Concepts and Artistry in the Treatment of Scapholunate Ligament Injuries

Collagen and Vascular Changes in the Scapholunate Ligament Following Injury: An Immunohistochemical Study

PURPOSE

The scapholunate ligament (SLL) is the most frequently injured wrist ligament. The aim of this study was to investigate cellular and extracellular changes within the SLL following injury.

METHODS

Fifteen SLLs were harvested, ranging between 39 days to 20 years from time of injury. These specimens were subject to immunohistochemical analysis to characterize their vascular and collagen constitution.

RESULTS

Of the 15 ligaments, 4 were harvested <3 months from injury, and 11 harvested >3 months from injury. The mean type I collagen density was 45.6% (25.2% to 55.9%) in all specimens. The mean type III collagen density was 47% (38.2% to 51.8%) of the ligament area in specimens <3 months after injury and 30.6% (13.3% to 44.1%) in those >3 months after injury. Type III collagen density was highest in the volar subunit. Type I collagen decreased only minimally in specimens taken within 2 years of injury. The increase in the type I:III collagen ratio reflected the decline in type III collagen. Blood vessels were found in 13 of 15 specimens. Mean vessel density for all specimens was 1.3% (0% to 7.1%), with the highest density of 1.8% (0% to 10%) in the volar subunit. The vessel density decreased from 2.9% (1.3% to 4.3%) to 1.6% (0% to 10%) in the volar subunit in specimens harvested >3 months after injury.

CONCLUSIONS

Mean type III collagen density decreased with time, most notably within the volar subunit. Mean type I collagen density held comparatively stable in ligaments taken within 2 years from injury. Blood vessels were detected in 87% of specimens, with the highest density in the volar subunit.

CLINICAL RELEVANCE

The SLL displays a collagen profile similar to other ligaments with favorable healing capacity. The volar subunit possessed a collagen ratio and vessel density that may suggest its acute repair and inclusion in reconstructive techniques has merit.

Immunohistochemical Investigation of Mechanoreceptors Within the Injured Scapholunate Ligament

PURPOSE

Scapholunate ligaments (SLLs) play a well-established role in maintaining carpal alignment and kinematics, and are innervated with sensory mechanoreceptors located within the ligaments. They are involved in the afferent arc of dynamic wrist stability. The aim of this study was to describe the changes in these mechanoreceptor populations in injured SLLs.

METHODS

Injured SLLs were collected from human wrists at the time of SLL reconstruction or limited wrist fusion, where the ligament remnants would otherwise be discarded. These specimens were formalin-fixed and paraffin-embedded for immunohistochemical analysis to identify mechanoreceptors, which were then classified by type and location within the ligament.

RESULTS

A total of 15 ligaments were collected, with the interval from injury ranging from 39 days-20 years. Eleven ligaments were collected less than one year after injury, and four ligaments were collected two years or more after injury. A total of 66 mechanoreceptors were identified, with 50 mechanoreceptors identified in nine of the 11 specimens collected less than one year after injury. In this group, 54% of the mechanoreceptors resided in the volar subunit, 20% in the dorsal subunit, and 26% in the proximal subunit. Two of the four specimens collected two years or later after injury contained mechanoreceptors, all of which were located in the dorsal subunit. Increasing time from injury demonstrated a decline in mechanoreceptor numbers within the volar subunit.

CONCLUSIONS

Mechanoreceptors were consistently located in the SLL, particularly in the volar subunit of specimens collected less than one year after injury.

CLINICAL RELEVANCE

Ligament reconstruction techniques aim to primarily reconstitute the biomechanical function of the disrupted SLL; however, re-establishing the afferent proprioceptive capacity of the SLL may be a secondary objective. This suggests the need to consider the reconstruction of its volar subunit particularly in those managed within one year of injury.

Recognition and conservative management for a spectrum of sport-related scapholunate interosseous ligament injuries: a case series

This case series presents four cases of scapholunate interosseous ligament (SLIL) injury. We discuss the process of early recognition and highlight difficulties encountered in current diagnostic and conservative management strategies. The cases profile interdisciplinary management of four scapholunate (SL) injuries that have different clinical presentations and injury mechanisms. Three sport-related SL injuries were managed conservatively by a sport specialist chiropractor and one sport-related case was self-managed. Management strategies included early wrist immobilization, soft tissue manual therapy, low-level laser therapy, proprioceptive and strengthening exercises, and early orthopedic referral. This case series highlights: (1) the spectrum of SL injuries (2) the importance of early specialty referral, (3) the paucity of literature with respect to conservative management of these injuries and (4) the role of manual therapy and rehabilitation professionals as part of the healthcare team in detecting and helping manage these wrist injuries.

Treatment Recommendations for Suspected Scapholunate Ligament Pathology

Background  The diagnosis and treatment of scapholunate interosseous ligament (SLIL) pathology is debated and notably variable. This study assessed the influence of diagnostic arthroscopy on treatment recommendations and the interobserver reliability of the arthroscopic classification of SLIL pathology. Methods  The influence of diagnostic arthroscopy on treatment recommendations and the reliability of the arthroscopic classification of SLIL pathology were tested in a survey-based experiment. Seventy-seven surgeons evaluated 16 scenarios of people with wrist pain with variation in symptoms, scaphoid shift, time of symptom onset, and MRI appearance of the SLIL. Participants were randomized to view or not to view diagnostic wrist arthroscopy. Factors associated with recommendation for repair, capsulodesis, or tenodesis were analyzed. Results  Viewing arthroscopic videos was associated with both offering surgery and a more reconstructive option. Other factors independently associated with recommendation for surgery included greater pain intensity and activity intolerance, women surgeons, an asymmetric scaphoid shift, and a recent onset of symptoms. The interobserver reliability of SLIL classification was slight. Conclusions  Diagnostic arthroscopy leads to more surgery, and more invasive surgery, in spite of unreliable assessment of pathology. Clinical Relevance  This points to the need to measure the potential benefits and harms of diagnostic wrist arthroscopy among people with wrist pain and no clear diagnosis on interview, examination, and radiographs. Level of Evidence  Not applicable.

Alterations in forearm muscle activation patterns after scapholunate interosseous ligament injury: A dynamic electromyography study

STUDY DESIGN

Case control.

PURPOSE OF THE STUDY

This study aimed to investigate the alterations seen in the activation patterns of the forearm muscles and to demonstrate the associated functional outcomes, in patients with scapholunate interosseous ligament (SLIL) injury.

METHODS

The study involved 15 patients with SLIL injury (instability group) and 11 healthy participants (control group). Both groups were evaluated with regard to their pain, grip strength, and upper extremity functional level (disabilities of the arm, shoulder and hand and patient-rated wrist evaluation questionnaires), and they also underwent a dynamic electromyography analysis of their forearm muscle activity. The activation patterns of the extensor carpi ulnaris (ECU), extensor carpi radialis (ECR), flexor carpi ulnaris, and flexor carpi radialis muscles during wrist extension and flexion were recorded by means of surface electromyography.

RESULTS

In the instability group, the pain severity was higher and the functional level was worse than in the control group (P < .05). Furthermore, during wrist extension, the ECR activity was lower and the ECU activity was higher in the instability group than in the control group (P < .05).

CONCLUSION

Dynamic stabilization of the wrist, flexor carpi ulnaris, and flexor carpi radialis muscles have been shown to play an active role with ECU and ECR. Increased ECU and decreased ECR activation may pose a potential risk in terms of enhancing the scapholunate gap. We, therefore, propose that appropriate preventive neuromuscular exercise strategies implemented as part of a physiotherapy program for patients with SLIL lesions might increase the contribution of the dynamic stability effect of the relevant muscles.