroscopy, the technique is reliably adaptable and reproducible.

Outcomes after Bone-Ligament-Bone Intercarpal Ligament Reconstruction

BACKGROUND

Numerous surgical reconstructive techniques have been described for chronic scapholunate and lunotriquetral interosseous ligament instability.

METHODS

The authors retrospectively reviewed 16 consecutive patients who underwent bone-ligament-bone reconstruction for scapholunate or lunotriquetral intraosseous ligament predynamic and dynamic instability at a single tertiary care institution from 2013 to 2019. Clinical and radiographic outcomes, and complications, were recorded.

RESULTS

Eleven patients had bone-ligament-bone reconstruction for scapholunate ligament injury and five for lunotriquetral instability. Fourteen patients (87.5 percent) underwent diagnostic arthroscopy before bone-ligament-bone reconstruction, with nine of 14 having grade 3 and four of 14 having grade 4 injury. Capitohamate bone-ligament-bone grafts were used in nine patients (56 percent) and the graft was taken from Lister tubercle in seven (44 percent). The average age at surgery was 37 years. The average follow-up was 60.6 weeks. There were no significant differences between preoperative and postoperative radiographic parameters. Median postoperative wrist flexion was 45 degrees, and mean postoperative wrist extension was 53 degrees, which were significantly less than contralateral flexion (85 degrees; p < 0.0001) and extension (78 degrees; p < 0.0001). Thirty-eight percent of patients complained of persistent pain at final follow-up, and two patients (13 percent) underwent salvage procedures, both at approximately 6.5 months after the index reconstruction.

CONCLUSION

Short-term outcomes of bone-ligament-bone reconstruction for early-stage scapholunate and lunotriquetral ligament injuries reveal many patients with residual postoperative wrist pain and disability, and almost uniform limitations in flexion-extension motion.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The Biomechanical Effects of Augmentation With Flat Braided Suture on Dorsal Intercarpal Ligament Capsulodesis for Scapholunate Instability

PURPOSE

Selecting treatment for scapholunate (SL) instability is notoriously difficult. Many methods of reconstruction have been described, but no procedure demonstrates clear superiority. New methods proposed use internal bracing (IB) with suture anchors and flat braided suture (FBS), alone or as an augmentation with tendon autograft for SL ligament injuries. Our goal was to use computed tomography (CT) to analyze alignment of the SL joint after 3 different modes of fixation of SL instability: after reconstruction with IB incorporating either tendon autograft or the dorsal intercarpal ligament (DICL), or DICL capsulodesis without FBS.

METHODS

Ten fresh-frozen, matched-pair, forearm-to-hand specimens were used. Serial sectioning of the SL stabilizing ligaments was performed and the SL interval was measured with CT. We reconstructed the SL ligament with DICL capsulodesis alone (DICL) or with IB augmented with either tendon autograft (IB plus T) or DICL (DICL plus IB). The SL interval was measured with CT. Specimens underwent 500 weighted cycles on a jig and were reimaged. Differences in SL interval after repair and cycling were compared.

RESULTS

Dorsal intercarpal ligament capsulodesis augmented with IB best maintained the SL interval before and after cycling. Dorsal intercarpal ligament capsulodesis alone was inferior to DICL plus IB and IB plus T both before and after cycling.

CONCLUSIONS

Dorsal intercarpal ligament capsulodesis augmented with IB appears to maintain better SL joint reduction than IB with tendon autograft.

CLINICAL RELEVANCE

This work serves as a necessary step for further study of the biomechanical strength and clinical application of FBS technology in the reconstruction of SL instability. Flat braided suture augmentation of DICL capsulodesis may provide another option to consider for reconstruction of SL instability.

A Biomechanical Evaluation of the ECRL Tenodesis for Reconstruction of the Scapholunate Ligament

PURPOSE

Reconstruction of the scapholunate ligament (SLL) in the setting of dynamic instability remains a surgical challenge, with lack of consensus on the best reconstructive procedure. Reconstruction of only the dorsal component may lead to volar gapping and abnormal wrist kinematics. This cadaveric active motion simulation study determined whether scapholunate (SL) motion, angulation, and contact are restored following open reconstruction using the extensor carpi radialis longus (ECRL) tenodesis, which reconstructs both the volar and the dorsal SLL components.

METHODS

Seven fresh-frozen cadaveric upper limbs (mean age, 68 ± 10.1 years) underwent a 4-stage protocol of cyclic dart-throw motion and flexion-extension motion (utilizing an active wrist motion simulator that used tendon load/motion-controlled actuation. Scaphoid and lunate motion, relative scaphoid translation, SL angle, and dorsal-volar SL diastasis were measured with (1) wrist ligaments intact, (2) following complete sectioning of the SLL, and (3) following SL reconstruction using the ECRL tenodesis technique.

RESULTS

Complete SLL sectioning resulted in a typical pattern of SL instability. Following the ECRL tenodesis, lunate extension was not corrected. Scaphoid flexion, however, was not significantly different from the native state in FEM but remained significantly flexed during dart-throw motion. Differential dorsal and volar gapping did not significantly improve following ECRL tenodesis (dorsal, 1.2-2.3 mm; volar, 1.1-1.7 mm).

CONCLUSIONS

This biomechanical study demonstrates that the ECRL tenodesis did not fully restore native carpal kinematics, despite dorsal and volar SLL, and scaphotrapeziotrapezoid reconstruction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Surgical outcomes of chronic isolated scapholunate interosseous ligament injuries: a systematic review of 805 wrists

Background

Management of chronic isolated scapholunate interosseous ligament (SLIL) injuries has generated a substantial volume of low-quality literature with descriptions of multiple new surgical techniques, and the impact of instability pattern and the optimal surgical technique remain unclear. The primary goal of this review was to compare clinical, radiographic and patient-rated outcomes between current surgical techniques.

Methods

We performed a systematic literature search using multiple databases. We analyzed clinical, radiographic and patient-reported outcomes. We used a fixed-effects model weighted by sample size with combined outcomes estimated via least squares means with 95% confidence intervals. We also performed a subgroup analysis of static versus dynamic instability.

Results

We assessed 805 procedures from 37 study groups, with 429 procedures used in subgroup analysis. There were no statistically significant differences in outcomes between surgical techniques or in subgroup analysis. Overall, postoperative wrist flexion and pain scores decreased, and grip strength and patient-rated outcomes improved.

Conclusion

Compared to overall preoperative values, modest improvements in pain score, grip strength and functional outcome scores were obtained from a range of reconstructive procedures performed for chronic isolated SLIL injuries. No significant differences could be ascertained between surgical techniques, potentially owing to the low quality of evidence and procedure heterogeneity. This study provides accurate preoperative reference values for future studies, highlights the controversial clinical impact of instability classification, and the need for higher-quality multicentre or collaborative trials to improve our understanding and management of this common injury.

Arthroscopic scapholunate dorsal capsulodesis: A 30-patient case series comparing postoperative splint immobilization versus immobilization and connected K-wiring

The aim of this retrospective study was to compare the results of arthroscopic dorsal capsulodesis performed with or without temporary K-wiring to treat patients who had sustained scapholunate ligament injuries. Our case series included 30 patients with an average age of 37 years (range: 19-55) of whom 12 were female. Dorsal scapholunate capsulodesis was carried out in all patients. In 15 patients, splint immobilization only was used (group I). For the remaining 15 patients, supplementary scapholunate and scaphocapitate K-wiring was performed (group II). The outcomes, whether K-wiring was used or not, were not as good as the outcomes of other published studies. In our study, the reported QuickDASH score was on average higher than 20/100, pain score was higher than 2/10, grip strength was less than 70% of the contralateral side. There was one postoperative complication in the first group and three complications in the second group; five cases of DISI were reported in the first group and three in the second group. There were no significant differences between the two groups. Based on our findings, supplementary K-wiring is not necessary when a dorsal scapholunate capsulodesis is performed. The outcomes of our study were not as good as those of other published series, potentially due to a shorter follow-up and the more severe ligament injuries in our case series.

Length Changes in Scapholunate Interosseous Ligament With Resisted Wrist Radial and Ulnar Inclination

PURPOSE

To investigate the changes in length of the scapholunate interosseous ligament (SLIL) when the wrist is resisting horizontal lateral load and the forearm is in full pronation in vivo.

METHODS

We obtained computed tomography scans of the wrists of 6 volunteers in 3 situations: 0° position (0° extension and 0° ulnar inclination) and full forearm pronation without force, and in the same position but with resisted ulnar and radial deviation. Nine zones of 3 subregions of the SLIL were measured and analyzed with computer modeling.

RESULTS

Changes in length of the palmar SLIL with resisted ulnar deviation were significantly greater than those without an applied lateral load. In contrast, the changes in length of the dorsal SLIL with resisted radial deviation were statistically greater than those in the 0° position without loading. However, no significant differences in the changes in length of the proximal SLIL were found in any of 3 situations, except the dorsal zone with resisted radial deviation.

CONCLUSIONS

Application of lateral load has an effect on the separation of the palmar and dorsal insertions of the SLIL. The palmar subregion of the SLIL was more highly strained with wrist-resisted ulnar deviation. Conversely, the dorsal subregion of the SLIL was under greater tension with wrist-resisted radial deviation.

CLINICAL RELEVANCE

For patients undergoing nonsurgical treatment of SLIL tears, a sudden contraction of ulnar or radial deviation agonist muscles may be harmful and contribute to SL instability.

Changes in Wrist Motion After Simulated Scapholunate Arthrodesis: A Cadaveric Study

PURPOSE

A high incidence of nonunion and relatively poor outcomes with prior fixation techniques has precluded scapholunate (SL) arthrodesis as a standard treatment for SL instability. Our purpose was to determine the impact on range of motion (ROM) of simulated SL arthrodesis via headless screw fixation.

METHODS

We performed baseline wrist ROM for 10 cadaveric wrists using a standardized mounting-and-weights system. Extension, flexion, radial deviation, ulnar deviation, dart-thrower's extension, and dart-thrower's flexion were assessed. Two 3.0-mm headless compression screws were inserted across the SL joint to simulate SL arthrodesis. Goniometric measurements and fluoroscopic imaging were repeated to assess ROM differences after simulated SL arthrodesis. We assessed SL angle and gap during testing to ensure there was no significant motion between the scaphoid and lunate, thus confirming stable simulated fusion. Differences in ROM were compared between baseline and simulated SL arthrodesis using paired t tests.

RESULTS

Mean SL angle remained constant between pre- and post-arthrodesis imaging (47° ± 6° vs 46° ± 4°) and did not change during post-arthrodesis ROM testing, indicating a stable simulated fusion. Compared with baseline, SL arthrodesis had a statistically significant reduction in maximum flexion of 6° and 9° based on fluoroscopy and goniometry, respectively, in dart-thrower's extension of 5° and 9° based on fluoroscopy and goniometry, respectively, and in dart-thrower's flexion of 6° for both fluoroscopy and goniometry. No other ROMs after simulated SL arthrodesis were significantly different compared with baseline.

CONCLUSIONS

The effects of simulated SL arthrodesis on radiocarpal and midcarpal motion compare favorably with motion after SL soft tissue repair and other reconstructive techniques that have been previously reported. The statistically significant decreases in wrist flexion and dart-thrower's extension-flexion after simulated SL arthrodesis are of questionable clinical importance.

CLINICAL RELEVANCE

These results may support reconsidering SL arthrodesis as a viable treatment option for acute or chronic SL instability with regard to apparent minimal adverse effects on functional wrist ROM.