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

One-Year Outcomes of the Anatomical Front and Back Reconstruction for Scapholunate Dissociation

PURPOSE

Anatomical front and back (ANAFAB) reconstruction addresses the critical volar and dorsal ligaments associated with scapholunate dissociation. We hypothesized that patients with symptomatic, chronic, late-stage scapholunate dissociation would demonstrate improvements in all radiographic parameters and patient-reported outcomes (PROMs) after ANAFAB reconstruction.

METHODS

From 2018 to 2021, 21 ANAFAB reconstructions performed by a single surgeon were followed prospectively, with 20 patients having a minimum follow-up of 12 months. In total, 17 men and four women were included, with an average age of 49 years. Three patients had modified Garcia-Elias stage 3 disease, eight stage 4, seven stage 5, and three stage 7. ANAFAB reconstruction of intrinsic and extrinsic ligament stabilizers was performed using a hybrid synthetic tape/tendon graft in a transosseous reconstruction. Pre- and postoperative radiographic parameters, grip, pinch strength, the Patient-Rated Wrist Evaluation, PROMIS Upper Extremity Function, and PROMIS Pain Interference outcome measures were compared.

RESULTS

Mean follow-up was 17.9 months (range: 12-38). Radiographic parameters were improved at follow-up, including the following: scapholunate angle (mean 75.3° preoperatively to 69.2°), scapholunate gap (5.9-4.2 mm), dorsal scaphoid translation (1.2-0.2 mm), and radiolunate angle (13.5° to 1.8°). Mean Patient-Rated Wrist Evaluation scores for pain and function decreased from 40.6 before surgery to 10.4. We were unable to detect a significant difference in grip or pinch strength or radioscaphoid angle with the numbers tested. There were two minor complications, and two complications required re-operations, one patient who was converted to a proximal row carpectomy for failure of fixation, and one who required tenolysis/arthrolysis for arthrofibrosis.

CONCLUSIONS

At 17.9-month average follow-up, radiographic and patient-reported outcome parameters improved after reconstruction of the critical dorsal and volar ligament stabilizers of the proximal carpal row with the ANAFAB technique.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Scapholunate Instability: Diagnosis and Management - Classification and Treatment Considerations - Part 2

Intervention for scapholunate instability is aimed at halting the degenerative process by restoring ligament integrity and normalizing carpal kinematics. Part 1 of this Current Concepts article reviewed the anatomy, kinematics, and biomechanical properties of the scapholunate ligament as well as its critical stabilizers. In this section, we provide a foundation for understanding the spectrum of scapholunate ligament instability and incorporate meaningful new anatomical insights that influence treatment considerations. These updates clarify the importance of the critical stabilizers of the scapholunate interval, ligament-specific considerations in scapholunate ligament reconstruction, and the risks of ligament disinsertion when surgically exposing the dorsal wrist. We propose a ligament-based treatment algorithm based on the stage of injury, degree and nature of ligament damage, and presence of arthritic changes.

Dorsal Scapholunate Ligament Reconstruction by Using Palmaris Longus Tendon Graft in Chronic Static Scapholunate Dissociations: Does It Yield Favorable Radiographic and Functional Results?

Background  Scapholunate (SL) instability is the most common dissociative carpal instability, and the most frequent cause of wrist osteoarthritis (OA), termed as scapholunate advanced collapse (SLAC). The aim of this study was to present the mid-term clinical and radiographic results of dorsal SL ligament reconstruction by utilizing free palmaris longus tendon graft in patients with symptomatic, chronic, static SL dissociation; while assessing the safety and efficacy of this technique, Materials and Methods  In total, 42 patients with a mean age of 44.1 (range 26-53) and mean follow-up duration of 69.4 months (range 60-72) with a diagnosis of chronic, static, and reducible SL instabilities with no chondral damage were enrolled. They all underwent dorsal SL ligament reconstruction with the exam same technique. Results  At the last follow-up, patients' mean preoperative SL gap improved from 4.7 (range 4-6) to 2.1 (range 2-3), as did SLA from 84 degrees (range 67-101 degrees) to 66 degrees (range 49-72 degrees)( p <0.001 for both). Preoperative mean VAS (visual analog score), DASH (Disabilities of the Arm, Shoulder and Hand), Mayo wrist scores and SF-36 scores showed significant improvements in the last follow-up visit ( p <0.001, for all). No major complications were acquired in either of the patients. Conclusion  Dorsal SL ligament reconstruction by using free PL tendon graft was detected to provide successful restoration of the normal carpal alignment together with SL joint stability. This procedure, by significantly reducing pain and improving grip strength was detected to yield significantly improved clinical and functional outcomes, together with high patient satisfaction indicated by improved health-related quality of life (HRQOL) scores. Level of Evidence  IV.

Wide arthroscopic dorsal capsuloligamentous repair in patients with severe scapholunate instability

A conventional arthroscopic capsuloligamentous repair is a reliable surgical solution in most patients with scapholunate instability. However, this repair does not seem to be sufficient for more advanced injuries. The aim of this study was to evaluate the functional results of a wide arthroscopic dorsal capsuloligamentous repair (WADCLR) in the management of severe scapholunate instability. This was a prospective single-centre study undertaken between March 2019 and May 2021. The primary outcome was the evaluation of the reduction of the radiological deformity and the functional outcomes after WADCLR. A secondary outcome was the evaluation of the effectiveness of this technique in patients with the most severe instability (European Wrist Arthroscopy Society (EWAS) stage 5). The patients were reviewed postoperatively at three, six, and 12 months. The study included 112 patients (70 male and 42 female). Their mean age was 31.6 years (16 to 55). A total of three patients had EWAS stage 3A injuries, 12 had stage 3B injuries, 29 had stage 3C injuries, 56 had stage 4 injuries, and 12 had stage 5 injuries. There was a significant improvement of the radiological signs in all patients with a return to normal values. There was also a significant improvement in all aspects of function except for flexion, in which the mean increase was negligible (0.18° on average). There was also a significant improvement in all criteria for patients with a stage 5 injury, except for some limitation of extension, flexion, and radial and ulnar deviation, although these showed a trend towards improvement (except for flexion). WADCLR is a minimally invasive, easy, and reproducible technique with few complications, offering a clear improvement in function and a reduction in the radiological deformity at one year postoperatively.

Surgical Technique: Wide Arthroscopic Dorsal Capsuloligamentous Repair for Advanced Scapholunate Instability

In the most advanced cases of scapholunate instability with dynamic or static signs, classical arthroscopic repair seems impossible. Ligamentoplasties or open surgery procedures are technically demanding, hampered by significant operative complications and often stiffening. Therapeutic simplification is therefore necessary for the management of these complex cases of advanced scapholunate instability. We propose a minimally invasive, reliable, and easily reproducible solution that requires little equipment other than arthroscopic material.

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

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

Radiological and functional correlation following "SLIC" scapholunate-intercarpal ligamentoplasty at minimum 12 months' follow-up

We report outcomes for scapholunate-intercarpal ligamentoplasty ("SLIC procedure"), performed in 22 patients (mean age at surgery, 39.7 years), for reducible static scapholunate (SL) instability without repairable stump. Patients were evaluated for pain and active wrist range of motion, grip strength, functional scores (QuickDASH and PRWE) and radiological appearance (SL gap, SL angle, radiolunate angle, capitolunate angle), preoperatively and at a mean 28.3 months' follow-up (range 12-65). A CT scan without injection was performed at follow-up to measure the posterior radioscaphoid angle (PRSA). The objective was to assess radiological-functional correlations after SLIC ligamentoplasty and to analyze postoperative PRSA correction. The hypothesis was that correcting the PRSA improves clinical and functional outcomes. Pain on a visual analog scale improved significantly, from 2.7 to 0.7 at rest and from 7 to 3.2 during hand use. Mean wrist flexion was 46.4° and extension 59.1°. Grip strength reached 82.8% of the contralateral value. Functional scores improved significantly. Mean SL angle decreased significantly from 81.1° to 73.5°, and static scapholunate gap from 4.7 mm to 3.6 mm. Scaphoid subluxation was fully corrected in 15 cases (68%). PRSA angle was significantly corrected, from a mean 112.7° to 104.2°. Patients in whom PRSA was corrected showed a tendency for better clinical and subjective outcomes. There was 1 case of scaphoid necrosis, 7 of recurrent static instability, including 3 early at 4 months, 3 of scaphocapitate osteoarthritis, and 5 of carpal collapse with SLAC wrist. There were no significant correlations between clinical and radiological results in the medium term after SL ligamentoplasty by the SLIC procedure. The results were quite good in the medium term and pointed to the importance of correcting rotatory subluxation of the scaphoid, revealed by the PRSA, more than correcting the scapholunate gap.

Narrative Review of Ligamentous Wrist Injuries

Ligamentous wrist injuries are common occurrences that require complex anatomical mastery and extensive understanding of diagnostic and treatment modalities. The purpose of this educational review article is to delve into the most clinically relevant wrist ligaments in an organized manner to provide the reader with an overview of relevant anatomy, function, clinical examination findings, imaging modalities, and options for management. Emphasis is placed on elucidating reported diagnostic accuracies and treatment outcomes to encourage evidence-based practice.

Intercarpal ligamentoplasty for scapholunate dissociation: comparison of two techniques

We modified our original surgical technique of scapholunate intercarpal ligamentoplasty for treating chronic scapholunate dissociation. The aim of this study was to compare the outcomes in patients treated by the same surgical team with the original method and the modified method over two different time periods. Nineteen patients with a mean age of 40 years were treated with the original method (mean follow-up of 34 months, range 12-54), and 21 patients with a mean age of 38 years were treated with the modified method (mean follow-up of 27 months, range 13-40). In both groups, we found a significant improvement in pain levels, grip strength, functional scores in terms of QuickDASH and Patient-Rated Wrist Evaluation, and radiographic scapholunate gap and scapholunate angle after surgery. There were no significant differences between the two groups in outcome measures except the scapholunate gap, which was significantly better controlled by the modified procedure. Between the immediate postoperative period and the last follow-up, there was a significant increase in the scapholunate gap and scapholunate angle after the original method, while there only a small increase after the modified method. We conclude that both versions of the scapholunate intercarpal ligamentoplasty yield satisfactory clinical and radiological results in the short to mid-term. The modified method makes the triquetral surgical step easier and seems to better optimize the tension across the ligamentoplasty, thus maintaining the intercarpal correction.Level of evidence: III.

Modified Viegas dorsal capsuloplasty for chronic partial injury of the scapholunate ligament in young athletes: outcomes at 24 months

The treatment of chronic scapholunate ligament tears in patients with high demand, such as young athletes, is difficult as traditional techniques are associated with some loss of wrist motion and grip strength. This retrospective investigation studied young athletes (≤20 years old) with chronic scapholunate ligament lesions and a minimum follow-up of 24 months, treated with a modified Viegas dorsal capsuloplasty. Twenty-six young athletes (mean age 17 years) were included. A partial scapholunate ligament tear (Geissler III) was seen in 25 patients. At the last follow-up, a significantly different improvement was seen in all measured parameters and all patients could return to their original competitive activity, within 6 months (range 4-12) after surgery.Level of evidence: IV.

Dorsal intercarpal ligament capsulodesis: a retrospective study of 120 patients according to types of chronic scapholunate instability

The purpose of this study was to assess the results of dorsal intercarpal ligament capsulodesis (Mayo technique) for cases of chronic scapholunate instability and to specify the indications according to the severity of instability. A retrospective analysis was conducted and examined dorsal intercarpal ligament capsulodesis procedures performed for chronic scapholunate instability without intercarpal or radiocarpal arthritis. One-hundred and twenty patients were examined by an independent observer (48 predynamic, 48 dynamic and 24 static scapholunate instabilities). The follow-up period averaged 54 months (range 24-127). Mean final Mayo wrist score was 70, mean final Patient-Rated Wrist Evaluation was 27 and mean final QuickDASH score was 26. Functional, clinical and radiological data were improved for the operated patients. We concluded that dorsal intercarpal ligament capsulodesis is a good option for treating early stages of scapholunate instability.Level of evidence: IV.

Evaluation of Dorsal Subluxation of the Scaphoid in Patients With Scapholunate Ligament Tears: A 4D CT Study

OBJECTIVE. The purpose of this study was to evaluate the variation of the posterior radioscaphoid (RS) angle in patients with and without scapholunate ligament (SLL) tears during wrist radioulnar deviation. SUBJECTS AND METHODS. Seventy-three patients with clinically suspected scapholunate instability were prospectively evaluated with 4D CT and CT arthrography from February 2015 to April 2018. The posterior RS angle is formed between the articular surface of the scaphoid fossa of the radius and the most posterior point of the scaphoid in the sagittal plane. Two independent radiologists calculated this angle during radioulnar deviation. Posterior RS angles were correlated with the SLL status and the presence of a scapholunate diastasis on conventional stress radiographs. RESULTS. Readers 1 and 2 found mean posterior RS angles of 99° and 98°, respectively, in patients without and 107° and 111°, respectively, in patients with a scapholunate diastasis. The posterior RS angle amplitude varied 7.6-9.3° in the subgroups studied. The reproducibility of posterior RS angle measurement was considered good (intraclass correlation coefficient, 0.73). Mean posterior RS angles increased 6-10% and 12-14% when patients with an intact SLL were compared with those with partial tears and full tears, respectively (p < 0.001). These values also increased 8-13% when patients with diastasis were compared with those without (p < 0.0001). A dynamic acquisition was not necessary to assess this angle, with neutral posterior RS angles yielding a sensitivity of 64% and 72% and specificity of 79% and 94% for the diagnosis of SLL tears by readers 1 and 2, respectively. CONCLUSION. Posterior RS angle tended to increase with the severity of SLL tears and with the presence of scapholunate instability and yielded high sensitivity and specificity for the detection of SLL tears.

Satisfactory function 12 years after triscaphoid arthrodesis for chronic scapholunate ligament injury

Scapholunate ligament (SLL) injury represents a hazard to the wrist and the treatment of these injuries has been the focus of much debate. We performed a long-term follow (>10 years) of triscaphoid arthrodesis for symptomatic chronic SLL injuries in 10 (8 men) patients 37 (22-49) years of age. All arthrodesis healed. One patient was converted to total wrist arthrodesis during the follow-up period, and three had minor additional surgeries. At final follow-up, the patients had reduced active range of motion (AROM, 55%) and grip strength (85%) compared to the opposite side, but reported low Quick Disability of Arm, Shoulder and Hand (QDASH) (11), Patient-Rated Wrist and Hand Evaluation (PRWHE) (25) and visual analog scale (VAS) pain scores (0 and 10 at rest and activity). Radiographs found minimal degenerative changes in four patients, while CT scans demonstrated changes in seven patients, in three of these scaphoid was subluxed on the rim of the radius. The patients working prior to surgery were working at follow-up. A triscaphoid arthrodesis for SLL renders a functional wrist function in most patients for many years and has postponed more extensive surgery like total wrist arthrodesis or wrist arthroplasty. The patients are still young, and the degenerative changes seen especially on CT scans warrants attention.

A four-dimensional-CT study of in vivo scapholunate rotation axes: possible implications for scapholunate ligament reconstruction

Additional fixation of the palmar scapholunate interosseous ligament has been advocated to improve the long-term results of dorsal scapholunate interosseous ligament reconstruction. To investigate the validity of this approach, we determined normal scapholunate motion patterns and calculated the location of the scapholunate rotation axis. We hypothesized that the optimal location of the scapholunate interosseous ligament insertion could be determined from the scapholunate rotation axis. Four-dimensional computerized tomography was used to study the wrist motion in 21 healthy participants. During flexion-extension motions, the scaphoid rotates 38° (SD 0.6°) relative to the lunate; the rotation axis intersects the dorsal ridge of the proximal pole of the scaphoid and the dorsal ridge of the lunate. Minimal scapholunate motion is present during radioulnar deviation. Since the scapholunate rotation axis runs through the dorsal proximal pole of the scaphoid, this is probably the optimal location for attaching the scapholunate ligament during reconstructive surgery.