Arthroscopically Assisted Ligamentoplasty for Axial and Dorsal Reconstruction of the Scapholunate Ligament.
ABSTRACT: Scapholunate (SL) ligament injury is among the most common injuries of the intrinsic ligaments of the carpus. Arthroscopic treatment in complete and nonacute injuries has had poor results. These cases have typically been treated using open surgical techniques that require a broad dorsal approach and produce soft tissue impairment, which leads to reduced wrist mobility. The development of wrist arthroscopy techniques has allowed the treatment of complete and nonacute injuries of the SL ligament, without the disadvantages of open surgery, respecting the soft tissues and avoiding injury of the posterior interosseous nerve, in an attempt to preserve the proprioception of the wrist and the secondary dorsal stabilizers. This arthroscopically assisted technique reconstructs the SL ligament using a tendon graft placed between the scaphoid and lunate and complemented by the reconstruction of the dorsal portion of the SL ligament, with the aim of creating an axial and dorsal tendinous ligamentoplasty between both bones.
Project description:Scapholunate ligament (SLL) injury is the most frequent injury of the intrinsic carpal ligaments. The dorsal part of the SLL is the most important part for the stability of the scapholunate joint, and tears of this part and at least one of its secondary capsular attachments cause scapholunate dissociation. The arthroscopic technique most frequently used for acute injuries is reduction and fixation with Kirschner wires, and techniques that involve a primary repair of the injured ligament are performed by open surgery with efficient results. However, they lead to significant stiffness of the wrist due to injury to the soft tissue caused by damage to the secondary dorsal stabilizers; the dorsal blood supply; and in many cases, the proprioceptive innervation of the posterior interosseous nerve. We present an all-arthroscopic technique for the direct repair of acute injuries of the dorsal part of the SLL using bone anchors, complemented by a dorsal arthroscopic plication that reconstructs the dorsal capsulo-scapholunate septum of the scapholunate complex.
Project description:Background The dorsal capsuloligamentous scapholunate septum (DCSS) is a confluence of the dorsal capsule, the dorsal intercarpal ligament (DIC), and the scapholunate interosseous ligament (SLIOL). It appears to play a role in the stability of the scapholunate articulation. The purpose of this study was to describe the anatomical basis for this structure and to investigate its role in scapholunate instability through sectioning of this structure followed by an arthroscopic and fluoroscopic analysis. Material and Methods In the anatomical part of the study we dissected 3 fresh cadaver wrists to examine the anatomy of the DCSS. In the arthroscopic part of the study we assessed the EWAS grade of SL instability before and after sectioning the DCSS and measured the scapholunate and radiolunate angles fluoroscopically. Results Sectioning the DCSS increased the EWAS grade of SL instability but did not affect the scapholunate gap, the scapholunate angle or radiolunate angle. Conclusion We have demonstrated that there is a distinct structure that is separate from the dorsal capsule, which we have labeled the Dorsal Capsuloligamentous Scapholunate Septum. We believe that the DCSS is a previously unreported secondary stabilizer of the SL joint which may have therapeutic and prognostic implications.
Project description:Background Untreated scapholunate ligament disruption may lead to progressive wrist arthritis. Current techniques used to treat the disruption may not prevent arthritis because of attenuation of a reconstructive ligament substitute or failure to re-establish normal wrist kinematics. Questions/Purposes This study evaluates a combined synthetic-autologous technique for the treatment of scapholunate dissociation. Methods Scapholunate dissociation was created in six cadaveric wrists. The dorsal and volar components of the scapholunate ligament were reconstructed using the Ligament Augmentation & Reconstruction System (LARS; LARS, Arc-sur-Tille, France) and a modified Blatt capsulodesis performed. Reconstructed wrists were subjected to cyclic passive motion. Outcomes were measured radiologically and compared using Student's t-test. Results Carpal alignment was re-established following scapholunate ligament reconstruction. Carpal alignment was maintained after cyclic loading. Conclusions The technique described corrected the carpal malalignment associated with scapholunate dissociation. Corrected positions were maintained after one thousand cycles of flexion and extension without fraying or loosening of the LARS. Clinical Relevance Current popular techniques for scapholunate reconstruction do not address the important dorsal and palmar components of the ligament that control their intercarpal motion. Reconstruction of the dorsal and palmar components of the scapholunate ligament can be achieved through a dorsal approach to the wrist.
Project description:BACKGROUND:Optimal treatment of chronic scapholunate (SL) instability remains controversial. Many surgical techniques have been proposed with varied results in subsequent case series; however, there is limited evidence demonstrating the relative effectiveness of the different treatment options. QUESTIONS/PURPOSES:We conducted a systematic review of the English literature to compare outcomes from capsulodesis and ligament reconstruction for treatment of chronic scapholunate instability. METHODS:An electronic database search using keywords associated with scapholunate ligament instability was performed. A total of 511 studies were identified. All studies with scapholunate ligament tears >4 weeks after the initial injury were included in the review. Data extracted included patient demographics, wrist range of motion, and radiographic outcome measures. RESULTS:A total of 308 patients from 11 studies met the inclusion criteria and were included in the study. The average time to surgery from initial injury was 11 months. There was no significant difference in wrist flexion or extension after capsulodesis or reconstruction. The weighted mean for postoperative wrist extension/flexion was 56°/45.6° in the capsulodesis group and 40.9°/47.3° in the reconstruction group. Pooled means of SL angle and SL gap were 60.3° and 3.44 mm after capsulodesis and 56.5 and 2.72 mm after reconstruction, respectively. CONCLUSIONS:This systematic review failed to demonstrate any significant difference in outcomes from capsulodesis or reconstruction for treatment of chronic scapholunate instability. However, the retrospective studies examined were notably heterogeneous in design with high estimates of variance. Further prospective trials are necessary to determine an ideal treatment strategy.
Project description:UNLABELLED: Early diagnosis of scapholunate interosseous ligament tears with distal radius fractures is likely important in treatment and outcome, but identification of these injuries has not been well explored. We asked whether there was a difference in the scapholunate interval between high-grade and low-grade tears of the scapholunate interosseous ligament in distal radius fractures, the best position of the wrists to identify any differences; we also asked what gap width accurately identified high-grade tears on fluoroscopic evaluation. We fluoroscopically evaluated the scapholunate gap in six different wrist positions and then performed arthroscopic examination in 45 distal radius fractures in 44 consecutive patients. The tears were classified as high-grade (Grade 3 or greater) or low-grade (Grade 2 or less) based on arthroscopic findings. We then compared the scapholunate gap measured on fluoroscopic images between the high-grade tear group and the low-grade tear group and between the different positions of the same wrist. The scapholunate gap was wider in the high-grade tear group than in the low-grade tear group and wider in ulnar deviation than in radial deviation. A 2-mm scapholunate gap appeared the best cutoff point for the fluoroscopic diagnosis. We concluded fluoroscopic examination is a good test for identifying high-grade tears of the scapholunate interosseous ligament in distal radius fractures. LEVEL OF EVIDENCE: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Project description:The arthroscopic technique most frequently used in acute scapholunate instability is reduction and fixation with Kirschner wires. To repair the injured ligament, open surgery and dorsal capsular plication are recommended, but this procedure has the risk of damaging secondary dorsal stabilizers, the dorsal blood supply, and the proprioceptive innervation of the posterior interosseous nerve. In this report, we present an all-arthroscopic technique of a dorsal reconstruction of the scapholunate interosseous ligament for scapholunate instability using a tape by tethering the scaphoid to the lunate.
Project description:Introduction Scapholunate ligament injuries usually result due to a fall on the outstretched hand leading to scapholunate instability. The natural history of untreated scapholunate instability remains controversial and usually results in late arthritic changes- the so-called "SLAC" wrist. The advent of wrist arthroscopy helps in early diagnosis and treatment of these serious injuries. In selected cases with reducible scapholunate instability (Garcia-Elias stages 2, 3 and 4) we propose a new "all arthroscopic dorsal capsulo- ligamentous repair" with the added advantage of early rehabilitation and prevention of post-operative stiffness. Material and Methods We report the results of our series of 57 consecutive patients suffering from chronic wrist pain refractory to conservative measures. All patients underwent a thorough clinical examination in addition to a standard set of radiographs and MRI exam; and they were treated by an all-arthroscopic dorsal capsulo-ligamentous repair under loco-regional anesthesia on an ambulatory basis. All patients were available for follow-up at regular intervals during the post-operative period. At follow-up, the wrist ROM in all directions, the grip strength, DASH questionnaire and pain relief based on the VAS were recorded for both- the operated and contra-lateral sides. Results There were 34 males & 23 females with a mean age of 38.72 ± 11.33 years (range 17-63 years). The dominant side was involved in 52 cases. The mean time since injury was 9.42 ± 6.33 months (range 3-24 months) and the mean follow-up was 30.74 ± 7.05 months (range 18-43 months). The mean range of motion improved in all directions. The mean difference between the post- and pre-operative extension was 14.03° (SEM = 1.27°; p < 0.001); while the mean difference between the post-and pre-operative flexion was 11.14° (SEM = 1.3°; p < 0.0001) with flexion and radial deviation reaching 84.3% and 95.72% respectively of the unaffected wrist. The mean difference for the VAS score was -5.46 (SEM = 0.19; p < 0.0001). The mean post-operative grip strength of the affected side was 38.42 ± 10.27 kg (range 20-60 kg) as compared with mean pre-operative grip strength of 24.07 ± 10.51 kg (range 8-40 kg) (p < 0.0001). The mean post-operative grip strength of the operated side was 93.4% of the unaffected side. The DISI was corrected in all cases on post-operative radiographs. The mean difference between the post-and pre-operative SL angles was -8.95° (SEM = 1.28°; p < 0.0001). The mean post-operative DASH score was 8.3 ± 7.82 as compared with mean pre-operative DASH score of 46.04 ± 16.57 (p < 0.0001). There was a negative co-relation between the overall DASH score and the post-operative correction of the DISI deformity with a lower DASH score associated with increasing SL angles. Discussion The dorsal portion of the scapholunate ligament is critical for the stability scapholunate articulation, largely due to its attachment to the dorsal capsule. We have recently conducted a multi-centric anatomical study with international collaboration demonstrating the critical importance of this dorsal scapholunate complex. The all arthroscopic capsulo-ligamentous repair technique provides reliable results in addition to avoiding postoperative stiffness. The overall results at a mean follow-up period of more than 2 years in our series of young, active patients appear to be encouraging.
Project description:Carpal instabilities continue to be a controversial topic in hand surgery. Accurate diagnosis of the ligament injuries is usually difficult without an arthroscopic evaluation. Few studies have focused on the diagnosis and proper management of simultaneous scapholunate (SL) and lunotriquetral (LT) ligament tears. This is an uncommon injury that leads to marked disability and chronic wrist pain. This is essentially a "floating lunate" and indicates a severe ligamentous lesion. Thirteen patients (six female and seven male) with complete SL and LT tears and with gross arthroscopic dynamic carpal instability were included in the present study. None of the patients showed radiographic evidence of lunate dislocation. One patient presented acutely and was operated on 3 days after the injury. The average time from the initial injury to the arthroscopy for the other 12 patients was 13.5 months (range 1.5-84 months). All patients underwent arthroscopic debridement of the SL and LT ligaments coupled with percutaneous pinning (two 0.045-in. Kirschner wires) in both joints. At the final follow-up, the average range of motion was 50 degrees of flexion, 54 degrees of extension, 77 degrees of pronation, 80 degrees of supination, 25 degrees of ulnar deviation, and 15 degrees of radial deviation. The average final grip strength was 67% from the non-affected side. All patients had negative shifting tests at final follow-up. Furthermore, there was no evidence of any static or dynamic instability in all the patients except for one patient who developed a volar intercalated segment instability 8 months after the surgery. At the final follow-up, ten patients had no pain, one had mild pain, and two experienced moderate pain.
Project description:Background An increased scapholunate gap is sometimes seen in patients with a distal radial fracture. The question remains as to whether this represents a scapholunate ligament injury that requires treatment. Questions/purposes We wished to examine the natural history of an increased scapholunate gap in patients following an extra-articular distal radial fracture. Patients and Methods We reviewed 260 patients who had sustained a distal radial fracture at a mean of 6.2 (2.7-11.9) years previously and identified 12 extra-articular fractures with an increased gap between the lunate and scaphoid. The mean scapholunate gap was 2.6 (2.1-3.4) mm, and the mean scapholunate angle 62° (39°-90°). Controls were found among the remaining patients with extra-articular fractures. Selection criteria were same sex, age at fracture within 5 years, time between injury and review within 2 years, ulnar variance within 2 mm, and dorsal angulation within 5° of index patient. When more than one control fulfilled the criteria for an index patient, their values were averaged. In total there were 54 controls for the 12 index patients. Results The mean difference between index patients and controls in wrist range of motion was 4%, in grip strength 5%, in visual analog scale (VAS) for pain 1 (on a scale from 1 to 100), in Quick-DASH (Disability of the Arm, Shoulder, and Hand) score 5, and in PRWE score 1. The study was calculated to have the power to detect a difference in Quick-DASH scores and in Patient-Rated Wrist Evaluation (PRWE) scores of 14. Conclusions We conclude that at a mean follow up of 6.2 years following an extra-articular distal radial fracture, no surgical treatment is usually needed with a scapholunate gap of between 2.1-3.4 mm. Level of Evidence III, Case control study.
Project description: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.