Internal Bracing Augmentation for Scapholunate Interosseous Ligament Repair: A Cadaveric Biomechanical Study

Scapholunate Ligament Reconstruction With Internal Brace Augmentation Techniques for Chronic Scapholunate Dissociation: A Clinical Follow-up Study

INTRODUCTION

The scapholunate ligament is the most important stabilizer of the scapholunate articulation. The management of chronic irreversible injuries of this ligament in the absence of preexisting arthritis of the wrist joint remains controversial. Recently, surgeons introduced a novel surgical technique using an internal brace (IB). Several biomechanical studies on this technique have been conducted using cadavers; however, very few studies have discussed the results in detail in actual clinical practice. Therefore, herein, we investigated the radiological and functional results of patients who underwent IB augmentation as a treatment for chronic scapholunate dissociation.

METHODS

This retrospective study was conducted from April 2018 to May 2022. Twenty-two patients with chronic scapholunate dissociation were treated using the IB augmentation technique, of whom 17 were followed-up for at least 1 year. Radiological results, including scapholunate distance, scapholunate angle, and radioscaphoid angle, were collected. Furthermore, clinical parameters, such as the visual analog scale (preoperative and at final follow-up), the Disabilities of the Arm, Shoulder, and Hand scores (preoperatively and at 3, 6, and 12 months postoperatively), and Mayo wrist scores (preoperative and at final follow-up), were measured.

RESULTS

The scapholunate distance increased significantly in the affected wrist compared to the unaffected wrist, which improved after reconstruction in all wrist positions ( P < 0.05). Compared to the unaffected wrist, the scapholunate angle increased significantly in all positions ( P < 0.05) except for extension ( P = 0.535) and improved after reconstruction in all wrist positions. The radioscaphoid angle significantly increased compared to the angle of the unaffected wrist in all positions ( P < 0.05) except for extension ( P = 0.602) and clenched fist ( P = 0.556). This angle improved after reconstruction in all wrist positions except for extension ( P = 0.900). The visual analog scale score (7-2, preoperatively and at final follow-up) and Mayo wrist score (53-82, preoperatively and at final follow-up) improved after surgery. The Disabilities of the Arm, Shoulder, and Hand scores also improved after surgery (68, 53, 30, 7, preoperatively and at 3, 6, and 12 months postoperatively).

CONCLUSIONS

This study revealed that scapholunate ligament reconstruction using an autologous tendon and suture tape is a good reconstruction technique that can improve clinical symptoms and radiographic parameters with a shorter operation time and fewer complications than other reconstruction methods.

Foveal Triangular Fibrocartilage Complex Tear Repair With Nonabsorbent Suture Tape

PURPOSE

Arthroscopic repair is performed for fovea injuries of the triangular fibrocartilage complex (TFCC) when instability of the distal radioulnar joint results in pain, decreased grip strength, and mechanical symptoms. During TFCC repair, reconstruction of its attachment to the fovea is important. Nonabsorbent suture tapes have gained attention for ligament repair in the trapeziometacarpal joint, scapholunate ligament, and thumb metacarpophalangeal ligament. However, there are no reports of TFCC repair using suture tapes. We evaluated the early postoperative results of this approach.

METHODS

Participants underwent arthroscopic suture tape repair of foveal TFCC tears and were observed for more than 1 year. All repairs were performed using suture tapes and an outside-in technique with a bone tunnel from the ulnar shaft to the fovea. The postoperative complications, postoperative wrist range of motion, grip strength, and the Modified Mayo Score were evaluated.

RESULTS

Arthroscopic repair with a suture tape was performed for 20 hands using the outside-in technique. The ranges of motion for the operated and nonoperated hands were comparable 1 year after surgery (pronation, 84° ± 4°; supination, 83° ± 4°). The mean grip strength improved from 65% ± 13% before surgery to 89% ± 9% after a year. The mean Modified Mayo Score improved from 58 ± 11 before surgery to 91 ± 8 after a year. Postoperative complications included abnormal sensation of the dorsal ulnar side in 2 hands.

CONCLUSIONS

After using a suture tape to attach the TFCC to the fovea, satisfactory function was achieved in the early postoperative period with grip strength restoration. For the repair of foveal TFCC tears, attachment to the ulnar fovea is important, and repair by a suture tape may be useful.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Internal brace augmentation improves the biomechanical properties of trapeziometacarpal joint dorsoradial ligament repair

This study investigated whether dorsoradial ligament repair with internal brace augmentation provided more immediate stability in the trapeziometacarpal joint than dorsoradial ligament repair alone. Seven matched pairs of cadaveric hands were used. One specimen from each pair was assigned to the repair-only group and the other to the repair + internal brace augmentation group. Trapeziometacarpal joint range of motion and translation were quantified under different conditions for both groups: (1) intact, (2) transected dorsoradial ligament, and (3) repaired dorsoradial ligament or repaired dorsoradial ligament plus internal brace augmentation. Load-to-failure tests were performed after repair. Range of motion and translation were increased by dorsoradial ligament transection and were decreased by dorsoradial ligament repair; however, compared to the intact condition, the repair-only group demonstrated greater flexion/extension range, while the repair + internal brace group showed no significant difference in range of motion. Mean loads at 2- and 3-mm displacements were greater in the repair + internal brace group than in the repair-only group (18.0 ± 1.8 N vs. 10.8 ± 1.3 N for 2 mm displacement and 35.3 ± 3.7 N vs. 23.1 ± 2.9 N for 3 mm displacement, respectively). Internal brace augmentation improved the load-to-failure characteristics of dorsoradial ligament repair without compromising range of motion. LEVEL OF EVIDENCE: IV.

Preliminary Outcomes of Scapholunate Ligament Augmentation with Internal Brace Technique

Purpose

Injury to the scapholunate (SL) interosseous ligament (SLIL) is a common cause of carpal instability. Internal brace augmentation has been used in various ligament repair procedures; however, further investigation of its outcomes in hand surgery is needed. This study aimed to examine outcomes for patients who underwent SLIL repair with internal brace augmentation.

Methods

Patients who underwent SLIL repair with the internal brace technique and had at least 1 year of follow-up were contacted. Available patients returned for an in-person evaluation with new radiographs and physical examination. If patients could not be contacted but had x-rays and physical examinations performed at greater than 1 year after surgery, these data were collected from their medical records. Participating patients completed the QuickDASH and Patient-Rated Wrist Evaluation surveys and rated their satisfaction with the surgery. Outcomes assessed included wrist range of motion, grip strength, scaphoid shift test, SL gap, SL angle, and radiographic evidence of radiocarpal arthritis.

Results

We collected outcomes for 14 SLIL repairs among 13 patients (12 male). Mean length of the follow-up was 41 months (n = 14, 17-64). Mean QuickDASH and Patient-Rated Wrist Evaluation scores were 6.1 (0-43.2) and 9.6 (0-65), respectively. Radiographic measurements remained stable from immediate to latest follow-up, and no radiocarpal arthritic changes were noted. However, SL gap decreased from a mean of 5.33 mm (3.4-6.7) before surgery to 3.34 mm (2-4.6) at the latest follow-up, and SL angle decreased from a mean of 79.5° (67°-97°) before surgery to 67.3° (51°-85°) at the latest follow-up. All scaphoid shift tests were stable.

Conclusions

Therefore, SL internal brace augmentation has favorable short-term results with improvements in pain, function, satisfaction, and carpal alignment at greater than 1 year postoperatively. This technique can be an effective option for the management of SL instability in the short term.

Type of study/level of evidence

Therapeutic IV.

Suture Tape Augmentation for the Repair of Index Finger Radial Collateral Ligament Injury: A Biomechanical Study

PURPOSE

Despite their clinical importance in maintaining the stability of the pinch mechanism, injuries of the radial collateral ligament (RCL) of the index finger may be underrecognized and underreported. The purpose of this biomechanical study was to compare the repair of index finger RCL tears with either a standard suture anchor or suture tape augmentation.

METHODS

The index fingers from 24 fresh-frozen human cadavers underwent repair of torn RCLs using either a standard suture anchor or suture tape augmentation. Following the repairs, the initial displacement of the repair with a 3-N ulnar deviating load was evaluated. Next, the change in displacement (cyclic deformation) of the repair after 1,000 cycles of 3 N of ulnar deviating force was calculated (displacement of the 1000th cycle - displacement of the first cycle). Finally, the amount of force required to cause clinical failure (30° ulnar deviation) of the repair was determined.

RESULTS

Suture tape augmentation repairs displayed significantly less cyclic deformation (0.8 ± 0.5 mm) after cyclic loading than suture anchor repairs (1.8 ± 0.7 mm). There was no significant difference in the force required to cause the clinical failure of the repairs between the suture tape (35.1 ± 18.1 N) and suture anchor (24.5 ± 9.2 N) repairs.

CONCLUSIONS

Index finger RCL repair with suture tape augmentation results in decreased deformation with repetitive motion compared with RCL repair alone.

CLINICAL RELEVANCE

Suture tape augmentation may allow for early mobilization following index finger RCL repair by acting as a brace that protects the repaired ligament from deforming forces.

Scapholunate ligament injuries: an instructional review for the FRCS examination

An instructional review of the anatomy, investigation, and management of scapholunate ligament injuries. Aimed at the knowledge level required for the trauma and orthopaedic FRCS examination.

Biomechanical Comparisons of Different Reconstructive Techniques for Scapholunate Dissociation: A Cadaveric Study

There are many techniques for the treatment of chronic scapholunate dissociation. The three-ligament tenodesis (3LT) is used most widely, but reconstruction of the dorsal ligament alone may not provide sufficient stability. The Mark-Henry technique (MHT) compensates for the insufficient stability of 3LT by additional reconstruction of the volar ligament, but the procedure is complex. The SwiveLock technique (SWT), a recently introduced method, provides stability by using autologous tendons with synthetic tapes, but lacks long-term clinical results. To perform biomechanical comparisons of different reconstructive techniques for scapholunate dissociation using a controlled laboratory cadaveric model. Eleven fresh-frozen upper-extremity cadaveric specimens were prepared. The scapholunate distance, scaphoid rotation, and lunate rotation of the specimens were measured during continuous flexion-extension and ulnar-radial deviation movements. The data were collected using a wrist simulator with a linear guide rail system (tendon load/motion-controlled system) and a motion capture system. Results were compared in five conditions: (1) intact, (2) scapholunate dissociation, (3) SWT, (4) 3LT, and (5) MHT. Paired t-test was employed to compare the biomechanical characteristics of intact wrists to those of scapholunate dissociated wrists, and to those of wrists after each of the three reconstruction methods. SWT and MHT were effective solutions for reducing the widening in scapholunate distance. According to the radioscaphoid angle, all three reconstruction techniques were effective in addressing the flexion deformity of the scaphoid. According to the radiolunate angle, only SWT was effective in addressing the extension deformity of the lunate. In terms of scapholunate angle, only the results after SWT did not differ from those of the intact wrist. The SWT technique most effectively improved distraction intensity and rotational strength for the treatment of scapholunate dissociation. Taking into account the technical complexity of 3LT and MHT, SWT may be a more efficient technique to reduce operating time and minimize complications due to multiple incisions, transosseous tunnels, and complicated shuttling.

Ligament augmentation repair is broadly applied across different orthopaedic subspecialities: an ISAKOS international survey of orthopaedic surgeons

OBJECTIVES

To evaluate how ligament augmentation repair (LAR) techniques are currently used in different anatomic regions in orthopaedic sports medicine, and to identify the most common indications and limitations of LAR.

METHODS

We sent survey invitations to 4,000 members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine society. The survey consisted of 37 questions total, with members only receiving some branching questions specific to their area of specialisation. Data were analysed using descriptive statistics, and the significance between groups was evaluated using chi-square tests of independence.

RESULTS

Of 515 surveys received, 502 were complete and included for the analysis (97% completion rate). 27% of respondents report from Europe, 26% South America, 23% Asia, 15% North America, 5.2% Oceania, and 3.4% Africa. 75% of all survey respondents report using LAR, most frequently using it for the anterior talofibular ligament ( 69%), acromioclavicular joint ( 58%), and the anterior cruciate ligament (51%). Surgeons in Asia report using LAR the most (80%), and surgeons in Africa the least (59%). LAR is most commonly indicated for additional stability (72%), poor tissue quality (54%), and more rapid return-to-play (47%). LAR users state their greatest limitation is cost (62%), while non-LAR users state their greatest reason not to use LAR is that patients do well without it (46%). We also find that the frequency of LAR use among surgeons may differ based on practice characteristics and training. For example, surgeons who treat athletes at the professional or Olympic level are significantly more likely to have a high annual use of LAR (20+ cases) compared to surgeons that treat only recreational athletes (45% and 25%, respectively, p ​= ​0.005).

CONCLUSION

LAR is broadly applied in orthopaedics but its rate of use is not homogeneous. Outcomes and perceived benefits vary depending on factors such as surgeon specialty and treatment population.

LEVEL OF EVIDENCE

Level V.

Arthroscopy-Assisted Scapholunate Reconstruction With Internal Brace Augmentation

Various surgical techniques exist to repair or reconstruct complete scapholunate (SL) interosseous ligament tears, including capsulodesis, static or dynamic tenodesis, ligament reconstruction with tendon graft, bone-retinaculum-bone reconstruction, and the reduction and association of the scaphoid and lunate (RASL) procedure. The choice of surgical technique depends on arthroscopic assessment using the Geissler classification and European Wrist Arthroscopy Society staging of SL injury. This article describes arthroscopy-assisted extracapsular SL reconstruction using free tendon graft and internal brace augmentation for the treatment of unrepairable complete SL interosseous ligament tears.

Current Concepts in Scapholunate Instability Without Arthritic Changes

Scapholunate instability (SLI) is the most common carpal instability described. SLI leads to a degenerative arthritic pattern known as scapholunate advanced collapse (SLAC). Diagnosis of SLI can be challenging in pre-dynamic and dynamic stages. CT arthrogram, MR arthrogram and dynamic fluoroscopy are helpful in diagnosis while arthroscopy remains the gold standard. SLI is a multi-ligament injury, which involves not only the scapholunate interosseous ligament (SLIL) but also the extrinsic carpal ligaments. Hence, it is better described as an injury compromising the 'dorsal scapholunate(dSLL) complex'. A repair can be attempted for acute SLI presenting within 6 weeks of injury. Reconstruction is the mainstay of treatment for chronic SLI without degenerative changes. Multiple repair techniques have been described which include capsulodesis and tenodesis procedures. The clinical outcomes of the techniques have improved over the years. However, a common problem of all these techniques is the lack of long-term data on the outcomes and deteriorating radiological parameters over time. SLI staging is an important factor to be considered in choosing the reconstruction techniques for a better outcome. Currently, there is a trend towards more biological and less invasive techniques. Regardless of the technique, it is important to preserve the nerve supply of the dorsal capsuloligamentous structures of the wrist. Arthroscopic techniques being minimally invasive have the advantage of less collateral damage to the capsuloligamentous structures. Rehabilitation involves a team approach where a protected dart thrower's motion is allowed after a period of immobilization. Strengthening SL-friendly muscles and inhibiting SL-unfriendly muscles is a key principle in rehabilitation.

Scapholunate Ligament Reconstruction without Immobilization Is Safe and Leads to Better Functional Results

Background Reconstruction of the scapholunate ligament (SL) is associated with a reduction in range of motion. In this study, we compared SL reconstruction and early mobilization with SL reconstruction and Kirschner wires (K-wire) fixation for 6 weeks. Methods We performed a nonrandomized trial involving patients with an arthroscopically confirmed SL ligament injury. In total, 11 patients were assigned to SL reconstruction with internal brace augmentation and early mobilization and 10 were assigned to standard SL reconstruction and K-wire fixation for 6 weeks before mobilization started. We assessed the range of motion, grip strength, functional status, intensity of pain, global perceived effect, and duration until return to work. Results In both groups, there was one traumatic breakout of the reconstructed ligament and two patients in the control group were lost to follow-up. The 10 patients in the internal brace group had a mean increase in wrist flexion of 1.8 degrees at 1 year compared with a decrease in wrist flexion of 13.4 degrees in the seven patients of the control group. Wrist extension increased by 4.5 degrees in the internal brace group and decreased by 4.5 degrees in the control group. In addition, the internal brace group scored 6.1 (much improved) for the global perceived effect and the control group 4.7 (slightly improved), and treatment without immobilization resulted in an earlier return to work (35.1 vs. 73.6 days). Conclusions In SL reconstruction, internal brace augmentation and early mobilization result in improved wrist flexion and extension, higher satisfaction, and earlier return to work.

Scaphometacarpal Stabilization Technique for Repairable Scapholunate Injury

Despite the numerous techniques (both arthroscopic and open) for the treatment of acute scapholunate instability, there is no consensus on which one results in better healing of the ligaments. In the present work, we describe a new surgical technique to achieve stability of the scaphoid that enables the reduction inflexion and pronation of this bone when dissociation is produced. Using a high-strength suture wire with double cortical button anchor (Mini TightRope, Arthrex, Naples, FL, US, or MicroLink, Conmed, Largo, FL, US) stabilization of the scaphoid is achieved to protect ligament healing without the need for postoperative immobilization.

Scapholunate and lunotriquetral interosseous ligament augmentation with internal bracing in perilunate dislocation: Case reports

RATIONALE

The goals of surgical treatment of the perilunate dislocation (PLD) are confirmation of reduction, ligament repair, and supplemental fixation of the bony architecture. Open reduction and direct repair of the torn ligament are recommended for acute PLD. However, repair of the scapholunate interosseous ligament (SLIL) and lunotriquetral interosseous ligament (LTIL) is often unreliable, and secure repair is challenging. Internal bracing (IB) is an augmentation method that uses high-strength non-absorbable tape and enhances strength and support during the critical period of ligamentous healing. However, there is a paucity of data on the application of IB for PLD in the wrist. We report 3 cases of PLD that were augmented with IB after SLIL and LTIL repair.

PATIENT CONCERNS

All 3 cases were men who visited our emergency department with wrist after falling off a ladder.

DIAGNOSES

Initial radiographs revealed a dorsal PLD.

INTERVENTIONS

Surgically, complete rupture of the SLIL and LTIL were confirmed. K-wires were placed into the scaphoid and lunate and used as joysticks to correct the intercalated segment instability pattern. This usually requires correcting scaphoid flexion and lunate extension and closing the scapholunate interval. Prior to SLIL and LTIL repair, temporary intercarpal fixation was performed with K-wires to maintain the carpal relationship. The dorsal SLIL and LTIL were carefully repaired using suture anchors. However, ligament repair was unreliable, and insecure. In view of the likelihood of insufficient repair, we performed IB augmentation using synthetic tape.

OUTCOMES

At the last follow-up, all cases were pain-free and had returned to all activities. The last follow-up radiographs showed good alignment of the carpal bones and no arthritic changes.

LESSONS

IB augmentation can reduce the period of K-wire fixation and cast immobilization and can enable early joint motion. We believe that interosseous ligament augmentation using IB is a reasonable treatment option for PLD.

The Biomechanical Effects of Augmentation With Flat Braided Suture on Dorsal Intercarpal Ligament Capsulodesis for Scapholunate Instability

PURPOSE

Selecting treatment for scapholunate (SL) instability is notoriously difficult. Many methods of reconstruction have been described, but no procedure demonstrates clear superiority. New methods proposed use internal bracing (IB) with suture anchors and flat braided suture (FBS), alone or as an augmentation with tendon autograft for SL ligament injuries. Our goal was to use computed tomography (CT) to analyze alignment of the SL joint after 3 different modes of fixation of SL instability: after reconstruction with IB incorporating either tendon autograft or the dorsal intercarpal ligament (DICL), or DICL capsulodesis without FBS.

METHODS

Ten fresh-frozen, matched-pair, forearm-to-hand specimens were used. Serial sectioning of the SL stabilizing ligaments was performed and the SL interval was measured with CT. We reconstructed the SL ligament with DICL capsulodesis alone (DICL) or with IB augmented with either tendon autograft (IB plus T) or DICL (DICL plus IB). The SL interval was measured with CT. Specimens underwent 500 weighted cycles on a jig and were reimaged. Differences in SL interval after repair and cycling were compared.

RESULTS

Dorsal intercarpal ligament capsulodesis augmented with IB best maintained the SL interval before and after cycling. Dorsal intercarpal ligament capsulodesis alone was inferior to DICL plus IB and IB plus T both before and after cycling.

CONCLUSIONS

Dorsal intercarpal ligament capsulodesis augmented with IB appears to maintain better SL joint reduction than IB with tendon autograft.

CLINICAL RELEVANCE

This work serves as a necessary step for further study of the biomechanical strength and clinical application of FBS technology in the reconstruction of SL instability. Flat braided suture augmentation of DICL capsulodesis may provide another option to consider for reconstruction of SL instability.

Comparison of Three Different Internal Brace Augmentation Techniques for Scapholunate Dissociation: A Cadaveric Biomechanical Study

Internal bracing (IB) is an augmentation method using high-strength nonabsorbable tape. However, there is no detailed information about the direction, location, or number of IBs required for scapholunate interosseous ligament (SLIL) injury repair. Thus, this study compared the biomechanical characteristics of short-transverse IB, long-oblique IB, and the combination of short-transverse and long-oblique (Combo) IB for SLIL injury in a biomechanical cadaveric model. We prepared nine fresh-frozen full upper extremity cadaveric specimens for this study. The scapholunate distance, scapholunate angle, and radioscaphoid angle were measured using the MicroScribe digitizing system with the SLIL intact, after scapholunate dissociation and the three different reconstructions. Three-dimensional digital records were obtained in six wrist positions in each experimental condition. Short-transverse IB had a similar effect compared with long-oblique IB in addressing the widening of the scapholunate distance. However, both were less effective than Combo IB. For scaphoid flexion deformity, short-transverse IB had minimal effect, while long-oblique IB had a similar effect compared to Combo IB. Combo IB was the most effective for improving distraction intensity and rotational strength. This study provides important information about the biomechanical characteristics of three different IB methods for SLIL injury and may be useful to clinicians in treating scapholunate dissociation.