Bone-retinaculum-bone reconstruction of scapholunate ligament injuries

CMC Mimickers: Differential Diagnosis and Work-Up for Radial-Sided Wrist Pain

In patients with radial-sided wrist pain, a myriad of possible etiologies exists and as such, a detailed history, examination, and, where indicated, imaging is obtained to try and aid with its diagnosis. The purpose of this article is to provide an overview of radial-sided wrist pain, diagnostic modalities and discuss current treatment options. More detailed information is out-of-scope for this article and if needed, we would guide the reader to seek out other selected texts, as indicated.

The 50 most cited papers in chronic scapholunate reconstruction: a bibliometric analysis

PURPOSE

This study identifies the most impactful papers on scapholunate reconstruction and provides a quantitative assessment of the impact of these papers in order to inform future clinical practice, education, and research of this condition.

METHODS

The Scopus database was used in May 2020 to identify the 50 most cited clinical articles pertaining solely to chronic scapholunate reconstruction. Citation number and density, publication variables, and Altmetric Attention Scores (AASs) were collected and analyzed.

RESULTS

The top 50 articles on chronic scapholunate reconstruction produced 1,868 total citations, with an average of 37.36 ± 39.90 citations per article (range 7-196) and an average citation density of 2.44 ± 2.27. US-based publications (n = 20) and articles published in Journal of Hand Surgery (n = 24) were associated with significantly higher citation number and density (p < 0.01 - p = 0.018). In addition, sample size was positively correlated with citation density (rho = 0.312, p = 0.029). Fourteen articles were associated with an AAS (mean score = 4.07 ± 4.70). There was no significant association between AAS and citation number or density, but AAS did significantly predict citation density (coefficient = 0.378, 95% CI: [0.013-0.741], p = 0.043).

CONCLUSION

Numerous factors, such as journal of publication, location, and sample size, were significantly associated with citation number and/or citation density. Interestingly, AAS was predictive of, but not directly correlated with citation density, suggesting that the impact of scapholunate literature may not be adequately captured with a citation analysis.

Management of chronic scapholunate ligament injury

Scapholunate ligament is the most commonly injured ligament in the wrist and requires accurate diagnosis and treatment. It presents with pain, stiffness and can lead to carpal instability as well as degenerative arthritis if left untreated, with subsequent loss of function and disability. There are several management options currently available but there is no consensus on how best to manage a wrist with chronic sequelae of scapholunate ligament injury. This review explores available evidence in the literature on optimal treatment options including non-operative and operative procedures, relevant surgical techniques and their associated outcomes. A summary of the current concepts in the management of Chronic Scapholunate ligament injury is presented.

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.

Experiences with Osteoligamentoplasty According to Weiss for the Treatment of Scapholunate Dissociation

BACKGROUND

In post-traumatic, dynamic, or static scapholunate (SL) instability, an SL ligament reconstruction is advisable to avoid long-term complications. However, a sufficient primary reconstruction is best achieved in acute injuries. For chronic SL dissociation, there is still no satisfying standard surgical technique. In this context, we evaluated the clinical outcome of Weiss's osteoligamentoplasty as a treatment option.

METHODS

Over a three-year period, 16 patients with chronic and symptomatic SL dissociation Grade-II and III, without the signs of osteoarthrosis were, surgically treated using a bone-retinaculum-bone autograft from the distal radius. All patients underwent prior wrist arthroscopy. The clinical outcome was measured using the Mayo-Wrist, Krimmer, and DASH score. In addition, radiological measurements were also performed.

RESULTS

The postoperative clinical outcome successfully increased the Mayo-Wrist score: 32 to 64 points, Krimmer score: 30 to 53 points and DASH score: 41 to 30 points. The radiological follow-up demonstrated no evidence of an SL gap or significant loss of reposition in the SL angle in 13 of the 16 cases. Till date, two patients had to be revised to an arthrodesis.

CONCLUSIONS

The autogenous osteoligamentary span from the distal radius improves a chronic SL dissociation and, therefore, presents a suitable option to anatomically reconstruct the SL ligament. It leads to a proper realignment of the carpus and could help to prevent arthritic changes of the wrist. Nevertheless, in patients with postoperative high occupational physical strain, the procedure should be performed with reservations. As long as there is no satisfying standard surgical treatment, Weiss's osteoligamentoplasty is a convincing technique.

Combined Tenodesis-Capsulodesis for Scapholunate Instability: Minimum 2-Year Follow-Up

Background The aim of this study is to evaluate the clinical and radiological midterm results of a combined dorsal tenodesis-capsulodesis for static and reducible scapholunate dissociation (SLD). Patients and Methods We evaluated 20 of 22 consecutive patients with static SLD minimum with follow-up of 2 years operated between 2003 and 2012. The mean age was 40 years (range: 23-65 years). Seventeen were men. Final evaluation included comparative wrist range of motion (ROM) and grip strength, pre- and postoperative pain and function by visual analog scale, and QuickDASH and Wrightington scores. Radiographs included preoperative, early postoperative, and final X-rays. Scapholunate space (SLS) and scapholunate and radioscaphoid angles (SLA and RSA) were measured. Statistical significance was evaluated with Student t-test, considered significant when p < 0.05. Results Mean follow-up was 67 months (range: 24-126 months). Mean final ROM was: flexion 55 degrees (73%), extension 62 degrees (90%), radial deviation 19 degrees (82%), and ulnar deviation 44 degrees (90%). Mean grip strength was 44 kg (92%). Pain at rest improved from 3.4 to 0.5 (p < 0.05). Pain in activity improved from 7 to 1.7 (p < 0.05). Final function was 8.5 (preoperative, 5.2; p < 0.05). Mean QuickDASH score improved from 38 to 8 (p < 0.05). Functional Wrightington score was as follows: 13 excellent, 3 good, 1 regular, and 3 poor. There were three postoperative minor complications. Radiological results (preoperative/early postoperative/final follow-up) were as follows: SLS, 4.7/1.6/1.8 mm; and SLA, 60/50/62 degrees; RSA, 39/45/37 degrees. Four patients showed arthritic changes (two SLAC wrist). Conclusion The clinical and radiological results with more than 2-year follow-up suggest that this technique may be effective, reproducible, and safe for symptomatic static and reducible SLD. Level of Evidence Level IV, case series.

Chronic Scapholunate Ligament Injury: Techniques in Repair and Reconstruction

Although the true incidence of scapholunate interosseous ligament (SLIL) injury is unknown, a study found that 35% of cadaveric wrists had some degree of scapholunate tear. Of those wrists with SLIL injury, 29% had evidence of arthrosis. Early recognition and treatment of these injuries can delay or prevent the onset of arthritis. This article details treatment options for SLIL injury across the spectrum of pathology with a particular emphasis on chronic scapholunate repair and reconstruction. New techniques and outcomes data also are presented.

Biomechanical comparison of the hand-based transplant used in bone-tissue-bone scapho-lunate ligament reconstruction

Although work has been published comparing the five most commonly used transplant techniques to the properties of the scapho-lunate interosseous ligament (SLIL), no study has been carried out which compares the biomechanical properties of the different bone-tissue-bone autografts to each other, using a standard methodology of testing. The hypothesis of this study was that mechanically significant differences in the material properties of commonly used bone-tissue-bone exist when compared to each other. We tested the dorsal part of the SLIL and the five most quoted transplants in the literature: capitate to trapezoid; trapezoid to second metacarpal; third metacarpal-carpal; dorsal capitate-hamate; 4-5 extensor retinaculum. For each transplant, we measured failure load, failure displacement, width, and thickness. Anova was used to compare the different results obtained and the level of significance attributed to P<0.05. Load to failure were: SLIL 94.3±42.86N; capitate to trapezoid 37.7±23.13N; trapezoid to second metacarpal 45.43±14.28N; third metacarpal-carpal 60.11±19.94N; dorsal capitate-hamate 63±25.51N; 4-5 retinaculum 15.67±10.7N. Only the dorsal capitate-hamate ligament showed to have no significant (P>0.05) difference in term of load to failure, all the others was significantly weaker (P<0.05). Previous biomechanical studies have identified the dorsal region of the SLIL as the most structurally and functionally important area of the SLIL. As a result, attention has been more specifically brought to the replacement of the dorsal portion of the SLIL. An attempt to achieve a reconstruction that reproduces more closely the SLIL has generated research on the use of bone-tissue-bone composite graft, several donor sites have been used in order to find the most similar. Our results suggest that, using a normalized method to compare the previously described grafts harvested at the wrist level, that the dorsal capitate-hamate ligament has the closest properties to the native dorsal scapho-lunate ligament.

Tissue-engineered collateral ligament composite allografts for scapholunate ligament reconstruction: an experimental study

PURPOSE

In patients with chronic scapholunate (SL) dissociation or dynamic instability, ligament repair is often not possible, and surgical reconstruction is indicated. The ideal graft ligament would recreate both anatomical and biomechanical properties of the dorsal scapholunate ligament (dorsal SLIL). The finger proximal interphalangeal joint (PIP joint) collateral ligament could possibly be a substitute ligament.

METHODS

We harvested human PIP joint collateral ligaments and SL ligaments from 15 cadaveric limbs. We recorded ligament length, width, and thickness, and measured the biomechanical properties (ultimate load, stiffness, and displacement to failure) of native dorsal SLIL, untreated collateral ligaments, decellularized collateral ligaments, and SL repairs with bone-collateral ligament-bone composite collateral ligament grafts. As proof of concept, we then reseeded decellularized bone-collateral ligament-bone composite grafts with green fluorescent protein-labeled adipo-derived mesenchymal stem cells and evaluated them histologically.

RESULTS

There was no difference in ultimate load, stiffness, and displacement to failure among native dorsal SLIL, untreated and decellularized collateral ligaments, and SL repairs with tissue-engineered collateral ligament grafts. With pair-matched untreated and decellularized scaffolds, there was no difference in ultimate load or stiffness. However, decellularized ligaments revealed lower displacement to failure compared with untreated ligaments. There was no difference in displacement between decellularized ligaments and native dorsal SLIL. We successfully decellularized grafts with recently described techniques, and they could be similarly reseeded.

CONCLUSIONS

Proximal interphalangeal joint collateral ligament-based bone-collateral ligament-bone composite allografts had biomechanical properties similar to those of native dorsal SLIL. Decellularization did not adversely affect material properties.

CLINICAL RELEVANCE

These tissue-engineered grafts may offer surgeons another option for reconstruction of chronic SL instability.

Comparison of radiographic stress views for scapholunate dynamic instability in a cadaver model

PURPOSE

Many different stress views for the diagnosis of scapholunate (SL) instability have been described in the literature. The purpose of this study is to compare these stress views and determine which view has the greatest utility for demonstrating SL gap radiographically.

METHODS

We performed a literature search for articles describing SL radiographic stress views. We created SL instability in 9 cadaveric wrists by ligamentous sectioning and imaged each specimen using all radiographic views found in the literature. These included the "clenched pencil" view, clenched fist views in varying positions, and traction views. Scapholunate gaps were measured using digital calipers.

RESULTS

We found 8 different SL radiographic stress views specifically described in the literature. In order to further characterize the best stress views, we studied additional parameters, including varied ulnar deviation and degree of obliquity. The clenched pencil view resulted in the most consistent views with the widest SL gaps. With clenched fist views, SL gap trended to a peak at 30° of ulnar deviation.

CONCLUSIONS

The clenched pencil view was the best stress view to demonstrate dynamic SL instability. It also allows for a contralateral comparison on 1 radiograph. We recommend this view when evaluating for SL pathology.

CLINICAL RELEVANCE

This assessment of relative diagnostic utility might assist clinicians in the creation and use of protocols for the diagnosis of dynamic SL instability.

Dorsal intercarpal ligament capsulodesis for predynamic and dynamic scapholunate instability

We treated a prospective series of 18 patients (nine men and nine women) with a mean age of 35 years (range 15 to 57), with chronic predynamic or dynamic scapholunate instability by a dorsal intercarpal ligament capsulodesis using the modified Mayo technique. All the patients were assessed by the modified Mayo wrist score and DASH questionnaire. Wrist arthroscopy was done in all patients before open surgery in order to grade the scapholunate instability and correlate the findings with the radiographic and MRI results. At an average follow-up of 45 months (range 34 to 60) pain significantly diminished (P < 0.05) with improvement in the grip strength (P < 0.005) in all 18 cases. Wrist motion remained almost the same. The mean Mayo wrist score improved from 62 to 84 (P < 0.005).We recommend dorsal capsulodesis by using the dorsal intercarpal ligament flap for the treatment of scapholunate dissociation, when the ligament is still repairable.

Management of carpal instability in athletes

Hand and wrist injuries are common in most athletic events and sports. Carpal fractures and ligamentous injuries are common in athletes and require physicians, trainers, and therapists who treat and diagnosis these injuries to have an understanding of the carpal bone anatomy and vascularity along with the potential for progression to instability. Research is still needed to further investigate the optimal treatments of all carpal injuries in athletes along with designing new means to prevent these injuries.

[New bone-ligament-bone transplant from plantar plates of the toes and possible use in reconstruction of the scapholunate ligament. An anatomical study]

BACKGROUND

Various treatment options have been proposed for reconstruction of the scapholunate ligament. However, none of these methods prevent patients with scapholunate instability from developing wrist arthritis. This study was performed to investigate a new bone-ligament-bone autograft from the plantar plate of the toes for suitable reconstruction of the scapholunate interosseus ligament. The anatomical properties and the technical feasibility were investigated.

METHODS

The plantar plates of the metatarso-phalangeal joints and the proximal interphalangeal joints of the 2nd-5th toes were examined in 20 cadaver feet and measurements such as length, thickness and width were recorded.

RESULTS

The average lengths of the plantar ligaments of the proximal interphalangeal joint were 0.63 cm (D3) and 0.62 cm (D4), respectively and were therefore found to be similar to that of the scapholunate ligament. Bone-ligament-bone autografts of the plantar plates were designed and intercalated between the scaphoid and lunate bones and, contrary to all previous methods, not simply superimposed upon them.

CONCLUSIONS

It can be concluded from the data that this new graft of the proximal interphalangeal joint of the 3rd and 4th toes can be a suitable replacement for the scapholunate ligament.

Four-dimensional computed tomographic imaging in the wrist: proof of feasibility in a cadaveric model

OBJECTIVE

High-resolution real-time three-dimensional (3D) imaging of the moving wrist may provide novel insights into the pathophysiology of joint instability. The purpose of this work was to assess the feasibility of using retrospectively gated spiral computed tomography (CT) to perform four-dimensional (4D) imaging of the moving wrist joint.

MATERIALS AND METHODS

A cadaver forearm from below the elbow was mounted on a motion simulator which performed radioulnar deviation of the wrist at 30 cycles per minute. An electronic trigger from the simulator provided the "electrocardiogram" (ECG) signal required for gated reconstructions. Four-dimensional and 3D images were compared by a blinded observer for image quality and presence of artifacts.

RESULTS

Image quality of 4D images was found to be excellent at the extremes of radial and ulnar deviation (end-motion phases). Some artifacts were seen in mid-motion phases.

CONCLUSION

4D CT musculoskeletal imaging is feasible. Four-dimensional CT may allow clinicians to assess functional (dynamic) instabilities of the wrist joint.

Long-term outcomes of dorsal intercarpal ligament capsulodesis for chronic scapholunate dissociation

PURPOSE

Chronic scapholunate dissociation is the most common cause of symptomatic wrist instability. In an attempt to restore normal carpal mechanics and prevent wrist arthrosis, we developed and tested biomechanically the dorsal intercarpal ligament capsulodesis (DILC). Previously, we reported good early clinical results for this procedure at an average follow-up period of 25 months. Here, we report on the functional and radiographic outcomes at a longer follow-up period of a minimum of 5 years.

METHODS

Records of patients undergoing the DILC for chronic (greater than 6 weeks), flexible, static scapholunate dissociation were reviewed. Only patients with follow-up evaluation of greater than 60 months were included. Physical examination, radiographs, and validated outcome instruments were used to evaluate the patients.

RESULTS

Twenty-one patients (22 wrists) met the inclusion criteria. Fifteen of 21 patients (16 wrists) were available for follow-up evaluation. Average follow-up period was 86 months. Physical examination revealed average wrist flexion and extension of 50 degrees and 55 degrees , respectively, radial and ulnar deviation of 17 degrees and 36 degrees , respectively, and grip strength of 43 kgf. Disabilities of the Arm, Shoulder and Hand, Short Form-12, and Mayo wrist scores averaged 19, 78, and 78, respectively. Radiographs revealed an average scapholunate angle and gap of 62 degrees and 3.5 mm, respectively. Eight of the 16 wrists in our study demonstrated arthritic changes on radiographs.

CONCLUSIONS

The DILC does not consistently prevent radiographic deterioration and the development of arthrosis in the long-term; however, the level of functionality and patient satisfaction remained relatively high in 58% of our patients, suggesting a lack of correlation between the radiographic findings and development of arthrosis and the functional outcomes and patient satisfaction. We believe that the DILC is still a reasonable option for treating flexible static scapholunate dissociation in patients without radiographic signs of arthritis presenting with wrist pain despite conservative treatment. Prevention of radiographic deterioration and arthrosis remains an unsolved problem.

Bone-tissue-bone repairs for scapholunate dissociation

Scapholunate dissociation is a commonly seen and treated form of carpal instability. Several surgical options have been used for the repair of scapholunate instability over the past 50 years. These have included benign neglect, reduction and percutaneous pinning, primary repair, partial fusions, tendon weaves, and combinations of these. Recent advancements in scapholunate repair and anatomy have been aimed at a more physiologic repair. Composite replacement of the entire scapholunate interval, similar to other tendon repairs seen in orthopedic surgery, has become popular. Bone-tissue-bone (BTB) autograft replacement from the foot has been used but the problems of a secondary surgical site have resulted in other graft site selections. Currently more commonly used grafts are bone-retinaculum-bone, third or second metacarpal-carpal bone, or hamate-capitate grafts, all performed with or without screw augmentation. Vascularized autograft replacement on pedicled grafts from the hand is being explored. This review discusses the surgeons' indications and technical details of the surgery. The lack of long-term outcome measurements for these BTB surgeries makes it difficult for the hand surgeon to determine the appropriate use of these treatment modalities, but early reports have indicated that the BTB graft will be an important part of scapholunate dissociation treatment.

Outcomes of dorsal capsulodesis and tenodesis for treatment of scapholunate instability

PURPOSE

The ideal treatment for scapholunate (SL) instability has not yet been established. This study examined the results of 2 procedures for the primary treatment for chronic SL dissociation of dorsal capsulodesis and flexor carpi radialis tenodesis.

METHODS

A retrospective analysis was conducted that examined dorsal capsulodesis and tenodesis procedures performed for chronic SL instability between January 1995 and February of 2003. Twenty-nine patients were identified with isolated chronic SL instability. Of the 29 patients, 14 had a dorsal capsulodesis procedure and 15 had a tenodesis procedure. The follow-up period averaged 38 months in the capsulodesis group and 36 months in the tenodesis group. Results were reviewed clinically and radiographically. Groups were compared with a Student t test.

RESULTS

Postoperative wrist motion decreased in both groups after surgery. Final wrist range of motion was 64% of the unaffected side in the capsulodesis group and 63% of the unaffected side in the tenodesis group. Postoperative grip strength remained unchanged in both groups; grip strength measured 91% of the unaffected side in the capsulodesis group and 87% of the unaffected side in the tenodesis group. The average Mayo wrist scores were 77 in the capsulodesis group and 74 in the tenodesis group. One frank failure occurred in the tenodesis group resulting in a wrist fusion. There was no statistical difference in the overall wrist motion, grip strength, or wrist scores between the capsulodesis and tenodesis groups.

CONCLUSIONS

Dorsal capsulodesis and tenodesis provided improvement in symptoms for patients with chronic SL instability. Both procedures appear to provide similar results in the treatment of this difficult problem.

An anatomic and biomechanic study of the wrist extensor retinaculum septa and tendon compartments

PURPOSE

The anatomy of the extensor retinaculum of the wrist has been described previously; the purpose of this study was to describe the specific anatomy of the septal attachments on the radius and to investigate the mechanical strength of each septal attachment on the radius and each of the 6 compartments of the extensor retinaculum.

METHODS

Thirty-four wrists from 24 fresh-frozen and 10 embalmed cadavers were used. First, anatomic measurements of the individual extensor retinaculum septums were performed with calipers and a 3-dimensional digitizer. Next each extensor retinaculum septum was excised as a bone-retinaculum-bone autograft and was tested in tension to failure with a materials testing machine. Finally the 6 extensor retinaculum compartments were tested to failure.

RESULTS

Septum 1/2 had the largest radial surface area and septum 3/4 had the smallest. Septum 1/2 also was found to have the highest failure strength at 51.3 +/- 15.3 N. In compartment testing, compartments 1 and 2 had the highest overall resistance to failure and compartment 5 had the lowest. Compartment 6, which was thought to be the weakest because of clinically observed subluxation of the extensor carpi ulnaris tendon, had stronger failure data than expected.

CONCLUSIONS

This study offers detailed analysis of the extensor retinaculum compartments and 3-dimensional anatomy of the septal attachments. Clinically this study lends insight to the strength of bone-retinaculum-bone autografts and the etiology of extensor carpi ulnaris subluxation.

Scaphotrapeziotrapezoid arthrodesis for arthritis

The main indications for scaphotrapeziotrapezoid (STT) fusion are STT arthritis, rotary subluxation of the scaphoid, and Kienbock disease. The results of this procedure in the literature for each indication are discussed, as are the advantages, disadvantages,and alternative procedures. This article discusses the authors' surgical technique and results. The authors believe this procedure is a viable one in specific clinical scenarios.

Capsulodesis for the treatment of chronic scapholunate instability

PURPOSE

Scapholunate (SL) instability is the most common form of carpal instability. The treatment of this disorder is challenging and varying treatment options have been described. The purpose of this study was to examine the intermediate-term results of dorsal capsulodesis for cases of chronic SL dissociation.

METHODS

A retrospective analysis was conducted that examined all dorsal capsulodesis procedures performed for chronic SL dissociation between January of 1990 and February of 2000. Wrist pain had to be present for greater than 3 months. Patients had to have a minimum follow-up period of 2 years for inclusion in the study. Thirty-one patients were identified with isolated chronic SL dissociation. Of the 31 patients 18 had dynamic carpal instability and 13 had static carpal instability. The time from injury to surgery averaged 20 months. The follow-up period averaged 54 months (range, 24-96 mo). All patients had a dorsal capsulodesis procedure using either a Blatt or Mayo technique. Results were reviewed clinically and radiologically. Static and dynamic groups were compared with a Student t test.

RESULTS

There was a 20% decrease in wrist motion after capsulodesis. There was no improvement in grip strength after surgery. Most patients had improvement in pain but only 2 patients were completely pain free. Radiographically the SL gap increased over time from 2.7 mm before surgery to 3.9 mm at the final follow-up evaluation. The SL angle also increased from 56 degrees before surgery to 62 degrees on final follow-up evaluation. There was no statistical difference in overall wrist motion, grip strength, or wrist score between the dynamic and static groups. The time to surgery and age had no significant effect on overall outcome.

CONCLUSIONS

Dorsal capsulodesis provided pain relief for patients with both dynamic and static SL instability. Although pain was improved it was not completely resolved in the majority of cases. From a radiographic perspective dorsal capsulodesis did not provide maintenance of carpal alignment in cases of chronic SL dissociation.