Capsulodesis for the treatment of chronic scapholunate instability

PURPOSE: Scapholunate (SL) instability is the most common form of carpal instability. The treatment of this disorder is challenging and varying treatment options have been described. The purpose of this study was to examine the intermediate-term results of dorsal capsulodesis for cases of chronic SL dissociation. METHODS: A retrospective analysis was conducted that examined all dorsal capsulodesis procedures performed for chronic SL dissociation between January of 1990 and February of 2000. Wrist pain had to be present for greater than 3 months. Patients had to have a minimum follow-up period of 2 years for inclusion in the study. Thirty-one patients were identified with isolated chronic SL dissociation. Of the 31 patients 18 had dynamic carpal instability and 13 had static carpal instability. The time from injury to surgery averaged 20 months. The follow-up period averaged 54 months (range, 24-96 mo). All patients had a dorsal capsulodesis procedure using either a Blatt or Mayo technique. Results were reviewed clinically and radiologically. Static and dynamic groups were compared with a Student t test. RESULTS: There was a 20% decrease in wrist motion after capsulodesis. There was no improvement in grip strength after surgery. Most patients had improvement in pain but only 2 patients were completely pain free. Radiographically the SL gap increased over time from 2.7 mm before surgery to 3.9 mm at the final follow-up evaluation. The SL angle also increased from 56 degrees before surgery to 62 degrees on final follow-up evaluation. There was no statistical difference in overall wrist motion, grip strength, or wrist score between the dynamic and static groups. The time to surgery and age had no significant effect on overall outcome. CONCLUSIONS: Dorsal capsulodesis provided pain relief for patients with both dynamic and static SL instability. Although pain was improved it was not completely resolved in the majority of cases. From a radiographic perspective dorsal capsulodesis did not provide maintenance of carpal alignment in cases of chronic SL dissociation.     

Obvious radiographic scapholunate dissociation: X-ray the other wrist

Obvious radiographic scapholunate dissociation seen on plain radiographs may seem to establish the diagnosis in a patient who presents with wrist pain. This diagnosis, however, is based on the assumption that scapholunate dissociation is caused only by trauma. In questioning this assumption, we present 6 cases of obvious radiographic scapholunate dissociation with similar radiographic findings in both wrists. These cases illustrate the pitfalls of using unilateral wrist radiographs to diagnose traumatic scapholunate dissociation. We chose these cases as representative of more than 75 bilateral cases we are studying. We describe medical histories, physical findings, radiographs, other diagnoses, treatments, and outcomes. These patients' injury histories and clinical presentations were not necessarily suggestive of wrist instability. All the patients were asymptomatic in the contralateral, uninjured wrist, despite similarity in radiographic findings. Traumatic scapholunate dissociation cannot be diagnosed with unilateral radiographs, no matter how obvious the findings or suggestive the history of trauma.     

Attempted scapholunate arthrodesis for chronic scapholunate dissociation

We report a retrospective review of seven patients with chronic scapholunate dissociation treated with attempted scapholunate arthrodesis. All procedures were done between 1978 to 1983 by one surgeon. Seven patients with follow-up of nine months or greater were available for review. Follow-up for the four patients with successful operations averaged seventy-seven months. Average age was 34 years (range from 19 to 46). Only one patient demonstrated radiographic fusion. Of the remaining six patients, three had no further wrist pain. The other three operations were total failures requiring other procedures for pain relief. For all patients, flexion-extension are decreased an average of 4 degrees. Grip strength averaged 88% of the unaffected side. Lateral scapholunate angle improved from an average preoperative angle of 70 degrees to a postoperative angle of 59 degrees. We conclude that this procedure is not a predictable method to treat scapholunate dissociation.     

Bone-tissue-bone repairs for scapholunate dissociation

Scapholunate dissociation is a commonly seen and treated form of carpal instability. Several surgical options have been used for the repair of scapholunate instability over the past 50 years. These have included benign neglect, reduction and percutaneous pinning, primary repair, partial fusions, tendon weaves, and combinations of these. Recent advancements in scapholunate repair and anatomy have been aimed at a more physiologic repair. Composite replacement of the entire scapholunate interval, similar to other tendon repairs seen in orthopedic surgery, has become popular. Bone-tissue-bone (BTB) autograft replacement from the foot has been used but the problems of a secondary surgical site have resulted in other graft site selections. Currently more commonly used grafts are bone-retinaculum-bone, third or second metacarpal-carpal bone, or hamate-capitate grafts, all performed with or without screw augmentation. Vascularized autograft replacement on pedicled grafts from the hand is being explored. This review discusses the surgeons' indications and technical details of the surgery. The lack of long-term outcome measurements for these BTB surgeries makes it difficult for the hand surgeon to determine the appropriate use of these treatment modalities, but early reports have indicated that the BTB graft will be an important part of scapholunate dissociation treatment.     

舟月骨分离实验模型建立的新标准

目的探讨实验条件下舟月骨分离模型制作新标准,为临床研究提供实验模型。方法8具未经防腐处理的新鲜尸体标本(肘关节以远标本),左右各4具。依次切断桡舟月韧带、舟月骨间韧带掌侧部、舟月骨间韧带背侧部、桡舟头韧带后,将标本用夹具固定于腕关节动力学参数测试仪,做模拟屈伸、尺桡偏运动,并摄腕关节中立前后位及侧位X线片,测量舟月角、头月角、舟月间距、桡舟间距和舟骨长度。结果随着依次切断上述韧带,舟月角、头月角分别增大至80．0°±8．7°和22．0°±7．0°,舟月间距增宽至(2．3±0．5)mm,桡舟间距增宽至(2．8±1．1)mm,舟骨长度逐渐缩短至(22．3±2．7)mm,差异均具有统计学意义(P<0．05)。结论当舟月角>60°、头月角>20°、舟月间距> 2．0 mm、桡舟间距>2．5 mm、舟骨长度<22．0 mm时,即已达到舟月骨分离的建模标准,其中桡舟间距、舟骨长度的变化能反应舟月骨分离的损伤进程及舟骨旋转性半脱位的程度。     

Blatt's capsulodesis for chronic scapholunate dissociation.

We have reviewed prospectively 44 cases of chronic scapholunate dissociation treated by Blatt's dorsal capsulodesis. The diagnosis was based on clinical and arthroscopic criteria. The minimum follow-up was 2 years. The results were analysed clinically and radiologically. Postoperatively statistically significant reductions in wrist movements and grip strengths were noted. Delay in surgery and presence of compensation claims were also statistically significant factors. Patients with a high column/row index had higher overall good and excellent results. The scapholunate gap, scapholunate angle, carpal height and the type of instability as diagnosed on arthroscopy and cineradiography did not affect the outcome significantly. The scapholunate gap, scapholunate angle and the carpal height did not change significantly after operation.     

Dorsal intercarpal augmentation ligamentoplasty for scapholunate dissociation

Carpal instability secondary to scapholunate ligament tears can lead to significant disability of the wrist. Disruption of the ligamentous stabilizers of the scaphoid causes rotatory subluxation of the scaphoid and subsequent abnormal loads across the radioscaphoid joint. Arthritic changes involving the radioscaphoid and midcarpal joint will develop if the wrist is untreated. Treatment of scapholunate ligament tears has varied widely in the literature. Today, most surgeons perform either a soft tissue reconstruction using local tissue or a limited fusion. Motion of the wrist favors soft tissue reconstructions. Also, the relative intercarpal motion with a more flexible carpus may prevent abnormal load patterns that are associated with a rigid radial column and limited fusions. We have reconstructed flexible subacute (>3 weeks) and chronic (>2 months) scapholunate dissociations with a radial-based dorsal intercarpal ligament. Clinical results have demonstrated increased grip strength, decreased pain, and improved intercarpal alignment.     

Wrist kinetics after scapholunate dissociation: the effect of scapholunate interosseous ligament injury and persistent scapholunate gaps.

The purpose of this study was to investigate the effects of cutting of the scapholunate interosseous ligament (SLIL) and persistent widening of the scapholunate (SL) joint on changes in moment arms of the principal wrist motor tendons. In seven fresh frozen cadaveric upper extremities, excursions of the extensor carpi radialis longus (ECRL) and brevis (ECRB), extensor carpi ulnaris (ECU), flexor carpi radialis (FCR), and flexor carpi ulnaris (FCU) were recorded simultaneously with wrist joint angulation during wrist flexion-extension and radioulnar deviation. Tendon excursions were measured in intact wrists, then in the wrists with complete SLIL sectioning and in those with moderate or severe persistent SL joint widening. The data were converted to moment arms of the tendons. The results showed that moment arms of the ECRL and ECRB tendons after SLIL sectioning were, respectively, 110+/-6% and 105+/-3% of those in the intact wrist. In the wrists with moderate or severe SL joint widening, moment arms of the flexors significantly increased (P < 0.01 and P < 0.001, respectively). During radioulnar deviation, moment arms of the ECRL, ECRB, ECU, and FCU tendons decreased after SLIL sectioning and the SL joint widening. However, moment arms of the FCR tendon significantly increased 122+/-23% after the SLIL section, 133+/-28% after the moderate SL joint widening, and 138+/-24% after the severe SL joint widening compared with those of the intact wrists. This study demonstrated that integrity of the SLIL and appropriate SL joint space are important for mechanics of wrist motor tendons. Loss of integrity of the SLIL and persistent SL joint widening increase mechanical effects of the radial side wrist motor tendons, which may contribute to the pathomechanics of scaphoid malrotation, scapholunate advanced collapse, and early osteoarthritis in the radioscaphoid joint interface seen in SL dissociation. The results also suggest that reduction of the displaced SL joint is imperative to the recovery of wrist kinetics after SL dissociation.     

Radiographic analysis of anatomic risk factors for scapholunate dissociation

The aim of this study was to identify anatomic risk factors for scapholunate dissociation. On a PA view of the wrist, in zero position, the scaphoid and lunate diameter and height, lunate tilting angle, lunate uncovering index, lunate fossa inclination, radial inclination and ulnar variance were measured; on a lateral view the scapholunate angle and palmar tilting angle were measured. In a control group (N = 126) first left to right were compared which showed low correlations for radial inclination (r = 0.26), palmar tilt (r = 0.60) and ulnar variance (r = 0.68). These parameters were then measured on the affected hand in the study group, since they are not influenced by the dissociation, and no arthritic changes were seen. A statistically significant difference was found for a low lunate fossa inclination (p = 0.0001) and a low radial inclination (p = 0.0002). These factors may predispose to scapholunate dissociation.     

The disease factor of scapholunate dissociation]

Scapholunate dissociation is the most common form of instability of the wrist. Its occurrence has been consistently attributed to previous trauma and is supposed to be treated by operation. In the present paper we show that chronic bilateral scapholunate dissociation without any symptoms is not rare. In two years we accidently found four cases with bilateral scapholunate dissociation. In such cases an operation cannot be successful. Therefore, we recommend that a specific trauma should be checked very carefully and roentgenograms of both wrists done.     

A vascularized technique for bone-tissue-bone repair in scapholunate dissociation

Several surgical options have been used for the repair of scapholunate instability over the last 50 years. The many options have included neglect, reduction with percutaneous pinning, primary repair, partial fusions, tendon weaves, and others. Recent advancements in scapholunate repair and anatomy have been aimed at a more physiological repair. Composite replacement of the entire scapholunate interval similar to other tendon repairs seen in orthopedic surgery has become popular. Currently, more common hand-based grafts are bone-retinaculum-bone, third or second metacarpal-carpal bone or hamate-capitate grafts. There still exist some failures in the outcome after any of these procedures. This technique demonstrates the use of a vascularized autograft replacement on a pedicled graft. This procedure is the natural extension of the third or second metacarpal-carpal bone autograft, previously reported in the literature. The use of this proven graft, with a pedicle based on the intermetacarpal artery, may avoid some of the late complications seen with other autografts.     

Bilateral traumatic scapholunate dissociation: Case report

In 1923, Destot described scapholunate dissociation (SLD) which results from disruption of the scapholunate interosseous ligament. Several hypotheses have been proposed to explain SLD, such as traumatic, congenital, ligamentous laxity, and synovial pathology. We are presenting a very rare and challenging case of elderly patient who had traumatic bilateral scapholunate dissociation after a fall, which was managed by ligament reconstruction using bone anchor suture, and kirschner wire fixation. The identification of risk factors for frequent falls among older persons is of paramount importance to prevent further serious injuries.     

Dynamic scapholunate dissociation in a child.

We describe a case of dynamic scapholunate dissociation in a skeletally immature ten-year-old girl. The patient presented for pain in the anatomical snuffbox and swelling over the dorsum of the wrist and hand. Standard static and dynamic radiographs of the wrist did not reveal any pathology. Magnetic resonance imaging was inconclusive. The scapholunate dissociation was diagnosed by wrist arthroscopy, reduced, and stabilised using standard techniques. Full and pain-free motion of the wrist was restored.     

软组织重建舟月骨间韧带治疗慢性舟月分离的影像学改变

目的 观察背侧腕骨间韧带关节囊固定术和3-韧带肌腱固定术治疗慢性舟月分离术后腕关节的影像学改变,明确术后舟月分离复发的比例及时间.方法 自2008年1月至2011年1月,共治疗慢性舟月分离患者23例,19例行背侧腕骨间韧带关节囊固定术,4例行3-韧带肌腱固定术.平均随访10.1个月.分别记录术前、拔针后1个月和末次随访时的影像学和临床结果.在手术前后采用疼痛视觉模拟评分(visual analog scale,VAS)和DASH表格问卷评估主观的疼痛程度、功能改善和患者满意度.结果 影像学结果显示,所有患者腕骨的排列异常在手术中均获得完全纠正.拔针后1个月,舟月间隙平均为4 mm、舟月角平均为75°,舟月间隙和舟月角较术前改善,但61％患者的舟月间隙、52％患者的舟月角恢复至术前水平.末次随访时,舟月间隙平均为4,3 mm、舟月角平均为78°,舟月间隙和舟月角较拔针后1个月时畸形加重,但与术前比较差异无统计学意义.临床结果显示,腕关节屈曲和背伸分别从术前为健侧的66％和69％降至术后的52％和50％.握力从健侧的71％降至66％.结论 背侧腕骨间韧带关节囊固定术和3-韧带肌腱固定术后慢性舟月分离多在短期内复发,拔针后1个月时超过半数病例的舟月分离恢复至术前水平,治疗慢性舟月分离的理想手术方式仍不得而知.