Carpal Realignment Using a Strip of Extensor Carpi Radialis Longus Tendon

Osteolysis After Augmented Scapholunate Ligament Reconstruction: A Report of 3 Cases

CASE

Augmented scapholunate ligament reconstruction using polyether ether ketone anchors and ultra-high molecular weight polyethylene synthetic tape has the theoretical advantage of improved stability, avoidance of K-wire fixation, and the potential for earlier mobilization. We present 3 cases of scaphoid and lunate osteolysis/fragmentation, operative and histologic findings at reoperation, and the sequelae of this technique.

CONCLUSION

If planning to use suture anchors and synthetic tapes in small carpal bones, we recommend advising patients about the risk of osteolysis and monitoring closely patients who complain of pain with motion after surgery.

Tratamiento de lesiones escafolunares mediante reconstrucción con plastia del extensor radial largo del carpo

Objetivo Describir la técnica quirúrgica de reconstrucción del ligamento escafolunar asistida por artroscopia empleando como donante el extensor carpi radialis longus (ECRL), un músculo que, gracias a sus propiedades biomecánicas, puede ser muy ventajoso en este tipo de cirugía.

Técnica Quirúrgica Tras artroscopia diagnóstica inicial según la técnica habitual, se llevó a cabo la reconstrucción ligamentosa empleando un hemitendón del ECRL mediante técnica mínimamente invasiva. Los dispositivos de fijación empleados fueron el SwiveLock para el escafoides y el tornillo de biotenodesis de 3 × 8 mm (Arthrex, Naples, FL, EE.UU.) para el semilunar.

Complicaciones La complicación que puede surgir durante la realización de esta técnica es la extracción dificultosa de la plastia, por la intersección entre el primer y el segundo compartimentos extensores. Es fácilmente solventable realizando una incisión intermedia a nivel de la intersección para garantizar la adecuada liberación de la plastia a esta altura.

Conclusión Es posible reconstruir el intervalo escafolunar empleando un hemitendón del ECRL, que, por propiedades biomecánicas, puede ser más ventajoso a la hora de restaurar la biomecánica del carpo. Se precisan estudios posteriores para confirmar la idoneidad y la superioridad de este donante frente a otros empleados en las técnicas de reconstrucción.

Did implementation of three ligament tenodesis improve patient outcome after chronic scapholunate instability? A retrospective study

INTRODUCTION

Scapholunate instability frequently leads to chronic pain or even severe osteoarthritis of the wrist. Most favored reconstruction techniques of chronic SL-ligament injuries are based on the usage of a tendon, although there is still a lack of consensus which technique is superior.

MATERIALS AND METHODS

In a retrospective cohort analysis we compared 9 patients who underwent SL-ligament repair according to Van den Abbeele and 12 patients who underwent modified three ligament tenodesis according to Garcia-Elias, performed at a single institution.

RESULTS

Follow-up of Van den Abbeele group was 36-120 months and 13-39 months in the Garcia Elias cohort. Although both techniques showed good functional outcome in most cases, modified three ligament tenodesis seemed to be advantageous regarding wrist range of motion (162°) compared to Van den Abbeele cohort (87°). Moreover, pain score showed significant differences between the two cohorts during follow up (VAS Van den Abbeele 4.2; VAS Garcia Elias 1.7). Interestingly, DASH-score (16.1 Van den Abbeele; 16.8 Garcia Elias) and modified mayo wrist score (72 Van den Abbeele; 69 Garcia-Elias) did not show any differences between the two patient cohorts.

CONCLUSIONS

Via implementation of modified three ligament tenodesis as a standard of care for our patients we could improve the functional outcome after SL-ligament injuries and effectively decrease postoperative pain.

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.

Anatomical anterior and posterior reconstruction for scapholunate dissociation: preliminary outcome in ten patients

This study reviews the efficacy of a reconstruction to address scapholunate dissociation using an anterior and posterior approach with a hybrid synthetic tape/tendon weave between the trapezium, scaphoid, lunate and radius: an anatomical front and back (ANAFAB) repair. This repair is a compilation of the components of a number of previously reported repair techniques, and based on published kinematic evidence. It aims to restore the anatomical mechanical constraints on both anterior and posterior aspects of the carpus. Patients were immobilized in a cast for 6 weeks, but no stabilizing wires were used. Ten patients have undergone the reconstruction and were assessed at a minimum 24-month follow-up. They achieved excellent realignment of the carpus, a postoperative median scapholunate gap of 3 mm and a recovery of more than 75% of grip strength and range of motion. No patient required secondary surgery or treatment related to the carpal stabilization. Level of evidence: IV.

Dorsal Intercarpal Ligament Preserving Arthrotomy and Capsulodesis for Scapholunate Dissociation

Carpal instability secondary to scapholunate (SL) ligament tears can lead to a significant disability of the wrist. Different surgical procedures have been proposed to treat SL instability. A variety of dorsal capsulodesis techniques tethering the scaphoid have been used in patients with SL dissociation. We report a novel technique of modified dorsal intercarpal ligament (DICL) capsulodesis for the treatment of SL dissociation. The surgical indication for this procedure is complete SL ligament tear with a reducible carpal malalignment and no secondary osteoarthritis. This procedure is indicated when the remnant of torn ligament in the dorsal SL interosseous space is available for repair. First, carpal malalignment is corrected and the scaphoid and the lunate are temporarily fixed with a transosseous screw or Kirschner wires. Using a dorsal approach, the DICL is then exposed, which originates from the triquetrum and attaches to the scaphoid, trapezium, and trapezoid. The distal and proximal borders of the ligament are identified and elevated without detaching the attachment sites. The DICL is transferred proximally to reinforce the dorsal SL interosseous ligament. The wrist joint is immobilized for 3 weeks postoperatively, and dart-throwing motion is permitted until temporary SL fixation is removed at 2 to 3 months after surgery. A wrist brace is recommended until 3 to 6 months after the first surgery depending on the patient's occupation and sports activity.

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.

Force Required to Maintain Reduction of a Preexisting Scapholunate Dissociation

PURPOSE

To determine the force required to maintain reduction of Geissler grade 4 scapholunate dissociations during physiological wrist motions.

METHODS

Fresh-frozen cadaveric wrists with Geissler grade 4 scapholunate dissociations were identified by arthroscopy. Following reduction, a load cell was attached to measure the force across the scapholunate joint at a neutral position and during 4 different wrist motions re-created using a servohydraulic wrist simulator, including a large flexion-extension motion (FEM), small and large dart-thrower's motions (DTMs), and a large DTM with ulnar offset.

RESULTS

Five wrists with isolated preexisting scapholunate interosseous ligament (SLIL) tears were analyzed. The force required to maintain reduction was significantly greater in extension than in flexion during the large FEM and large DTM with ulnar offset. The forces were significantly larger in this study of preexisting SLIL dissociations compared with results from a prior study of acutely sectioned SLILs. In addition, forces to maintain reduction during DTMs were significantly less than forces during FEMs. Finally, a set of 3 wrists with preexisting scapholunate and lunotriquetral interosseous ligament (LTIL) tears were identified and had significantly decreased forces to maintain reduction at maximum extension and had decreased maximal forces during a cycle of motion compared with the wrists with isolated SLIL tears.

CONCLUSIONS

The forces required to maintain reduction of a Geissler grade 4 wrist are higher than forces after acutely sectioned SLIL. The forces are greater in extension than in flexion and less during the DTM compared with the FEM. Wrists with both SLIL and LTIL tears required less force to maintain reduction than those with isolated SLIL tears.

CLINICAL RELEVANCE

This study helps determine the strength of reconstruction required to maintain reduction of a Geissler grade 4 scapholunate dissociation.