Arthroscopic and open management of dynamic scaphoid instability

Long-term results of arthroscopic debridement and percutaneous pinning for chronic dynamic scapholunate instability

There are various treatments for chronic dynamic scapholunate instability and there is still much debate about the best method of treatment. We retrospectively analysed 42 patients who had been treated by arthroscopic debridement and percutaneous pinning for chronic dynamic scapholunate instability. All patients were clinically improved without radiographic changes after surgery and were still satisfied at a mean follow-up of 68 months. Arthroscopic debridement and percutaneous pinning may be a good option for treating chronic dynamic scapholunate instability. Level of evidence: IV.

Optimal detection of scapholunate ligament tears with MRI

Background Scapholunate interosseous ligament (SLIL) injuries can often be difficult to detect using magnetic resonance imaging (MRI), especially with older 1.0 and 1.5 Tesla magnets. Wrist arthroscopy is the gold standard for diagnosis of SLIL injuries, but is an invasive procedure with associated risks. Purpose To assess whether SLIL injuries can be more accurately detected using axial MRI sequences instead of coronal sequences. Material and Methods An institutional review board approved retrospective analysis of arthroscopic wrist surgeries performed at our institution. Patients that had a preoperative MRI performed at our university center using a 1.5 Tesla scanner with a dedicated wrist coil were included in the study. Three fellowship-trained musculoskeletal radiologists reviewed the axial sequences and coronal sequences independently. The accuracy of the coronal and axial sequences was compared with the arthroscopic/surgical findings. Result Twenty-six patients met the inclusion criteria. The sensitivity for SLIL tears was 79% and 65% for the axial and coronal sequences, respectively. The specificity was 82% for the axial and 69% for the coronal sequences, respectively. The positive and negative predictive values for the axial sequences were 76% and 84% respectively, compared to 68% and 71% for the coronal sequences, a statistically significant difference. Conclusion SLIL tears are more readily detectable on axial MRI sequences than coronal. Clinically, patients with radial-sided wrist pain and suspicion for SLIL tears should have the axial sequences scrutinized carefully. An otherwise normal study with the axial sequence being degraded by motion or other MRI artifacts might need repeat imaging.

Arthroscopic treatment of perilunate dislocations and fracture dislocations

Background The key to a successful result in the treatment of perilunate dislocations (PLDs) and fracture-dislocations (PLFDs) is the restoration of normal alignment of the carpal bones, followed by stable maintenance until healing. This article aimed to assess whether arthroscopic techniques are a reliable surgical option for the treatment of this challenging injury. Materials and Methods Twenty patients with an acute PLD or PLFD were treated by an arthroscopic technique. They were retrospectively reviewed at an average follow-up of 31.2 months (range 18-61 months). Functional outcomes were assessed with the Modified Mayo Wrist Score (MMWS), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and Patient-Rated Wrist Evaluation (PRWE) score as well as radiographic evaluations. Description of Technique Arthroscopic reduction and percutaneous fixation was performed to the scapholunate and lunotriquetral intervals using Kirschner wires (K-wires) as joysticks as well as to the scaphoid using a cannulated headless screw for transscaphoid-type injuries. The K-wires were removed at 10 weeks postoperation. Results Overall functional outcomes according to the MMWS were rated as excellent in three patients, good in eight, fair in seven, and poor in two. The mean DASH score was 18, and the mean PRWE score was 30. On the basis of radiographic parameters, reduction obtained at the operation was maintained within normal ranges in 15 patients. No patient had developed arthritis by the last follow-up. Conclusions The medium-term results show that arthroscopic treatment can provide proper restoration and stable fixation of carpal alignment and results in satisfactory functional and radiologic outcomes for acute perilunate injuries. Level of Evidence Level IV.

Perilunate dislocations treated with external fixation and percutaneous pinning

Background The purpose of this study was to review clinical and radiographic outcomes of perilunate dislocations (PLDs) and fracture-dislocations (PLFDs) treated with external fixation and Kirschner wires (K-wires). Materials and Methods Twenty patients (18 males and 2 females) with a mean age of 38 years (range 18-59) with an acute PLD or PLFD were treated with external fixator and K-wires. There were 12 PLDs and seven transscaphoid and one transstyloid PLFDs. The median time from trauma to operation was 8 hours (range 2-12 hours). Indirect reduction via ligamentotaxis was achieved in 17 patients with a mean age of 38years (range 18-59). There were 12 PLDs and 5 trans-scaphoid PLFDs; however, in three cases (two transscaphoid and one transstyloid PLFDs), indirect reduction failed and an open reduction was required. The intercarpal ligaments were not repaired even after open reduction. Results The mean follow-up was 39 months (range 18-68 months). The flexion-extension range of motion (ROM) and grip strength of the injured wrist averaged 80% and 88%, respectively, of the corresponding values for the contralateral wrists. According to Cooney's scoring system, overall functional outcomes of the 17 patients were rated as excellent in 4 patients, good in 8, fair in 4, and poor in 1. Fifteen patients returned to their former occupations. Two patients with a trans-scaphoid perilunate injury developed nonunion of the scaphoid, and two developed posttraumatic arthritis. Conclusion External fixation plus percutaneous K-wires for the treatment of acute PLDs has satisfactory midterm functional and radiographic outcomes. When successful, this minimally invasive technique is simple and provides restoration of the carpal alignment. It may especially be useful in the polytrauma patient, thanks to its decreased operative time and diminished blood loss, when other emergent surgical procedures may be necessary. An open reduction with possible fixation may be necessary for PLDs and PLFDs, especially in the presence of polytrauma and scaphoid comminution.

LEVEL OF EVIDENCE

IV.

Use of external fixation for perilunate dislocations and fracture dislocations

The purpose of this study was to review clinical and radiographic outcomes of perilunate dislocations and fracture dislocations treated with external fixation and K-wire fixation. Twenty patients (18 males and two females) with a mean age of 38 years (range 18–59) who had an acute dorsal perilunate dislocation or fracture dislocation were treated with the use of wrist external fixator and K-wires. The injuries included 12 perilunate dislocations, seven trans-scaphoid perilunate fracture dislocations, and one trans-styloid perilunate fracture dislocation. The median time from trauma to operation was 8 h (2–12 h). Indirect reduction via ligamentotaxis was achieved in all perilunate dislocation, and provisional K-wire fixation was added. In five of seven trans-scaphoid perilunate fracture dislocations, indirect reduction was achieved; whereas in the other two as well as in the case of trans-styloid perilunate fracture dislocation, open reduction was required. External fixator was supplemented with K-wires for stabilization of the fractures and the intercarpal intervals. The interosseous and capsular ligaments were not repaired, even after open reduction of fracture dislocations. The mean follow-up was 39 months (range 18–68 months). Range of motion and grip strength were measured. Cooney’s scoring system was used for the assessment of clinical function. Radiographic evaluation included time to scaphoid union, measurement of radiographic parameters (scapholunate gap, scapholunate angle, lunotriquetral gap, and carpal height ratio) and any development of arthritis. The flexion-extension motion arc and grip strength of the injured wrist averaged 80 and 88%, respectively, of the corresponding values for the contralateral wrists. According to Cooney’s clinical scoring system, overall functional outcomes were rated as excellent in four patients, good in eight, fair in six, and poor in two. Eighteen patients returned to their former occupations. Two patients with a trans-scaphoid perilunate injury developed nonunion of the scaphoid; one of them required scaphoid excision and midcarpal fusion. Two patients had radiographic evidence of arthritis. The use of external fixation and provisional K-wire fixation for the treatment of acute perilunate dislocations is associated with satisfactory midterm functional and radiographic outcomes. This minimally invasive treatment option is simple, reliable, and minimally invasive method that provides proper restoration and stable fixation of carpal alignment.

Arthroscopic reduction and percutaneous fixation of perilunate dislocations and fracture-dislocations

PURPOSE

The purpose of this study was to review clinical and radiographic outcomes of perilunate dislocations and fracture-dislocations treated with arthroscopic reduction and percutaneous fixation.

METHODS

Twenty patients who had an acute dorsal perilunate dislocation or fracture-dislocation were treated with an arthroscopic technique at a median interval of 3.9 days from the time of injury. They were retrospectively reviewed at a mean follow-up of 31.2 months (range, 18 to 61 months). Range of motion and grip strength were measured. Radiographic evaluations included time to scaphoid union, measurement of radiologic parameters, and any development of arthritis. Functional outcomes were determined by the modified Mayo wrist score; Disabilities of the Arm, Shoulder and Hand questionnaire; and Patient-Rated Wrist Evaluation score.

RESULTS

The flexion-extension motion arc and grip strength of the injured wrist averaged 79% and 78%, respectively, of the corresponding values for the contralateral wrists. The mean Disabilities of the Arm, Shoulder and Hand score was 18, and the mean Patient-Rated Wrist Evaluation score was 30. According to modified Mayo wrist scores, overall functional outcomes were rated as excellent in 3 patients, good in 8, fair in 7, and poor in 2. Nonunion developed in 2 patients with a trans-scaphoid perilunate injury; 1 of the 2 underwent scaphoid excision and midcarpal fusion. On the basis of radiographic parameters, reduction obtained during the operation was maintained within normal ranges in 15 patients. Arthritis had not developed in any patient by the last follow-up.

CONCLUSIONS

This study suggests that arthroscopic reduction with percutaneous fixation is a reliable minimally invasive surgical method for acute perilunate injuries in that it provides proper restoration and stable fixation of carpal alignment and results in satisfactory functional and radiologic outcomes on a midterm basis.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The use of thermal shrinkage for scapholunate instability

Scapholunate interosseous ligament (SLIL) instability is the most common form of carpal instability. There is a lack of consensus among hand surgeons as to the appropriate treatment of various stages. This article reviews the background and results of thermal treatment of predynamic instability of the SLIL. Case examples are discussed as well as a series of patients treated with our protocol for this injury.

Scaphoid kinematics before and after scaphotrapeziotrapezoidal ligament section. Assessment by radiostereometric analysis and computed tomography in a cadaver study

The purpose of this study was to measure changes in scaphoid kinematics after division of scaphotrapeziotrapezoidal ligaments, with the intention of determining a clinical measure that could be detected by computed tomography. Twelve freshly frozen cadaver upper extremities were marked with tantalum beads and fixed in positions of neutral, 30° extension, and 40° ulnar deviation. Stereoradiographs for bone migration analysis by radiostereometric analysis and computed tomography scans for visible assessment were obtained before and after scaphotrapeziotrapezoidal ligament section. After ligament resection there was a scaphoid supination of 5° and a small (less than 1 mm) radial, distal, and dorsal translation of the distal pole in 30° of wrist extension. In computed tomography reconstructions, the ligament section appeared as a 1 to 2 mm gap in the scaphotrapeziotrapezoidal corner, with loss of articulation between the distal scaphoid pole and the trapezoid bone and increased scaphoid flexion.

[Treatment of acute scapholunate ligament tears with simple wiring and arthroscopic assistance]

Scapholunate ligament tears give chronic instability leading in SLAC. The wrist arthroscopy allows to see the lesions, even in early stage, and to treat them, with a simple K-Wires fixation in acute cases. The patients were operated on in outpatient basis with tourniquet and local general anaesthesia. In acute cases, the scapholunate dissociation was reduced by external and internal manoeuvres. The fixation was done with two pins under arthroscopic and fluoroscopic controls. We report a series of 66 acute cases (less than 45 days after trauma). Forty-four patients were males and 22 females. The average age was 39 years old (range 19-46). Our average follow-up in acute cases was 36 months (range 14-61). According the "Mayo Wrist Score", we obtained 92 % of good or excellent results. The wrist arthroscopy is the best technique for early diagnosis, guarantee of best functional results.

Association between lunate morphology and carpal collapse in cases of scapholunate dissociation

PURPOSE

Type II lunate morphology has recently been shown to decrease the incidence of dorsal intercalated segment instability (DISI) deformity in patients with scaphoid nonunions. A similar association has been suggested for scapholunate dissociation, but a formal comparison has yet to be performed. The purpose of this study was to determine if an association exists between lunate morphology and DISI in cases of scapholunate dissociation.

METHODS

A retrospective review was performed on 58 patients with the diagnosis of scapholunate dissociation as determined by use of radiographs, magnetic resonance imaging, arthrotomy, and arthroscopy. Posteroanterior radiographs were used to assess the presence of a medial facet on the lunate and to determine the distance between the capitate and the triquetrum. A DISI deformity was defined as a radiolunate angle >15 degrees, and scapholunate instability was defined as a scapholunate angle >60 degrees using the tangential method. Statistical analysis was performed with a chi-squared test and kappa test.

RESULTS

Twenty-five patients had a type I lunate, and 33 patients had a type II lunate. A total of 15 patients had DISI deformity on preoperative radiographs; of these, 10 patients with a type I lunate and 5 patients with a type II lunate had DISI deformity. This difference was found to be significant.

CONCLUSIONS

In cases of scapholunate dissociation, type II lunates were associated with a significantly lower incidence of DISI despite having radiographic or arthroscopic evidence of a complete scapholunate interosseous ligament tear. Osseous morphology may play a role in the development of a radiographic DISI deformity. Further research is required to assess the clinical importance of this finding and the biomechanical cause of this phenomenon.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Incidence of dorsal radiocarpal ligament tears in the presence of other intercarpal derangements

PURPOSE

The aim of this study was to examine the incidence of dorsal radiocarpal ligament (DRCL) tears in patients who underwent wrist arthroscopy for chronic pain.

METHODS

A chart review was performed of 64 patients who underwent diagnostic wrist arthroscopy for wrist pain. Interosseous ligament instability/tears were graded according to the Geissler classification. Tears of the triangular fibrocartilage complex (TFCC) and other intracarpal pathology were documented. Any DRCL tears were noted.

RESULTS

The average duration of wrist pain before arthroscopy was 20 months. There were 35 of 64 patients with DRCL tears. The average duration of wrist pain before treatment was 20 months (range, 4 to 60 months). There were 5 patients who had an isolated DRCL tear. Thirteen patients in this series had a scapholunate interosseous ligament (SLIL) derangement; 7 of 13 also had a DRCL tear. Seven patients had a lunotriquetral interosseous ligament (LTIL) derangement; 2 of 7 also had a DRCL tear. Two patients had a capitohamate ligament tear; 1 of these patients also had a DRCL tear. There were 7 patients with a solitary TFCC tear; 6 of 7 were in association with a DRCL tear. One patient had a chronic ulnar styloid nonunion and a DRCL tear. Two or more lesions were present in 23 patients; DRCL tears were present in 12 of 23 patients. Three patients had generalized arthrofibrosis; 1 had a volar ganglion and 2 had a normal examination. None of these were associated with DRCL tears.

CONCLUSIONS

DRCL tears are commonly seen with injuries to the SLIL, the LTIL, and the TFCC. Isolated DRCL tears should be treated with an arthroscopic repair. DRCL repairs in the presence of other intracarpal pathologies requires further study.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The incidence of dorsal radiocarpal ligament tears in patients having diagnostic wrist arthroscopy for wrist pain

PURPOSE

The goal of this study was to examine the incidence of dorsal radiocarpal ligament (DRCL) tears in patients having diagnostic arthroscopy for chronic wrist pain.

METHODS

A chart review was performed of 64 patients who had diagnostic wrist arthroscopy for chronic wrist pain that was refractory to conservative measures. For each case, interosseous ligament instability/tears were graded according to the Geissler classification. Tears of the triangular fibrocartilage complex and the presence or absence of a DRCL tear were noted.

RESULTS

There were 35 of 64 wrists (in 64 patients) with DRCL tears. The average duration of wrist pain prior to treatment was 20 months. Only 10 patients could recall a specific injury. Five patients had an isolated DRCL tear. A scapholunate interosseous ligament injury was identified in 13 patients, of whom 7 had a concomitant DRCL tear. A lunotriquetral interosseous ligament injury was present in 7 patients, of whom 2 had a concomitant DRCL tear. Two patients had a capitohamate ligament tear: 1 of these patients had a DRCL tear. There were 7 patients with a solitary triangular fibrocartilage complex tear: 6 of 7 were in association with a DRCL tear. One patient had a chronic ulnar styloid nonunion and a DRCL tear. Two or more lesions were present in 23 patients; DRCL tears were present in 12.

CONCLUSIONS

DRCL tears are commonly seen with injuries to the primary wrist stabilizers. Recognition of this condition and further research into treatment methods are needed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Intérêt thérapeutique de l'arthroscopie du poignet : à propos de 1000 cas

Wrist arthroscopy is a relatively recent procedure because it was described in the 70's. During the first period of 80's it became an indisputable technique of diagnosis. Since the 90's many therapeutic procedure were described by several authors all over the world. This technique increase a lot the understanding of wrist pathologies and ameliorate significantly the results for patients. We report our experience about 1000 wrist arthroscopy between 1998 and 2005. The patients were always operated on outpatient basis under local regional anaesthesiology. The arm was laid on the table and the hand on in-line traction (5-7 kg). We used a 2.4 mm arthroscope, 30 degrees angled. The both joints, radiocarpal and midcarpal, were systematically explored. The small portals were not closed. In our experience, only 42 arthroscopies (4%) were without surgical procedure. We separated the indications in 7 chapters: 1) arthoscopic assistance for fractures treatment (distal radius and scaphoid: 7%; 2) TFCC tears (17%); 3) treatment of intrinsic ligaments tears (scapholunate and lunotriquetral: 21%); 4) ectomy (radial styloidectomy, wafer, carpal boss 13%); 5) resection of wrist ganglia (21%); 6) partial prosthesis (2,5%); 7) others techniques (arthrolysis, synovectomy 14,5%).

Arthroscopic debridement and closed pinning for chronic dynamic scapholunate instability

PURPOSE

For chronic dynamic scapholunate (SL) instability (>3 months after injury) open procedures (capsulodesis, limited intercarpal fusions, tenodesis, SL ligament reconstruction) have become popular in recent years but their long-term results have been suboptimal. We evaluated retrospectively the results of aggressive arthroscopic debridement of the SL ligament to bleeding bone in an effort to induce scar formation and closed pinning of the SL joint in patients unwilling to have an open procedure.

METHODS

Eleven patients (mean age, 37 y) presenting with persistent posttraumatic pain and weakness to the wrist were diagnosed with dynamic SL instability (positive Watson scaphoid shift test result, SL gapping on grip-view radiographs, arthroscopic findings of a Geissler grade III or IV SL tear) and treated. Range of motion, grip strength, radiographic measurements, and the Mayo wrist score were used to evaluate the results.

RESULTS

The mean follow-up period was 33 months (range, 12-76 mo). Three patients had subsequent surgery 9 to 11 months after the procedure. Subsequent surgeries included a dorsal capsulodesis, a four-corner fusion, and a wrist arthrodesis. Of the 8 remaining patients there were 2 excellent, 4 good, 1 fair, and 1 poor result based on the Mayo wrist score. In these patients the mean range of motion was 65 degrees of extension to 59 degrees of flexion and the mean grip strength was 82% of the uninjured contralateral extremity. Although persistent radiographic SL gapping in grip views was noted in all 8 patients none progressed to static instability or dorsal intercalated segment instability.

CONCLUSIONS

The results of this technique are suboptimal; however, it may be an option for patients unwilling to have more than an arthroscopic procedure or those requiring maintenance of wrist motion, provided they understand the risks and benefits of this approach.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.

Arthroscopic dorsal radiocarpal ligament repair

PURPOSE

The goal of this study was to determine if arthroscopic repair of a dorsal radiocarpal ligament (DRCL) tear is effective in ameliorating wrist pain.

TYPE OF STUDY

Retrospective study.

METHODS

A chart review was performed of 53 patients (56 wrists) who underwent wrist arthroscopy with use of a volar radial portal. There were 21 patients with DRCL tears. Mean follow-up was 16 months. Thirteen patients underwent arthroscopic DRCL repair and/or thermal shrinkage (5 repairs, 6 repair plus shrinkage, and 2 shrinkage). Lunotriquetral tears were treated with debridement and pinning. Triangular fibrocartilage (TFC) tears were debrided or repaired. Scapholunate ligament tears/instability were treated with capsulodesis.

RESULTS

The 4 patients who underwent repair of an isolated DRCL tear had excellent results with no or mild pain. All returned to their previous occupation. Dorsal capsulodesis was performed in 7 patients with 4 fair/poor results. Nine DRCL repairs/shrinkage were in association with other procedures for ulnar-sided pathology with 6 fair/poor results.

CONCLUSIONS

Tears of the DRCL are more common than previously suspected. They are best seen through a volar radial portal and are amenable to arthroscopic repair. DRCL tears appear to be part of a spectrum of radial and ulnar-sided carpal instability as evidenced by the frequent association with scapholunate ligament tears/instability or ulnar-sided pathology. Isolated DRCL tears can be solely responsible for wrist pain. Good results are obtained with arthroscopic repair of isolated DRCL tears. The presence of a DRCL tear when seen in combination with a scapholunate, lunotriquetral, or TFC tear connotes a greater degree and/or duration of carpal instability, and portends a poorer prognosis following treatment. Recognition of this condition and further research into treatment methods is needed.

LEVEL OF EVIDENCE

Level IV.

Stress views in the radiography of scapholunate instability

AIM

On the suspected carpal instabilities stress views are recommended but not often used. The present study evaluates the reliability of the dorsal and volar stress radiographs on patients with posttraumatic wrist pain.

PATIENTS AND METHODS

Stress radiographs of the wrists were examined in 22 patients with chronic wrist pain and the results were compared with scaphoid shift test and standard and positional views. The stress examination consists of applying to the wrist dorsal and volar stresses on the hand.

RESULTS

Static scapholunate instability was diagnosed in 4 patients in whom 3 of them had positive scaphoid shift test sign as well. There were, however, 18 patients with dynamic scapholunate instability in whom the standard films were normal but dorsal stress radiography showed gap greater than 3mm between the scaphoid and lunate.

CONCLUSION

Stress tests may provide considerable information in the evaluation of a patient who has a painful wrist in whom routine and special views do not demonstrate scapholunate dissociation.

Partial scapholunate ligament injuries treated with arthroscopic debridement and thermal shrinkage

PURPOSE

To present the early results of arthroscopic debridement and thermal shrinkage using radiofrequency probes for partial (Geissler grades I and II) scapholunate (SL) interosseous ligament injuries of the wrist.

METHODS

Sixteen patients with a mean age of 34 years (range, 18-54 y) presenting with chronic dorsoradial wrist pain unresponsive to initial conservative treatment for a mean period of 12 weeks were included in this study. No patient showed radiologic signs of static dissociation (SL interval, <3.5 mm; mean SL angle, 49 degrees ) before surgery. Diagnostic arthroscopy showed a partial SL tear in 14 patients and redundancy of the ligament in 2. Partial SL tears involved the membranous (proximal) and volar part of the ligament. All lesions were debrided and treated with thermal shrinkage using a bipolar radiofrequency probe.

RESULTS

The mean follow-up period was 19 months (range, 9-34 mo). Fourteen patients experienced substantial pain relief whereas in 2 the pain remained unchanged. Eight patients were completely pain free. The mean flexion-extension arc was 142 degrees and the mean grip strength was 78% that of the unaffected side. No patient showed radiologic signs of arthritis or static or dynamic instability after surgery (SL interval remained <3.5 mm; mean SL angle, 53 degrees ). Based on the modified Mayo wrist score there were 8 excellent, 6 good, 1 fair, and 1 poor result.

CONCLUSIONS

Partial SL ligament tears can be a source of radial-sided wrist pain. Scapholunate ligament debridement and thermal shrinkage effectively provided pain relief for most of the patients treated. Stability was maintained radiographically. No complications were noted from the use of radiofrequency probes. These reasonably favorable short-term results should be viewed cautiously. A longer follow-up study is necessary to determine the ultimate efficacy of this procedure.

The "clenched pencil" view: a modified clenched fist scapholunate stress view

Traditional radiographic imaging of the scapholunate interval is complicated by the lack of a view that combines the dynamism of the clenched-fist stress view with the ability to reliably duplicate the precise angle of pronation that shows optimally the scapholunate interval. We describe a simple radiographic technique that combines these 2 criteria that we have found helpful in the office diagnosis of scapholunate dissociation.