Arthroscopic management of scapholunate complex injuries associated with distal radius fractures

Scapholunate complex injuries are the most frequent lesions associated with distal radius fractures and the treatment algorithm according to the stage of the instability remains controversial. However, there is an admitted consensus around the necessary treatment of the associated high-grade instabilities. They occur frequently in young patients after high energy trauma, and not treated, they can lead to chronic wrist pain and eventually to scapholunate advanced collapse. The routine use of the arthroscopy provides an accurate intraoperative staging of the lesions and allows a tailored treatment depending on the severity of the scapholunate instability.

Can a structured home-based rehabilitation program reduce dorsal central wrist pain?

OBJECTIVES

Dorsal central wrist pain, often a consequence of peri-scapholunate ligament injury, can result in a decline in functional performance. There is a scarcity of clinical data evaluating the effectiveness of conservative management on peri-scapholunate ligament injury. Conservative management includes education, immobilization with orthotic devices, scapholunate-stabilizing muscle strengthening, and proprioception training. The identification of the ligamento-muscular reflex and scapholunate-stabilizing muscles formed the rationale for a rehabilitation training program. We have devised an innovative standardized 16-week treatment program for patients with dorsal central wrist pain associated with acute peri-SL ligament injury. We hypothesized that the program can effectively reduce dorsal wrist pain and improve functional performance.

MATERIALS AND METHODS

Recruited subjects underwent the 16-week home-based program, which included immobilization and rehabilitation exercises, to improve their wrist stability. Follow-up was arranged every 4 weeks for progress monitoring. The Short-Form 12 item questionnaire version 2, power grip, pinch grip, wrist range of motion, total performance score and total pain score when performing activities of daily living were used to evaluate the effectiveness of the program. An exercise adherence questionnaire was used to evaluate adherence to the home rehabilitation program.

RESULTS

Twenty-three subjects (26 wrists) completed the program. Pain on visual analog scale improved by 5.1 cm and total pain score improved from 14.4/20 to 19.5/20. Total performance score reached 39/40, which indicated near-normal wrist function. Power grip and pinch grip increased by 22.3% and 17.8%, respectively. The physical component scale of the Short-Form 12 item questionnaire showed significant improvement, while the mental component scale did not. Overall adherence was fair.

DISCUSSION

Conservative management, including immobilization and rehabilitation training, can provide significant clinical improvement in patients with dorsal central wrist pain associated with acute peri-scapholunate ligament injury.

CONCLUSION

Standardized wrist rehabilitation can be taken as a reference treatment modality. It is an evidence-based non-invasive treatment option for clinicians and therapists.

Correlation between dorsal capsulo-scapholunate septum (DCSS) lesion and predynamic scapholunate instability

OBJECTIVE

Scapholunate instability is the most common ligament injury of the wrist. In case of predynamic instability, diagnosis can be difficult, even under arthroscopy. Scapholunate instability is not the result of an isolated injury to the scapholunate interosseous ligament. Scapholunate stability is dependent not only on the scapholunate ligament, but on a complex that is comprising intrinsic and extrinsic ligaments. The dorsal capsule-scapholunate septum (DCSS) is one of the secondary stabilizers of the scapholunate complex. The objective of the present study was to investigate the correlation between DCSS lesion and predynamic scapholunate instability.

METHOD

A prospective multicenter study included patients who underwent wrist arthroscopy for traumatic wrist. Arthroscopic DCSS lesion stage and instability according to European Wrist Arthroscopy Society stage were assessed.

RESULTS

Twenty-seven subjects were included. We found a significant correlation between pathological DCSS and predynamic scapholunate instability and a correlation between DCSS lesion severity and instability level.

CONCLUSION

Isolated DCSS lesion should be considered a predictive factor for predynamic instability.

Radiographic evaluation of radial flexion osteotomy effect on static scapholunate instability: a preliminary cadaveric study

INTRODUCTION

The optimal treatment of chronic scapholunate instability has yet to be established. Scapholunate ligament grafts are still far from being the ideal solution. We conducted an experimental study to evaluate whether flexion-opening wedge osteotomy of the distal radius improves misalignment and avoids rotatory subluxation of the scaphoid in a cadaveric model of static scapholunate dissociative instability.

MATERIALS AND METHODS

Radiographic studies were performed on 15 cryopreserved specimens after recreating a model of scapholunate instability by division of the scapholunate interosseous ligament (SLIL) and secondary stabilizers, taking radiographs at baseline, after the instability model, and after distal radius osteotomy. Static and dynamic (under controlled tendon traction) anteroposterior and lateral views were obtained to measure the length (in mm) of the carpal scaphoid and scapholunate interval, scapholunate angle, radio-lunate angle, and palmar tilt of the distal joint surface of the radius and to measure the dorsal scaphoid translation by the concentric circles method. The Wilcoxon test was used for statistical comparisons.

RESULTS

The scapholunate interval was significantly decreased after osteotomy in all static anteroposterior views and in all lateral views under tendon traction. Dorsal scaphoid translation was significantly reduced in static lateral view in extension and in dynamic lateral view under 5-pound flexor carpi radialis tendon tension controlled by a digital dynamometer.

CONCLUSIONS

Flexion-addition osteotomy of the distal radius appears to improve carpal alignment parameters in a cadaveric model of static scapholunate instability, achieving similar values to those obtained before instability.

Arthroscopic Dorsal Ligamentocapsulodesis in the Treatment of Occult Dorsal Wrist Ganglion Cysts Associated with Scapholunate Instability: Surgical Technique and Preliminary Clinical Results

Background: This study aimed to evaluate our preliminary results and experience with the arthroscopic dorsal ligamentocapsulodesis in managing occult dorsal wrist ganglion cysts (ODGCs) associated with scapholunate (SL) instability. Methods: All patients who underwent arthroscopic dorsal ligamentocapsulodesis due to an ODGC with concomitant SL ligament tear were retrospectively reviewed. In addition to demographic data and length of follow-up, outcomes data that included range of motion, grip strength, modified Mayo wrist score (MMWS), complications and radiographs were collected. Results: The study included 18 patients (18 wrists; 10 female and 8 male). The mean age was 32 years (range: 19-48) and the mean follow-up was 34 months (range: 24-48). The mean preoperative extension deficit decreased from 5.5° (range: 0°-20°) to 2.7° (range: 0°-15°) at the final follow-up (p = 0.004). The mean preoperative flexion deficits decreased from 4.4° (range: 0°-15°) to 2.2° (range: 0°-10°) postoperatively (p = 0.003). The mean hand grip strength significantly increased from 27.7 kg (range: 22-36) to 38.3 kg (range: 31-46) at the final follow-up assessment (p < 0.001). The mean MMWS improved from 46 (range: 25-65) pre-operatively to 91 (range: 70-100) at the final follow-up (p = 0.0002). No major intra- or postoperative complications were observed. Conclusions: SL instability may have an important role in the aetiology of ODGCs, and arthroscopic dorsal ligamentocapsulodesis can provide pain relief and functional improvement without recurrence at the short- to mid-term follow-up in the treatment of ODGCs. Level of Evidence: Level IV (Therapeutic).

Arthroscopic scapholunate ligament repair and dorsal capsulodesis with suture anchor in acute and subacute scapholunate dissociation

PURPOSE

The objective of this study was to investigate the potential of arthroscopic scapholunate ligament repair and dorsal capsulodesis with suture anchor as a treatment option for patients experiencing symptomatic acute and subacute (< 3 months) scapholunate instability.

METHODS

From Jan. 2017 to Jan 2020, 19 wrists with acute or subacute tears of the SL ligament with symptomatic instability were treated with arthroscopic SL repair and dorsal capsulodesis with a suture anchor. The average time from injury to operation was 8.8 weeks (range, 4-11 weeks) and the regular follow-up mean duration at our clinic was 26.5 months (range, 24-32 months). The pain score according to the visual analog scale, wrist range of motion, grip strength, radiographic outcomes and functional outcomes according to the Modified Mayo Wrist Score (MMWS) were evaluated preoperatively and postoperatively during the follow-up period.

RESULTS

All 19 patients had rupture and dissociation of the SL ligament in the radiocarpal joint. The total arc of wrist motion in the flexion-extension plane loss averaged 5.1° (P > .01).The Wilcoxon signed-rank test was used to compare the results: grip force improved significantly with 14.7% improvement of that on the normal side (P < .01); the postoperative MMWS was significantly better than the preoperative scores (P < .01). Of 19 patients of the series, 18 patients (94.7%) achieved good or excellent results according to the MMWS and 16 patients (84.2%) resumed their previous activities. Only one patient (5.3%) had residual laxity of the scapholunate ligament joint at 15 months of follow-up.

CONCLUSIONS

At a minimum of two years of follow-up, patients with acute or subacute symptomatic dissociation of scapholunate ligament instability who underwent arthroscopic scapholunate ligament repair and dorsal capsulodesis with suture anchor treatment had satisfactory results.

LEVEL OF EVIDENCE

Level IV, case series.

Scaphoid, lunate and capitate kinematics in the normal and ligament deficient wrist: A bi-plane X-ray fluoroscopy study

The ligamentous structures of the wrist stabilise and constrain the interactions of the carpal bones during active wrist motion; however, the three-dimensional translations and rotations of the scaphoid, lunate and capitate in the normal and ligament deficient wrist during planar and oblique wrist motions remain poorly understood. This study employed a computer-controlled simulator to replicate physiological wrist motion by dynamic muscle force application, while carpal kinematics were simultaneously measured using bi-plane x-ray fluoroscopy. The aim was to quantify carpal kinematics in the native wrist and after sequential sectioning of the scapholunate interosseous ligament (SLIL) and secondary scapholunate ligament structures. Seven fresh-frozen cadaveric wrist specimens were harvested, and cycles of flexion-extension, radial-ulnar deviation and dart-thrower's motion were simulated. The results showed significant rotational and translational changes to these carpal bones in all stages of disruptions to the supporting ligaments (p < 0.05). Specifically, following the disruption of the dorsal SLIL (Stage II), the scaphoid became significantly more flexed, ulnarly deviated, and pronated relative to the radius, whereas the lunate became more extended, supinated and volarly translated (p < 0.05). Sectioning of the dorsal intercarpal (DIC), dorsal radiocarpal (DRC), and scaphotrapeziotrapezoid (STT) ligaments (Stage IV) caused the scaphoid to collapse further into flexion, ulnar deviation, and pronation. These findings highlight the importance of all the ligamentous attachments that relate to the stability of the scapholunate joint, but more importantly, the dorsal SLIL in maintaining scapholunate stability, and the preservation of the attachments of the DIC and DRC ligaments during dorsal surgical approaches. The findings will be useful in diagnosing wrist pathology and in surgical planning.

Scapholunate instability: why are the surgical outcomes still so far from ideal?

The wrist is a universal joint with intrinsic and extrinsic ligaments that function and fail as ligamentous complexes. Those related to scapholunate instability (SLI) include the dorsal scapholunate complex (DSLC), volar radiolunate complex and scaphotrapeziotrapezoid complex. Together the DSLC, scaphoid and lunate create an 'acetabulum' for the capitate, with the dorsal intercarpal ligament being a labrum to contain the capitate. SLI results from failure of the DSLC, typically from its scaphoid attachments. Failure of the lunate and or triquetral attachments increases the instability. DSLC failure leads to radioscaphoid instability, which is the symptomatic clinical problem. SLI reconstruction with open surgery and trans-osseous tendon graft techniques have been challenging. We discuss a biological arthroscopic approach to identify, mobilize and debride the disrupted DSLC. This ligament/capsular/periosteum sheet is then advanced and secured to the debrided footprint. Thereby reconstituting the acetabulum, labrum and scaphoid stability.

An algorithmic diagnostic approach to scapholunate ligament injuries based on comparison of X-ray examinations and arthroscopy in 414 patients

Conventional X-ray imaging is usually the first diagnostic assessment after clinical examination in case of suspected scapholunate interosseous ligament (SLIL) injury. Nevertheless, there is no consensus on the norms of the scapholunate distance (SLD) or carpal angles. Therefore, we aimed to determine the utility of static and dynamic radiographs in the diagnostic of an SLIL injury in comparison with the reference standard arthroscopy. We retrospectively analyzed the preoperative X-ray series and surgical records of arthroscopies of 414 patients. Radiological assessment included conventional static X-rays in the posteroanterior (PA) projection, clenched fist views in ulnar and radial deviations, in which the SLD at the midportion of the scapholunate (SL) joint was measured. The scapholunate angle (SLA) and radiolunate angle (RLA) were measured on lateral wrist radiographs. Receiver operating characteristic (ROC) curves were created to determine possible cut-off points of the radiological indices for the diagnosis of SLIL injury. Further, a logistic regression with the parameters having the highest area under the curve (AUC) was calculated. We found that SLD in ulnar inclination (AUC= 0.774), SLD in PA projection (AUC = 0.748), and SLA (AUC = 0.737) had the highest diagnostic value. The AUC of the combination of these three parameters was 0.822 for all patients with any SLIL lesion and 0.850 for patients with SLIL lesions of 3-4 Geissler grade. Further investigation of SLIL pathology would be appropriate in the case of SLD in ulnar inclination of 2.7 mm, SLD in PA projection of 1.9 mm and SLA of 63°.

Long-term follow-up of the three-ligament tenodesis for scapholunate ligament lesions: 9-year results

We report on a retrospective cohort of 50 cases of three-ligament tenodesis for scapholunate instability. Fifteen cases (30% of our cohort) needed salvage surgery (11 proximal row carpectomies, 2 partial and 2 total wrist fusions) at an average of 33 months and are considered "failures". Of the 35 remaining cases ("success"), 16 (32% of our cohort) were reviewed at average 111 months and had good functional outcomes (QuickDASH 18/100, PRWE 11/100, pain 1/10, satisfaction 9/10). Return to work was 81% and grip strength was 80% of the opposite side. Radiological review found no significant correction in the short-term: scapholunate angle (SLA) from 72° to 69° (p = 0.544), scapholunate distance (SLD) from 3.4 mm to 3.4 mm (p = 0.833) and radiolunate angle (RLA) from 17° to 13° (p = 0.253). A significant deterioration in SLA from 72° to 80° (p = 0.014), not correlated to function, was seen at final follow-up. Radiographic progression to wrist degeneration was seen in 63% of successful cases. In failed cases, we noticed inferior radiographic parameters in the short-term: SLD of 4.6 mm in failed versus 3.4 mm in successful cases (p = 0.038) and RLA of 22° in failed versus 13° in successful cases (p = 0.046). Complication rate was 10% (2 scaphoid necroses, 1 septic arthritis and 2 complex regional pain syndromes). Despite radiological deterioration of SLA and development of degeneration in most cases, three-ligament tenodesis can give satisfactory wrist function in some patients, but we observed a significant number of failures and a high complication rate. LEVEL OF EVIDENCE: IV.

Treatment of static scapholunate dissociation using a slip of the flexor carpi radialis

The purpose of this paper is to examine the results of reconstruction of the dorsal and palmar limbs of the scapholunate interosseous ligament in flexible static scapholunate instability using a slip of flexor carpi radialis tendon. Between June 2012 and August 2018, 13 patients with flexible static scapholunate instability underwent with this surgical technique. Mean patient age at surgery was 42 years. Average follow-up was 52, 8 months. The functional outcome postoperative according to Green and O'Brien was excellent in 1, good in 9 and regular in 3 patients. Postoperative disabilities of the arm, shoulder and hand and modified Mayo scores averaged were 9.02 and 80, respectively. At final follow-up, the radiographic findings demonstrated a significant decrease in scapholunate gap from 5 mm to 2, 5 mm and a significant improvement in scapholunate angle from 65° to 50°. Of the 13 patients, 10 were pain free and 3 had mild pain. Given the small number of cases, few conclusions can be drawn. However, results may be regarded as promising for this technique.

Treatment of Carpal Instability and Distal Radioulnar Joint Instability

Carpal instability and distal radioulnar joint instability represent an important set of conditions responsible for pain and disability in the wrist. Either condition can occur as a result of ligamentous failure or loss of articular congruity from fractures or a combination of both. Instability itself is a clinical diagnosis supported by relevant imaging modalities. Carpal and distal radioulnar joint instability needs to be considered according to its stage and severity as well as other factors like etiology and chronicity to determine the optimal treatment option. This article summarizes the conditions most relevant to the practice of a hand surgeon, with emphasis divided equally between assessment and diagnosis, staging, and treatment. The 3 most common carpal instability conditions are outlined in this article together with a review on acute and chronic distal radioulnar joint instability.

Treatment of chronic scapholunate dissociation with tenodesis: A systematic review

Scapholunate (SL) instability is the most common dissociative carpal instability condition. It is the most frequent cause of wrist osteoarthritis, defined as scapholunate advanced collapse or SLAC wrist. Familiarity with the SL ligament complex is required to understand the various features of SL instability. Damage to the SL interosseous ligament is the main prerequisite for SL instability; however the extrinsic, palmar and dorsal ligaments of the carpus also come into play. When more than 6 weeks has passed since the initial injury event, SL instability is considered chronic because ligament healing is no longer possible. Before osteoarthritis sets in and when the SL instability is still reducible (scaphoid can be reverticalized), ligament reconstruction surgery is indicated. Since the end of the 1970s, various ligament reconstruction or tenodesis techniques have been described. These techniques are used in cases of chronic, dynamic or static reducible SL instability, when no repairable ligament stump and no chondral lesions are present. The aim is to correct the SL instability using a free or pedicled tendon graft to reduce pain while limiting the loss of mobility and protecting against osteoarthritis-related collapse in the long-term. We will perform a systematic review of the various tenodesis techniques available in the literature.

Update on operative treatment of scapholunate (SL) instability for radiologists: part 1-SL ligament repair, dorsal capsulodesis and SL ligament reconstruction

Scapholunate instability is the most common form of carpal instability. Imaging (especially radiography) plays an important role in the staging, management and post-operative follow-up of scapholunate (SL) instability. The goals of this article are to review the pre-operative staging of SL instability, the surgical options for repair and reconstruction of the SL ligament, along with the normal postoperative imaging findings as well as complications associated with these surgical options.

Evaluation of the performance of three tenodesis techniques for the treatment of scapholunate instability: flexion-extension and radial-ulnar deviation

Chronic scapholunate ligament (SL) injuries are difficult to treat and can lead to wrist dysfunction. Whilst several tendon reconstruction techniques have been employed in the management of SL instability, SL gap reappearance after surgery has been reported. Using a finite element model and cadaveric study data, we investigated the performance of the Corella, scapholunate axis (SLAM) and modified Brunelli tenodesis (MBT) techniques. Scapholunate dorsal and volar gap and angle were obtained following virtual surgery undertaken using each of the three reconstruction methods with the wrist positioned in flexion, extension, ulnar deviation and radial deviation, in addition to the ulnar-deviated clenched fist and neutral positions. From the study, it was found that, following simulated scapholunate interosseous ligament rupture, the Corella technique was better able to restore the SL gap and angle close to the intact ligament for all wrist positions investigated, followed by SLAM and MBT. The results suggest that for the tendon reconstruction techniques, the use of multiple junction points between scaphoid and lunate may be of benefit.

Graphical abstract

Arthroscopic Scapholunate Ligament Reconstruction, Volar and Dorsal Reconstruction

Arthroscopic scapholunate volar and dorsal ligament reconstruction achieves an anatomic reconstruction, avoids an open approach and capsular detachment, and provides a strong construct for early mobilization. Clinical results are discussed. Detailed "surgical tips" and technical modifications are provided.

Salvage procedures, total wrist arthrodesis, and total wrist arthroplasty

Scapholunate (SL) instability is the most common form of carpal instability. Imaging (especially radiography) plays an important role in the staging, management, and postoperative follow-up of SL instability. In the final stage of SL instability, known as scapholunate advanced collapse, progressive degenerative changes occur at the carpal level. The goals of this article are to review the surgical options available for addressing the different stages of scapholunate advanced collapse, along with an emphasis on normal postoperative imaging and complications associated with each surgical option.

Sequential scapholunate and volar beak ligament reconstructions with flexor carpi radialis tendon grafts

The flexor carpi radialis tendon is considered by many the workhorse tendon in hand and wrist surgery. Some have expressed concerns about altering the mechanics of the wrist by sacrificing part or all of the flexor carpi radialis tendon. We present an interesting case of sequential scapholunate and volar beak ligament reconstructions using a flexor carpi radialis tendon autograft where a slip of tendon was harvested twice within three years, achieving a satisfactory clinical outcome at five years following the initial surgery.

Hamate and pisiform coalition: a case report and introduction to the carpal C-sign on lateral radiograph

Hamate-pisiform coalition is an exceptional form of carpal coalition. Case reports are essential to gain a better understanding of this variant. We report a case of congenital bilateral hamate-pisiform coalition in a 20-year-old male discovered in the context of a right wrist trauma. Radiographs also revealed a bilateral scapholunate diastasis. Clinical examination and radiological findings suggested that the right wrist scapholunate diastasis was related to scapholunate instability. Left wrist scapholunate diastasis could be related to (1) a pathological feature or (2) a normal variant associated with hamate-pisiform coalition. Lateral radiographs showed a volar C-shaped osseous bridge corresponding to the coalition. We associated it with a new sign: the "carpal C-sign". Computed tomography with three-dimensional reconstruction provides helpful information about the type of coalition (osseous versus non-osseous) and excludes potential fracture. We discuss the specific embryologic features of the hamate-pisiform coalition, as well as its prevalence, radiographic classification, clinical significance, and treatment.

Role of muscles in the stabilization of ligament-deficient wrists

This article reviews the results of a series of cadaver investigations aimed at clarifying the role of muscles in the stabilization of ligament-deficient wrists. According to these studies, isometric contraction of some forearm muscles induces midcarpal (MC) supination (ie, the abductor pollicis longus, extensor carpi radialis longus, and flexor carpi ulnaris), whereas other muscles induce MC pronation (ie, the extensor carpi ulnaris). Because MC supination implies tightening of the volar scaphoid-distal row ligaments, the MC supination muscles are likely to prevent scaphoid collapse of wrists with scapholunate ligament insufficiency. MC pronator muscles, by contrast, would be beneficial in stabilizing wrists with ulnar-sided ligament deficiencies owing to their ability to tighten the triquetrum-distal row ligaments. Should these laboratory findings be validated by additional clinical research, proprioceptive reeducation of selected muscles could become an important tool for the treatment of dynamic carpal instabilities.

Understanding carpal instability: a radiographic perspective

The wrist is disposed to a variety of instability patterns owing to its complex anatomical and biomechanical properties. Various classification schemes have been proposed to describe the different patterns of carpal instability, of which the Mayo classification is the most commonly used. Understanding the concepts and pertinent terminology of this classification scheme is important for the correct interpretation of images and optimal communication with referring physicians. Standard wrist radiographs are the first line of imaging in carpal instability. Additional information may be obtained with the use of stress radiographs and other imaging modalities.

Isolated or predominant capitolunate osteoarthritis is the consequence of lunotriquetral dissociation. X-ray analysis of 22 consecutive cases

Secondary osteoarthritis due to a scapholunate malalignment is well known, but is debatable in cases of lunotriquetral malalignment. It has been shown that lunotriquetral malalignment can lead to midcarpal osteoarthritis. The hypothesis of this retrospective study was that a relationship exists between the presence of midcarpal osteoarthritis and the presence of lunotriquetral malalignment. All patients with midcarpal osteoarthritis, isolated or predominant, treated between 1981 and 2013 were reviewed. Intracarpal angles were measured and the relative position of the carpal bones was analyzed by two examiners. Osteoarthritis of the wrist's joints was quantified in three stages. Diagnosis of static dissociative ligament lesion was made and correlated with the location of osteoarthritis. Twenty-two wrists in 20 patients (13 men and 7 women; mean age of 59 years) were included. The lunocapitate osteoarthritis was moderate in 6 cases and severe in 16 cases. The radioscaphoid osteoarthritis was moderate in 5 cases and severe in 1 case. Lunotriquetral malalignment was present in all cases; it was isolated in 8 cases and associated with scapholunate malalignment in 14 cases. In isolated lunotriquetral malalignment cases, midcarpal osteoarthritis was isolated or associated with degenerative lesions of lunotriquetral interval. Cases of perilunate instability in which the osteoarthritis is more severe in the midcarpal joint than in the radioscaphoid joint likely resulted from an injurying mechanism with ulnar beginning (ulnar-sided perilunate instability).

Outcome of arthroscopic reduction association of the scapholunate joint

This study evaluates the arthroscopic reduction association scapholunate technique and outcomes. A total of 18 patients with chronic scapholunate instability with mean follow-up of 36 months were reviewed. Postoperatively, the mean visual analogue score was 2.5 and the mean DASH score was 8. The grip strength was 27 kg on the operative side compared with 32 kg on the uninjured side. The mean wrist flexion was 46° and extension was 56°. Seven patients had complications. Six patients had scapholunate joint widening, one had windshield-wipering of the screws with loss of reduction, and two demonstrated progression of scapholunate advanced collapse deformity. Four patients underwent revision surgeries: two revision arthroscopic reduction association scapholunates and two proximal row carpectomies. A preoperative scapholunate gap of greater than 5 mm and the presence of scapholunate advanced collapse Grade I were both predictive of a complication or revision surgery. Patients with a scapholunate gap of greater than 5 mm or scapholunate advanced collapse had statistically higher complications rates.Level of Evidence IV.

Chronic Scapholunate Ligament Injuries: Treatment with Supplemental Fixation

Treatment of chronic scapholunate ligament injuries can be challenging. Traditional reconstructive techniques, including varied capsulodeses and tenodeses often yield inconsistent results with loss of reduction and radiographic deterioration. As a result, supplemental hardware fixation has become more popular and may allow more robust stabilization of the scapholunate reconstruction. However, these procedures have complications and few data regarding outcomes are currently available. This article evaluates the role of supplemental fixation in the management of chronic scapholunate instability.

Bone-Retinaculum-Bone Autografts for Scapholunate Interosseous Ligament Reconstruction

Carpal instability arising from an injury to the scapholunate interosseous ligament (SLIL) is commonly seen and treated by hand surgeons. No technique to this date has proved to provide optimal results for primary repair of acute SLIL tear and the treatment of chronic tears of the SLIL. Recently, attention has shifted toward replacement of the dorsal aspect of the SLIL, which is the most structurally and functionally important aspect of the SLIL. This article describes the indications, surgical technique, postoperative treatment and expected results of the use of a bone-retinaculum-bone autograft procedure in the treatment of scapholunate instability.

Acute Scapholunate Ligament Injuries: Arthroscopic Treatment

Wrist arthroscopy is an effective technique for treating acute scapholunate instability. It allows an accurate assessment of the degree and extent of the ligament injury. Partial injuries are effectively treated with arthroscopic debridement and electrothermal ligament tightening. Complete ligament injuries treated arthroscopically allow direct visualization of the torn ligament and assessment of the degree of scaphoid displacement and rotation. The use of arthroscopy allows a more accurate reduction of the scaphoid and lunate at the time of fixation than can be obtained using just fluoroscopy.

Comparisons of three radiographic views in assessing for scapholunate instability

BACKGROUND

Multiple wrist x-ray images have been described to assess for scapholunate (SL) instability. Some views may be redundant. The purpose of this study was to compare three plain x-ray views in identifying a traumatic diastasis of the SL interval.

METHODS

Nineteen patients (19 wrists) with a positive scaphoid shift test and surgically confirmed SL ligament damage were identified. There were 15 males and 4 females with a mean age of 39 years. Pre-operative x-rays were reviewed, including posteroanterior (PA) neutral and PA ulnar deviation views of the injured wrist, and PA clenched fist views of the injured and uninjured wrists. Dynamic SL instability was defined by an SL mid-interval gap of <3 mm and static SL instability by a gap of ≥3 mm in the PA neutral views. The mid-interval measurements were compared between x-ray images.

RESULTS

There were 10 dynamic and 9 static SL instability cases. The PA ulnar deviation and the PA clenched fist views showed significantly greater SL gaps in comparison to the PA neutral views in dynamic but not static SL instability cases. In both categories of instability, there was no significant difference in the SL gaps between the two stress images. The PA clenched fist view of the uninjured wrist revealed SL gapping of >3 mm in 50% of patients but with generally greater gapping in the clenched fist view of the injured wrist.

CONCLUSIONS

The PA ulnar deviation and clenched fist stress views were equally effective in showing a dynamic SL diastasis following wrist injury. Neither view was more effective than a neutral PA view in diagnosing static SL instability.

Arthroscopic ligamentoplasty of the dorsal and volar portions of the scapholunate ligament

Classical arthroscopic techniques for scapholunate instability consist of debridement, thermal shrinkage, and percutaneous pinning. Good results are obtained in acute lesions or in chronic partial tears, but they are less predictable when the lesion is complete, because of the poor healing capacity of the scapholunate ligament and because it is not possible to perform an anatomic ligamentous reconstruction with these techniques. Open techniques are thus required for reconstruction, but they damage the soft tissues. We recently published a description and cadaver study of an arthroscopic ligamentoplasty, trying to combine the advantages of arthroscopic techniques (minimally invasive surgery) and open techniques (reconstruction of the ligament). With this approach, it is possible to reconstruct the dorsal scapholunate ligament and the secondary stabilizers while causing minimal damage to the soft tissues and avoiding injury to the posterior interosseous nerve and detachment of the dorsal intercarpal ligament. The current report describes an additional step to this technique with which it is possible to reconstruct the volar portion of the scapholunate ligament. We also describe an early mobilization postoperative protocol that we believe is equally important.