Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique

Current Techniques in Scapholunate Ligament Reconstruction

Scapholunate ligament injuries are common and can lead to a predictable pattern of arthritis (scaphoid lunate advanced collapse wrist) if unrecognized or untreated. This article describes the relevant anatomy, biomechanics, and classification system, and provides an up-to-date literature-based review of treatment options, including acute repair and various reconstruction techniques. It also helps guide surgeons in making decisions regarding a systematic treatment algorithm for these injuries.

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.

Mid-Term Results of the Use of a Suture Anchor Fixation for Chronic Reducible Scapholunate Dissociation

Background: Scapholunate dissociation (SLD) is a common and sometimes disabling ligamentous injury of the wrist. The aim of the treatment is to restore carpal alignment and to prevent joint degeneration. In the current study, we reported mid-term results of our technique using suture anchor fixation within the SL interface. Methods: Nine male patients with an average age of 35 years underwent scapholunate suture anchor fixation (SLAF) for chronic and symptomatic dynamic or reducible static SLD from 2011 to 2016 with a mean follow-up of 36 months. After dorsal wrist exposure, a 2.8 mm suture anchor was inserted in the dorsoproximal lateral articular surface of the lunate bone. The two ends of the sutures were passed through the two divergent canals in the scaphoid. The sutures were tied over the tuberosity after reducing the SL alignment. Two K-wires supported SL and scaphocapitate (SC) alignment for 8 weeks. Radiographic parameters, wrist range of motion and grip strength were measured. Quick-DASH and Modified Mayo Wrist Score (MMWS) were used to assess the functional outcome. Results: The grip strength and passive motion reached to 75% and 88% of the other side, respectively. The SL gap was 5.4 mm, 2.6 mm and 3.4 mm before surgery, after pin removal, and on the follow-up stress radiographs, respectively. The SL angle was 82, 52 and 65 degrees at any time point, respectively. Average Quick-DASH score was improved from 60 to 25. According to MMWS score, one patient was excellent, one was good, five were fair, and two were poor. Conclusions: SLAF is a simple technique with minimal soft tissue manipulation that enables correction and maintaining of the carpal alignment with favorable mid-term results.

Reconstruction of chronic scapholunate dissociation with the modified scapholunate axis method (SLAM)

INTRODUCTION

Injury to the scapholunate (SL) ligament represents a common trauma of the wrist but is frequently misdiagnosed because of non-specific pain. Established methods for SL reconstruction mainly focus on reducing pain and maintaining the reposition result at the expense of mobility and strength. This study aimed at restoring stability and reducing pain while simultaneously maintaining mobility and strength using the scapholunate axis method (SLAM).

MATERIAL AND METHODS

22 patients (19 male and 3 female) aged between 26 and 64 years with an SL ligament lesion underwent SLAM reconstruction. Mean duration between injury and operation was 7.9 ± 5 (1-24) months. Hand functions using DASH, Mayo Wrist Score, range of motion, pain (at rest and weight-bearing) and grip strength were assessed prior and 12 months postoperative. Additionally SL angle was collected pre- and postoperative.

RESULTS

Each of the 22 patients improved significantly postoperative in DASH and Mayo Wrist Score with regard to pain at rest and under weight-bearing. Additionally, grip strength could be improved up to 31% compared to preoperatively. In contrast, range of motion and SL angle and grip strength did not change essentially.

CONCLUSIONS

The secondary SL ligament reconstruction technique SLAM shows promising results. Pain was significantly relieved and grip strength was significantly increased. Additionally, DASH and Mayo Wrist Score could be significantly improved. However, SL angle and range of motion could not be improved in every patient and plane.

Factors Associated with the Quality of Online Information about Scapholunate Interosseous Ligament Insufficiency

Background The Internet is increasingly used by patients to seek health information about their medical conditions. The online information is of variable quality, often difficult to read, and sometimes inaccurate or misleading. This study assessed factors associated with the quality, readability, and dominant tones of online information about scapholunate interosseous ligament (SLIL) insufficiency. Materials and Methods Using the three most used search engines, we entered the terms "wrist sprain," "scapholunate ligament injury," and "SL dissociation" and assessed the quality of the 45 Web sites identified using the DISCERN tool, readability by the Flesch Reading Ease Score, the Flesch-Kincaid Grade Level, the Gunning Fog Index, and the Simple Measure Of Gobbledygook, and dominant tones using the IBM Watson Tone Analyzer and the Linguistic Inquiry and Word Count. Results Online information about SLIL injuries had a mean DISCERN score of 39 ± 8.2. A dominant Web site tone of "sadness" correlated with lower DISCERN scores. A dominant tentative tone in text was associated with easier to comprehend texts. Conclusion The online information regarding SLIL insufficiency is of generally low quality, limited readability, and the underlying tones may be misleading. Professional societies might consider efforts to provide appealing, readable, information about SLIL insufficiency and other less common diagnoses on the Internet.

Additively Manufactured Multiphasic Bone-Ligament-Bone Scaffold for Scapholunate Interosseous Ligament Reconstruction

The scapholunate interosseous ligament (SLIL) is a frequently torn wrist ligament, and current surgical options for SLIL tears are suboptimal. This research aims to develop a novel multiphasic bone-ligament-bone scaffold (BLB) with a porous interface using 3D-printing and cell sheet technology for the reconstruction of the dorsal scapholunate interosseous ligament. The BLB comprises two bone compartments bridged by aligned polycaprolactone fibers mimicking the architecture of the native tissue. Mechanical testing of the BLBs shows their ability to withstand physiological forces. Combination of the BLB with human bone marrow mesenchymal stem cell sheet demonstrates that the harvesting did not compromise cell viability, while allowing homogeneous distribution in the ligament compartment. The BLBs are loaded with cell sheets and bone morphogenetic protein-2 in the ligament and bone compartment respectively prior to ectopic implantation into athymic rats. The histology demonstrates rapid tissue infiltration, high vascularization, and more importantly the maintenance of the compartmentalization as bone formation remains localized to the bone compartment despite the porous interface. The cells in the ligament compartment become preferentially aligned, and this proof-of-concept study demonstrates that the BLB can provide sufficient compartmentalization and fiber guiding properties necessary for the regeneration of the dorsal SLIL.

Bilateral scapholunate widening may have a nontraumatic aetiology and progress to carpal instability and osteoarthritis with advancing age

It was hypothesized that bilateral widening of the scapholunate gap is relatively common in the absence of trauma and that it progresses to radiological carpal instability and scapholunate advanced collapse. Electronic files of 1000 patients with bilateral X-rays were studied in retrospect. Wide scapholunate gaps were bilaterally present in 67 and unilaterally in 51 patients. Scapholunate advanced collapse was observed in 26 patients; in nine it was in both wrists. A trauma was recorded in less than half of the patients with a bilateral wide scapholunate gap. Patients with bilateral wide gaps were younger if signs of carpal instability or osteoarthritis were absent. Bilateral scapholunate widening may not be caused by an acute trauma, but may lead to carpal instability and degenerative changes with advancing age.

Scapholunate Ligament Internal Brace 360 Tenodesis (SLITT) Procedure: A Biomechanical Study

Background  Twelve paired fresh frozen cadaveric wrists were randomized to a 360-degree tenodesis repair group or the 360-degree tenodesis repair with an internal brace (suture tape) construct. Case Description  The specimens were preloaded to 5 N and subsequently biomechanically loaded to failure, at a rate of 0.1 mm/s on a jig that allowed for axial load. The maximum load and mode of failure were recorded. Load to failure in the 360 tenodesis group with internal brace was 283.47 ± 100.25 N, compared with the 360 tenodesis group only, whose yield strength was 143.61 ± 90.54 N. The mode of failure within the internal brace construct was either through knot slippage, graft disruption, or bone separation from strength testing construct. The 360 tenodesis group tended to fail via graft slippage or graft rupture. Literature Review  The management of scapholunate instability can be a difficult problem to treat. Traditionally, many of the surgical reconstructions have focused upon dorsal ligament reconstruction with Kirschner (K) wire fixation. This results in prolonged immobilization of the wrist with varied outcomes, in part due to the multiaxial instability that may persist due to concomitant volar ligament disruption. To address this instability, surgical techniques have been devised that address both the volar and dorsal ligament injuries. Clinical Relevance  Scapholunate reconstruction with a 360-degree tenodesis and internal brace augmentation (SLITT procedure) provided superior biomechanical stability than tenodesis alone.

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 instability: Results with three-ligament tenodesis vs. scapholunate and intercarpal ligamentoplasty

In this retrospective case control/comparison study, we compared the clinical and radiological outcomes in patients with chronic scapholunate dissociation treated with three-ligament tenodesis (3 LT) versus scapholunate and intercarpal ligamentoplasty (SLICL). Twenty patients with a mean age of 43 years were treated with the 3 LT procedure and 26 patients with a mean age of 44 years with the SLICL procedure. All patients had chronic reducible scapholunate dissociation without chondral lesions. The two groups of patients were operated on by senior surgeons, at the same facility, over two different time periods. All patients were evaluated (pain, motion, strength, function, X-rays) with a mean follow-up of 28 months (12-49) in the 3 LT group and 36 months (12-54) in the SLICL group. In the both groups, we found a significant improvement in pain levels, grip strength and functional scores (DASH and PRWE). The SLICL group had significantly less pain and greater grip strength than the 3 LT group. Patients in the SLICL group had a greater improvement in their DASH and PRWE Scores. The mean range of motion in flexion-extension was 82° (102° preoperative) in the 3 LT group and 113° (115° preoperative) in the SLICL group. In the 3 LT, there was no significant improvement in the mean static and dynamic scapholunate gaps (3.6 and 4.8 mm postoperatively versus 3.9 and 4.9 mm preoperatively), or the scapholunate angle (75° versus 72°). In the SLICL group, the mean static and dynamic gaps improved significantly (2.3 and 3.0 mm postoperatively versus 3.2 and 4.6 mm preoperatively), as did the scapholunate angle (62° versus 73°). In the 3 LT group, 4 patients developed osteoarthritis. In conclusion, the SLICL procedure for scapholunate ligament reconstruction led to better clinical and early radiological results than the 3 LT technique.

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.

Reduction and Association of the Scaphoid and Lunate: A Functional and Radiographical Outcome Study

Background  Management of scapholunate (SL) ligament disruption is a challenging problem. The reduction and association of the scaphoid and lunate (RASL) procedure has been described with varying results. This study assessed the outcomes of the RASL procedure. Purpose  The objective of this study was to assess the outcomes of patients undergoing the RASL procedure at our institution in regard to pain relief, range of motion, radiographic and functional outcomes, complications, and reoperations. Materials and Methods  Twelve patients with symptomatic chronic SL instability underwent the RASL procedure. The mean age was 35 years. The mean time from injury to surgery was 40 weeks. The mean follow-up was 89 months. Outcomes included visual analog score for pain, wrist range of motion, grip strength, and Mayo Wrist Scores. Preoperative and postoperative radiographs were reviewed. Results  Pain scores improved in 10 wrists. Range of motion and grip strength worsened. The average Mayo Wrist Score was 63.3. The mean SL diastasis and angle improved, but seven wrists developed progressive degenerative changes, with two requiring a salvage procedure. Symptomatic progressive screw lucency occurred in eight wrists requiring screw removal. Conclusion  The RASL procedure can improve SL widening but has a high rate of early failure and reoperation. Following reoperation, long-term follow-up demonstrates reasonable long-term durability in some cases. Level of Evidence  This is a Level IV, therapeutic case study.

The Quantitative Anatomy of the Dorsal Scapholunate Interosseous Ligament

BACKGROUND

The anatomy of the scapholunate interosseous ligament (SLIL) has been described qualitatively in great detail, with recognition of the dorsal component's importance for carpal stability. The purpose of this study was to define the quantitative anatomy of the dorsal SLIL and to assess the use of high-frequency ultrasound to image the dorsal SLIL.

METHODS

We used high-frequency ultrasound imaging to evaluate 40 wrists in 20 volunteers and recorded the radial-ulnar (length) and dorsal-volar (thickness) dimensions of the dorsal SLIL and the dimensions of the scapholunate interval. We assessed the use of high-frequency ultrasound by comparing the length and thickness of the dorsal SLIL on ultrasound evaluation and open dissection of 12 cadaveric wrists. Student's t test was used to assess the relationship between measurements obtained on cadaver ultrasound and open dissection.

RESULTS

In the volunteer wrists, the mean dorsal SLIL length was 7.5 ± 1.4 mm and thickness was 1.8 ± 0.4 mm; the mean scapholunate interval was 5.0 mm dorsally and 2.5 mm centrally. In the cadaver wrists, there was no difference in dorsal SLIL length or thickness between ultrasound and open dissection.

CONCLUSIONS

The dorsal SLIL is approximately 7.5 mm long and 1.8 mm thick. These parameters may be useful in treatment of SLIL injuries to restore the native anatomy. High-frequency ultrasound is a useful imaging technique to assess the dorsal SLIL, although further study is needed to assess the use of high-frequency ultrasound in detection of SLIL pathology.

Changes in Scaphoid and Lunate Position and Loading at Two Wrist Pushup Positions

BACKGROUND

Scapholunate interosseous ligament (SLIL) injury following a fall on an outstretched hand may lead to carpal instability and in some cases require long-term rehabilitation following repair. Rehabilitation, especially in athletes, may include pushups, but little is known as to what type of pushup may be safer.

OBJECTIVE

To determine biomechanical differences between two pushup positions (neutral or extended).

METHODS

Six fresh cadaver wrists with pre-existing SLIL damage were uni-axially loaded in neutral and extension in order to simulate two different pushup styles. The motions of the scaphoid and lunate in relation to the radius were measured. The dorsal, proximal, and volar insertion sites of the SLIL were identified and, using the collected kinematic data, gap distances were calculated for each site.

RESULTS

Gap distance between the proximal SLIL insertion points was significantly greater in neutral than in extension. There was a trend that the dorsal and volar SLIL insertion points were also greater in neutral than in extension. After the wrist was extended 90o, the scaphoid extended 70.1o and the lunate extended 28.6o compared to their positions with the wrist in neutral.

CONCLUSION

The larger gap distances between the scaphoid and lunate in neutral suggest that a neutral style pushup could put higher forces on a wrist with pre-existing SLIL damage and may thus hinder recovery for a person with a repaired SLIL. A pushup in extension, in these injured wrists, may be less detrimental.

Carpal Tunnel Syndrome and Flexor Tendon Rupture in the Wrist with Asymptomatic Scapholunate Advanced Collapse: A Case Report

We experienced a rare case of carpal tunnel syndrome and rupture of the flexor digitorum profundus tendon to the index finger with a scapholunate advanced collapse wrist. We speculated that the lunate that had extruded into the carpal tunnel compressed the median nerve and caused wear of the flexor tendon following neglected perilunate subluxation. Carpal tunnel release, opponensplasty by palmaris longus tendon transfer, and a bridge graft by a half-slip of the flexor carpi radialis tendon resulted in recovery of pinch function and improvement in numbness of the hand.

Dynamic CT Scan of the Normal Scapholunate Joint in a Clenched Fist and Radial and Ulnar Deviation

BACKGROUND

Injuries to the scapholunate can have severe long-term effects on the wrist. Early detection of these injuries can help identify pathology. The purpose of this study was to evaluate the motions of the scapholunate joint in normal wrists in a clenched fist and through radial and ulnar deviation using novel dynamic computed tomography (CT) imaging.

METHODS

Fifteen participants below 40 years of age consented to have their wrist scanned. Eight participants were randomized to have the right wrist scanned and 7 the left wrist. Volunteers were positioned at the back of the gantry with the wrist placed on the table, palmar side down. Participants began with the hand in a relaxed fist position and then proceeded through an established range of motion protocol. Dynamic CT imaging was captured throughout the range of motion.

RESULTS

The movement in the healthy scapholunate joint through a clenched fist and radial and ulnar deviation is minimal. The averages were 1.19, 1.01, and 0.95 mm, representing the middle, dorsal, and volar measurements, respectively.

CONCLUSIONS

This novel dynamic CT scan of the wrist is a user-friendly way of measuring of the scapholunate distance, which is minimal in the normal wrist below 40 years of age.

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

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

Scapholunate Ligament Reconstruction: A Critical Analysis Review

Scapholunate reconstruction procedures are best stratified according to preoperative stages of dissociative instability, injury chronicity, and arthrosis. In general, procedures aimed at correcting scapholunate instability focus on reestablishing ligament continuity in order to normalize carpal biomechanics; however, many existing interventions have shown differential success when performed on patients with varying stages of instability and degrees of carpal malalignment. The Mayo dorsal intercarpal ligament capsulodesis has proven most effective for preserving range of motion, whereas the Blatt capsulodesis has been associated with substantial improvements in terms of the postoperative pain rating and perceived functional capacity.

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.

Tensile and Torsional Structural Properties of the Native Scapholunate Ligament

PURPOSE

The ideal material for reconstruction of the scapholunate interosseous ligament (SLIL) should replicate the mechanical properties of the native SLIL to recreate normal kinematics and prevent posttraumatic arthritis. The purpose of our study was to evaluate the cyclic torsional and tensile properties of the native SLIL and load to failure tensile properties of the dorsal SLIL.

METHODS

The SLIL bone complex was resected from 10 fresh-frozen cadavers. The scaphoid and lunate were secured in polymethylmethacrylate and mounted on a test machine that incorporated an x-y stage and universal joint, which permitted translations perpendicular to the rotation/pull axis as well as nonaxial angulations. After a 1 N preload, specimens underwent cyclic torsional testing (±0.45 N m flexion/extension at 0.5 Hz) and tensile testing (1-50 N at 1 Hz) for 500 cycles. Lastly, the dorsal 10 mm of the SLIL was isolated and displaced at 10 mm/min until failure.

RESULTS

During intact SLIL cyclic torsional testing, the neutral zone was 29.7° ± 6.6° and the range of rotation 46.6° ± 7.1°. Stiffness in flexion and extension were 0.11 ± 0.02 and 0.12 ± 0.02 N m/deg, respectively. During cyclic tensile testing, the engagement length was 0.2 ± 0.1 mm, the mean stiffness was 276 ± 67 N/mm, and the range of displacement was 0.4 ± 0.1 mm. The dorsal SLIL displayed a 0.3 ± 0.2 mm engagement length, 240 ± 65 N/mm stiffness, peak load of 270 ± 91 N, and displacement at peak load of 1.8 ± 0.3 mm.

CONCLUSIONS

We report the torsional properties of the SLIL. Our novel test setup allows for free rotation and translation, which reduces out-of-plane force application. This may explain our observation of greater dorsal SLIL load to failure than previous reports.

CLINICAL RELEVANCE

By matching the natural ligament with respect to its tensile and torsional properties, we believe that reconstructions will better restore the natural kinematics of the wrist and lead to improved outcomes. Future clinical studies should aim to investigate this further.

Scapholunate Ligament Internal Brace 360-Degree Tenodesis (SLITT) Procedure

Background  Scapholunate (SL) joint instability is one of the most common injuries of the wrist and may result from a fall or high-energy mechanism on the outstretched hand. The purpose of this case report is to describe the outcome of a 360-degree tenodesis to the SL joint with an internal brace (SLITT) for the treatment of SL instability. Case Description  A 42-year-old male patient underwent SL ligament reconstruction with the SLITT procedure 12 months after injury. Given the intrinsic stability of the reconstruction, Kirschner (K) wires were not used and an early range of motion protocol was initiated. Thirteen months after his reconstruction, he was back at work with maintenance of his carpal alignment. Discussion  Since its initial description, a myriad of different surgical techniques for SL instability have been devised with varied success. These include capsular shrinkage, dorsal capsulodesis, reduction-association with a screw of the scapholunate joint (RASL), scapholunate axis method (SLAM), bone ligament bone grafts, and a variety of tendon reconstructions. Possible explanations for this varied outcome may be related to the use of soft tissue reconstructions for irreducible injuries and reconstruction of only the dorsal SL ligament. In addition, many of these techniques involve prolonged immobilization with the use of K-wires. Clinical Relevance  The SLITT procedure reconstructs both the volar and dorsal SL ligament. Given the added stability afforded by intrinsic bracing, we feel that this reconstruction may permit earlier range of motion without the need for K-wire stabilization.

Outcomes of scapholunate intercarpal ligamentoplasty for chronic scapholunate dissociation: a prospective study in 26 patients

We report the outcomes of scapholunate intercarpal ligamentoplasty in 26 wrists. For 15 wrists with static instability and 11 with dynamic instability, we used a free palmaris longus graft to reconstruct the dorsal part of the scapholunate interosseous ligament and the dorsal intercarpal ligament. These patients were evaluated for pain and active wrist range of motion, grip strength and radiological appearance after a mean follow-up of 36 months (range 12-54) after surgery. Pain score was improved from 4.5 to 1.4 at rest and 6.7 to 1.9 during hand use. The average wrist flexion was 57°, extension 56°. Grip strength was 89% of the contralateral side. The mean scapholunate angle decreased from 76° to 62°, and static scapholunate gap reduced from 3.2 mm to 2.3 mm and the dynamic gap from 4.6 mm to 3.0 mm. Scaphoid subluxation was corrected. We conclude that this procedure led to satisfactory clinical and radiological results in a short- to mid-term follow-up.

LEVEL OF EVIDENCE

II.

Arthroscopic Dorsal Capsuloplasty in Scapholunate Tears EWAS 3: Preliminary Results after a Minimum Follow-up of 1 Year

Purpose  We retrospectively evaluated the results of all arthroscopic dorsal scapholunate (SL) capsuloplasty without pinning in patients presenting predynamic instability and dorsal capsuloscapholunate septum lesions on arthro-computed tomography scan after failed medical treatment. Materials and Methods  Fifteen patients, mean age 34.3 years, underwent all arthroscopically assisted dorsal capsuloplasty. Patients were assessed preoperatively and postoperatively by a clinical (pain, Watson's test, range of motion, and strength), functional (quick disabilities of the arm, shoulder, and hand), patient-rated wrist evaluation, and Mayo wrist score scores), and radiological (SL gap and dorsal intercalated segmental instability [DISI]) examination. SL tears were evaluated during surgery by European Wrist Arthroscopy Society (EWAS) classification. Results  The mean follow-up period was 20.2 months (range, 12-41). Preoperatively, positive Watson's test was noted in all cases. DISI deformity was noted in three cases without any SL gap. The SL instability was graded EWAS IIIB ( n  = 8) or EWAS IIIC ( n  = 7). Postoperatively, positive Watson's test was noted in only one case. Activity pain decreased from 7.8 preoperatively to 2.4 postoperatively. Range of motion in flexion-extension increased from 92.9 degrees preoperatively to 126.2 degrees postoperatively. Grip strength increased from 24.2 preoperatively to 38.2 postoperatively. At final follow-up, range of motion in flexion-extension and grip strength were estimated at 87 and 91% compared with contralateral side, respectively. All functional scores were significantly improved at the last follow-up. No radiographic SL gapping in grip views or DISI deformity was noted. Discussion  Cadaveric studies demonstrated that the dorsal portion of SL ligament is critical for the stability of the SL complex. The entire arthroscopic SL capsuloplasty technique provides reliable results for pain relief, avoiding postoperative stiffness associated with open procedures. It is an alternative technique for patients with predynamic SL instability after failure of medical management and shall not prelude the resort to any further open procedure. Level of Evidence  This is a level IV, case series.

Optimal management of scapholunate ligament injuries

Scapholunate ligament (SLL) injuries are a common cause of wrist pain and instability. Treatment of SLL injuries requires intricate understanding of wrist anatomy and biomechanics. Mindful physical exam and appropriate diagnostic studies can orient the surgeon to the defined stage of injury. Review of the literature on each treatment by stage can prepare the upper extremity surgeon to provide the best evidence-based care. The optimal management of SLL injuries should result in a stable, painless wrist.

The effect of screw trajectory for the reduction and association of the scaphoid and lunate (RASL) procedure: a biomechanical analysis

The purpose of this study was to determine if screw placement in the reduction and association of the scaphoid and the lunate (RASL) procedure affected the ability of the scapholunate joint to withstand force. After completely disrupting of the scapholunate ligament in 29 fresh-frozen cadaveric wrists, we placed the RASL screw either distal or proximal to the lateral aspect of the dorsal ridge of the scaphoid and into the dorsal or volar aspect of the lunate. Specimens were subjected to repeated cycles of transcarpal axial force, mimicking clenched-fist loading, until failure. Screw placement distal to the lateral aspect of the dorsal scaphoid ridge was significantly associated with failure when examined manually, radiographically (1.8 vs. 0.5 mm) and using real-time motion capture (diastasis: 1.6 vs. 0.4 mm; Euler angle: 4.5 ° vs. 0.8 °). The lateral aspect of the dorsal ridge is a reliable radiographic landmark on the scaphoid and provides surgeons with a convenient starting point to achieve the most biomechanically stable RASL construct, and, therefore, enhances the potential for an optimal clinical outcome.

Arthroscopic Reduction-Association of the Scapholunate with an Absorbable Screw

Background  The treatment of chronic scapholunate instability is yet a controversial topic. Arthroscopic reduction-association scapholunate technique is a minimally invasive option in which a stable pseudoarthrosis at the scapholunate joint is obtained, allowing some degree of movement while maintaining the normal alignment of the wrist. The purpose of this study was to review the results of arthroscopic reduction-association scapholunate with an absorbable screw. Methods  We retrospectively evaluated patients with dynamic or static, but reducible, chronic scapholunate instability who underwent arthroscopic reduction-association scapholunate between 2012 and 2015. An absorbable headless compression screw was used in the technique. Results  A total of 33 patients (21 males, 12 females) were included. Average follow-up time was 17 months. At final follow-up, the average postoperative Disabilities of the Arm, Shoulder and Hand (DASH) score was 18 (range, 8-46). The average postoperative grip strength was 30 kg, 73% of the uninjured side. The average extension-palmar flexion arc was 112 degrees, 79% of the uninjured side. The scapholunate angle decreased from 70 degrees preoperatively to 52 degrees postoperatively. In the cases of static lesion, the scapholunate interval decreased from 4.1 mm preoperatively to 2.8 mm at final follow-up. One patient had a breakage of the screw at 4 months, four developed a complex regional pain syndrome, one had a prominence of the screw at the waist of the scaphoid, and four maintained symptoms of instability. From these 10 patients, 5 were submitted to revision surgery. Conclusion  The arthroscopic reduction-association technique is capable of maintaining the reduction of the scapholunate joint and of improving symptoms, while preserving range-of-motion. The use of an absorbable screw is an option in this technique, and may diminish screw-related complications.

Concepts and Artistry in the Treatment of Scapholunate Ligament Injuries

BACKGROUND

Scapholunate ligament injuries are highly challenging injuries to treat. Great uncertainly remains in determining which operative procedures are most effective. Furthermore, there is no consensus on whether surgical intervention changes the natural course of scapholunate injuries.

METHODS

The authors present their assessment of scapholunate injuries and the senior author's preferred surgical techniques. Surgical videos are included. The authors' postoperative management is described.

RESULTS

Operative procedures are selected based on the patient's timing and pattern of injury, degree of associated carpal changes and arthritis, and goals.

CONCLUSION

Over the past 20 years, the senior author has had good success with these techniques, but prospective, longterm outcome studies are needed to critically assess whether these surgical techniques improve patients' long-term function and pain.

Level of evidence in wrist ligament repair and reconstruction research: a systematic review

There have been numerous studies on surgery of wrist ligament injuries, but a quick assessment reveals few with a high level of evidence (LoE). The primary aim of this study was to categorize the study type and LoE of studies on repair and reconstruction of the scapholunate ligament, the lunotriquetral ligament and the triangular fibrocartilage complex by applying the LoE rating system proposed by the Oxford Centre for Evidence-Based Medicine. The secondary aims were to evaluate the journal- and geographic- distribution of the included studies.

An electronic literature search of articles published 1985–2016, in PubMed, Embase, and Cochrane Library was carried out in May 2016 and updated in April 2017. Therapeutic studies written in English were included. The PRISMA checklist guided the extraction and reporting of data.

A total of 1889 studies were analyzed, of which 362 were included. Three journals represented 40% of the included studies and American authors dominated.

Most studies (97%) had low LoE (IV-V). No studies of LoE I-II were found. There is insufficient evidence to recommend one technique over the other in terms of wrist ligament surgery in clinical practice. There is an immense lack of comparison studies with high level of evidence in the area of wrist ligament repair and reconstruction.

Hand and Wrist Injuries: Common Problems and Solutions

Injuries to the hands and wrist are common in athletes. Injuries include acute fractures, dislocations, ligamentous, and tendon injuries, as well as more chronic injuries such as sprains and strains. Complications in the treatment of sports injuries of the hand and wrist may be divided into 2 categories: incorrect or delayed diagnosis and iatrogenic injury related to treatment. This article highlights common sports injuries of the hand and wrist and their complications, and includes tips for successful management.

A three-dimensional printed patient-specific scaphoid replacement: a cadaveric study

We present our first cadaveric test results of a three-dimensional printed patient-specific scaphoid replacement with tendon suspension, which showed normal motion behaviour and preservation of a stable scapholunate interval during physiological range of motion.

Radiological evaluation of scapholunate intercarpal ligamentoplasty for chronic scapholunate dissociation in cadavers

We performed a cadaveric study to evaluate radiological performance of a technique for scapholunate intercarpal ligamentoplasty designed for treating reducible scapholunate dissociation. We created scapholunate instability in 12 fresh adult cadaveric forearms by sectioning the dorsal scapholunate interosseous ligament and the dorsal intercarpal ligament. All wrists showed scapholunate diastasis, dorsal intercalated segmental instability and posterior scaphoid subluxation. We performed scapholunate intercarpal ligamentoplasty in six wrists and Garcia-Elias three-ligament tenodesis in another six. Wrists were examined radiographically both after ligament sectioning and after ligamentoplasty to compare static and dynamic scapholunate gaps and scapholunate and capitolunate angles. Improvement was statistically significant in all measurements, reflecting a return to normal values. Posterior scaphoid subluxation was also corrected. There was no significant difference between the two treatment groups. Our findings suggest that ligamentoplasty can restore scapholunate joint stability and normal carpal anatomy.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL RELEVANCE

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

The management of chronic non-arthritic scapholunate dissociation: a systematic review

A systematic review was conducted to identify the best management for chronic scapholunate dissociation. EMBASE, MEDLINE, and CENTRAL were searched from 1965-2016. A narrative synthesis was performed. One thousand, one hundred and ninety-one citations were identified, of which 17 had final analysis. In all interventions, the pain score at 2 years reduced from 6.0 to 2.8 with similar effect from capsulodesis and tenodesis techniques. Overall there was an 18% loss of flexion arc. Radial to ulnar arc improved in capsulodesis (+19%; n = 45) and worsened in tenodesis (-6%; n = 45). Grip strength was better in capsulodesis (+31%; n = 64 versus + 11%; n = 56). There was insufficient evidence to link radiological outcome with clinical outcome. Rates of complications (20%) and CRPS (3.8%) were high, with implications for patient consent. Due to heterogeneity in data collection, the lack of comparative studies and short-term follow-up, no conclusion regarding the superiority of a single technique was possible. Longer term comparative studies are required, as are natural history studies. A minimum data set has been advised.

LEVEL OF EVIDENCE

II.

Biomechanics of an Articulated Screw in Acute Scapholunate Ligament Disruption

Background  An injury to the scapholunate interosseous ligament (SLIL) leads to instability in the scapholunate joint. Temporary fixation is used to protect the ligament during reconstruction or healing of the repair. Rigid screw fixation-by blocking relative physiological motion between the scaphoid and lunate-can lead to screw loosening, pullout, and fracture. Purpose  This study aims to evaluate changes in scaphoid and lunate kinematics following SLIL injury and the effectiveness of an articulating screw at restoring preinjury motion. Materials and Methods  The kinematics of the scaphoid and lunate were measured in 10 cadaver wrists through three motions driven by a motion simulator. The specimens were tested intact, immediately following SLIL injury, after subsequent cycling, and after fixation with a screw. Results  Significant changes in scaphoid and lunate motion occurred following SLIL injury. Postinjury cycling increased motion changes in flexion-extension and radial-ulnar deviation. The motion was not significantly different from the intact scapholunate joint after placement of the articulating screw. Conclusion  In agreement with other studies, sectioning of the SLIL led to significant kinematic changes of the scaphoid and lunate in all motions tested. Compared with intact scapholunate joint, no significant difference in kinematics was found after placement of the screw indicating a correction of some of the changes produced by SLIL transection. These findings suggest that the articulating screw may be effective for protecting a SLIL repair while allowing the physiological rotation to occur between the scaphoid and lunate. Clinical Relevance  A less rigid construct, such as the articulating screw, may allow earlier wrist rehabilitation with less screw pullout or failure.

Cadaveric Testing of a Novel Scapholunate Ligament Reconstruction

Background  Existing scapholunate interosseous ligament (SLIL) reconstruction techniques include fixation spanning the radiocarpal joint, which do not reduce the volar aspect of the scapholunate interval and may limit wrist motion. Questions/Purpose  This study tested the ability of an SLIL reconstruction technique that approximates both the volar and dorsal scapholunate intervals, without spanning the radiocarpal joint, to restore static scapholunate relationships. Materials and Methods  Scapholunate interval, scapholunate angle, and radiolunate angle were measured in nine human cadaveric specimens with the SLIL intact, sectioned, and reconstructed. Fluoroscopic images were obtained in six wrist positions. The reconstruction was performed by passing tendon graft through bone tunnels from the dorsal surface toward the volar corner of the interosseous surface. After reduction of the scapholunate articulation, the graft was tensioned within the lunate bone tunnel, secured with an interference screw in the scaphoid, and sutured to the dorsal SLIL remnant. Differences among testing states were evaluated using repeated measures ANOVA. Results  There was a significant increase in the scapholunate interval in all wrist positions after complete SLIL disruption. Compared with the disrupted state, there was a significant decrease in scapholunate interval in all wrist positions after reconstruction using a tendon graft and interference screw. Conclusion  Our SLIL reconstruction technique reconstructs the volar and dorsal ligaments of the scapholunate joint and adequately restores static measures of scapholunate stability. This technique does not tether the radiocarpal joint and aims to optimize volar reduction. Clinical Relevance  Our technique offers an alternative option for SLIL reconstruction that successfully restores static scapholunate relationships.

Locking Dorsal Plate in Four-Bone Arthrodesis in SLAC and SNAC 3 Wrist

Purpose  The aim of this study was to evaluate the effectiveness and the safety of performing a four-bone arthrodesis (FBA) with dorsal locking plate in patients suffering from stage III scapholunate advanced collapse/scaphoid nonunion advance collapse (SLAC/SNAC) wrist. Methods  We evaluated retrospectively 20 patients surgically treated by a FBA with the use of locking dorsal plate. All the patients were clinically evaluated at follow-up for grip strength, range of motion, and pain (visual analog scale), and with the Disability of the Arm, Shoulder and Hand score and the Mayo wrist score. Imaging evaluation was performed on standard X-rays. Results  The mean follow-up was 6 years (range: 1-11 years). During follow-up, the patients showed good clinical outcomes in terms of pain relief and grip strength. Revision surgery was necessary only in one case because of screws loosening. In all cases, a solid bone fusion was achieved except in one patient, who presented a healing of lunocapitate joint. This condition did not affect the clinical outcomes. Conclusion  FBA performed using a dorsal locking plate is a salvage procedure effective in treating stage III SLAC/SNAC wrist. In our study, this technique provided good clinical outcomes at mid-term follow-up with a very low complication rate. Level of Evidence  Level IV, therapeutic case series.

Impact of scapholunate dissociation on human wrist kinematics

Neither the complex motions of the scapholunate joint, nor the kinematic changes that occur as a result of injury to it, are fully understood. We used electromagnetic tracking within affected bones to evaluate the physiologic motions in the planes of flexion and extension, and of radial and ulnar deviation of human cadaver wrists, before and after complete transection of the scapholunate ligaments. Despite individual variance between each wrist, we were able to establish a pattern in the changes that occurred after scapholunate ligament injury. During the motions examined, the scaphoid showed an increase in translational deviation in almost all motion axes. In contrast, the movement of the lunate seemed to be impaired, especially in radial-ulnar deviation.

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.

Dorsal capsulodesis associated with arthoscopy-assisted scapholunate ligament reconstruction using a palmaris longus tendon graft

Objectives

To measure the quality of life, the time to work return, and clinical, functional, and radiographic parameters of patients treated with dorsal capsulodesis associated with scapholunate (SL) reconstruction, assisted by arthroscopy.

Methods

From January 2015 to September 2016, 14 adult patients with SL dissociation underwent surgical treatment with the SL reconstruction procedure assisted by arthroscopy, using the new technique proposed in this study. All patients were assessed by the occupational therapy department at regular intervals after surgery and performed the same sequence of rehabilitation. The parameters analyzed were: range of motion (ROM), Disability of the Arm, Shoulder, and Hand (DASH), visual analog scale (VAS), and radiographic analysis to visualize the pre- and postoperative SL gap and the pre- and postoperative dorsal intercalated segment instability (DISI) deformity the. The complications and the time to return to work activities were described.

Results

The follow-up time was 12 months (3-17). The ROM averaged 321° (96.9% of the normal side). VAS was 1.79/10 (1-6). DASH was 6.50/100 (1-30). The time to work return work was 4.42 months (2-17). As for complications, one patient developed SLAC, and underwent four-corner fusion one year after ligament reconstruction. Currently, he has experienced pain relief, with a functional range of motion of the wrist, and has not yet returned to professional activities.The preoperative SL gap was 4.29 mm (2-7); in the postoperative period, it was 1.79 mm (1-4). The DISI deformity was present in ten patients with SL angle > 70° (preoperative) and it was corrected after surgery, in all patients. SLAC stage I was identified in a patient. Arthroscopy was performed in all cases. The SL instability was classified as Geissler grade III in four cases and as grade IV in ten cases.

Conclusion

The new approach (dorsal capsulodesis associated with SL reconstruction, assisted by arthroscopy) presented in this study is safe and effective in the treatment of SL dissociation, since it offers satisfactory clinical, radiographic and functional results, showing low rates of complications. For patients, it allows the return to their social and professional activities, and increases their life quality.

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.

Analysis of tenodesis techniques for treatment of scapholunate instability using the finite element method

Chronic scapholunate ligament (SL) injury is a common disorder affecting the wrist. Despite advances in surgical techniques used to treat this injury, SL gap re-emergence may occur postoperatively. This paper presents an investigation into the performance of the Corella, schapolunate axis (SLAM), and modified Brunelli tenodesis (MBT) surgical reconstruction techniques used to treat scapholunate instability. Finite element (FE) models were used to undertake virtual surgery, and the resulting scapholunate (SL) gap and angle obtained using the 3 techniques were compared. The Corella technique was found to achieve the SL gap and angle closest to the intact (ligament) wrist, restoring SL gap and angle to within 5.6% and 0.6%, respectively. The MBT method resulted in an SL gap least close to the intact. The results of our study indicate that the contribution of volar scapholunate interosseous ligament to scapholunate stability could be important.

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

Treatment of scapholunate ligament injury: Current concepts

Injuries to the scapholunate joint are the most common cause of carpal instability.

An isolated injury to the scapholunate ligament may progress to abnormal joint mechanics and degenerative cartilage changes.

Treatment for scapholunate instability is aimed at arresting the degenerative process by restoring ligament continuity and normalising carpal kinematics.

Early arthroscopic diagnosis of scapholunate injury is mandatory for establishing the prognosis of the injury, as a proper ligament repair is recommended within four to six weeks after trauma.

In this review, anatomy, diagnosis and treatment of scapholunate ligament injury and carpal instability are discussed. Recommendations for treatment based on the stage and classification of injury and the degree of instability and arthritic changes are proposed.

Cite this article: EFORT Open Rev 2017;2:382–393. DOI: 10.1302/2058-5241.2.170016

Tratamiento de la disociación estática escafolunar utilizando una plastia de palmar mayor: resultados preliminares

Objetivo: Examinar los primeros resultados de la reconstrucción de la zona dorsal y palmar del ligamento escafolunar utilizando una plastia de palmar mayor en el tratamiento de la inestabilidad escafolunar estática reductible.

Material y método: Desde junio del 2012, 7 pacientes con inestabilidad escafolunar estática reductible fueron intervenidos con reconstrucción de la zona dorsal y palmar del ligamento escafolunar utilizando una plastia de palmar mayor. La edad media de los pacientes fue de 44años. El seguimiento medio fue de 18 meses (rango 12-35 meses).

Resultados: Los resultados funcionales según Green y O’Brien fueron buenos en 6 pacientes y satisfactorios en el otro y según las escalas Quick-DASH y Mayo modificada, 6,3 y 80 respectivamente. Radiográficamente, la diastasis escafolunar y el ángulo escafolunar preoperatorio pasaron de 4,6 a 2,4 mm y de 59,3 a 46,6°, respectivamente, al final del seguimiento.

Conclusiones: Los resultados clínicos y radiográficos al final del seguimiento son buenos. Esta técnica permite reconstruir la zona dorsal y palmar del ligamento interóseo escafolunar y reforzar y tensar los ligamentos escafo-trapecio-trapezoidales reconstruyendo eficazmente la anatomía del carpo. Si bien los resultados son esperanzadores, se necesita un mayor número de pacientes y mayor seguimiento para obtener conclusiones más definitivas.