Scapholunate stabilization with dynamic extensor carpi radialis longus tendon transfer

Dynamic extensor carpi radialis longus tendon transfer to the distal pole of the scaphoid acts synchronously and synergistically with wrist motion to restore the slider crank mechanism of the scaphoid after scapholunate interosseous ligament (SLIL) injury. The procedure is designed to simulate a hypothetical dorsal radioscaphoid ligament that more closely approximates the normal viscoelastic forces acting on the scaphoid throughout all phases of wrist motion than does the static checkrein effect and motion limitations of capsulodesis or tenodesis. Extensor carpi radialis longus transfer may be independently sufficient to support normal or near-normal scapholunate and midcarpal kinematics and prevent further injury propagation in patients with partial SLIL tears and dynamic scapholunate instability. Extensor carpi radialis longus transfer alone may improve carpal congruity in patients with static scapholunate instability, but SLIL and dorsal lunate ligament repair or reconstruction is essential for favorable durable outcomes. Extensor carpi radialis longus transfer offers a simple and reasonable alternative to capsulodesis or tenodesis to support these ligament repairs or reconstructions, does not require intercarpal fixation, and allows rehabilitation to proceed expeditiously at approximately 1 month after surgery.     

Soft tissue stabilization in the management of chronic scapholunate instability without osteoarthritis. A 15-year series

Management of chronic scapholunate instability without osteoarthritis remains controversial. Some surgeons favor partial wrist arthrodesis; others, soft tissue stabilization. Many techniques for soft tissue repair have been described but with few or unpredictable results. We reviewed all our cases of scapholunate instability without osteoarthritis treated by soft tissue stabilization. Since 1979, 37 soft tissue stabilization procedures have been performed to correct dynamic (25) or static (12) scapholunate instability without osteoarthritis. The average time from injury to surgical treatment was 7.2 mos. (range 0.25 to 36 mos.). Three cases were treated within the first month of injury. The choice of repair was determined intraoperatively. The scaphoid shift must be easily reducible to make the case eligible for soft tissue repair. The scapholunate ligament was usually disrupted from palmar to dorsal, and the average amount of disruption was 74%. When scapholunate ligament remnants were of sufficient quality, secondary repair was performed; but if not, ligament reconstruction using tendon grafts or capsulodesis was performed. The procedures used were secondary ligamentous repair in 16 (by direct suture, reinsertion using anchor and/or transosseous reattachment), ligament reconstruction using tendon grafts in 6, capsulodesis in 7 and a combination of these procedures in 8. The mean follow-up was 27 mos. (range 2 to 62 mos.). Postoperatively, there was an 83% decrease in pain. The average wrist motion was 60 degrees extension, 47 degrees flexion, 18 degrees radial deviation and 28 degrees ulnar deviation (92%, 84%, 106% and 88% of preoperative values and 88%, 75%, 78% and 76% of the uninvolved wrists, respectively), and the grip strength was 28 kg (117% of preoperative value and 78% of the uninvolved wrists). On roentgenograms, the mean static scapholunate distance was 4.2 mm (a 26% loss of reduction compared to the early postoperative gap), but scapholunate and radiolunate angles were within normal values (58 degrees and 9 degrees, respectively). At follow-up, one patient presenting a small zone of chondromalacia on the scaphoid at the time of secondary ligamentous repair developed severe radioscaphoid arthritis 15 months postoperatively. The results were further assessed according to the form of instability, delay before surgery, severity of disruption and type of repair. Patients with static instability showed worse clinical and radiological findings than those with dynamic instability. Surgical delay did not influence the outcome. The more severe the ligament disruption was, the poorer were the results. All types of repair had a comparable outcome except those treated by ligament reconstruction using tendon grafts. The results in the latter group were unsatisfactory in terms of motion, grip strength and radiological findings. This technique has been abandoned by the group. In conclusion, soft tissue stabilization is part of the armamentarium in the management of reducible chronic scapholunate instability without osteoarthritis. Ligament reconstruction using tendon grafts gave, in our hands, unsatisfactory results. Otherwise, all types of repair achieved a relatively pain-free wrist, with acceptable motion, grip strength, scapholunate and radiolunate angles but with a wider than normal static scapholunate distance. A longer follow-up is needed to assess the effect of this abnormal gap. Factors that favorably affected the outcome were: dynamic type of instability and partial disruption of the ligament.     

Volar intercalated segment instability after scapholunate ligament reconstruction

We describe an 18-year-old man with an acute lunate dislocation treated with open reduction, ligament repair, capsulodesis, and percutaneous pinning. After pin removal and mobilization, the patient was found to have midcarpal collapse; the lateral radiographs showed a volar intercalary segment instability. We now, besides open reduction internal fixation scapholunate repair, recommend routine pinning of the lunotriquetral interval and careful evaluation of the dorsal radiocarpal ligament during repair of lunate and perilunate dislocations.     

Blatt dorsal capsulodesis for scapholunate instability

This retrospective series reviews 17 patients with scapholunate instability treated with the Blatt procedure between 1994 and 1997. Indications were 11 cases of preradiographic instability, three dynamic and three static instabilities. Subjective and objective assessment was carried out. Average pain and level of activity score was 60.8/80 (good). Only three patients failed to continue their jobs. Ten patients were fully satisfied, and seven had minor to major reservations. Flexion loss averaged 11 degrees and extension loss was 11.3 degrees. Grip force improved significantly by 11.2 kg. Associated scapholunate interosseous ligament repair in 6 patients resulted in no further improvement. Major complications were deep infection (one case) and reflex sympathetic dystrophy (two cases). Given the lack of a superior procedure, we considered the Blatt capsulodesis a valuable therapeutic option for cases of preradiographic and dynamic instability, or as an adjunct to scapholunate interosseous ligament repair in more acute lesions.     

Chronic scapholunate dissociation: ligament reconstruction combining a new extensor carpi radialis longus tenodesis and a dorsal intercarpal ligament capsulodesis

Scapholunate dissociation (SLD) is the commonest cause of carpal instability and wrist osteoarthrosis. The value of early diagnosis and treatment of this injury is well established in the literature. When a partial or total rupture of the scapholunate ligament is treated with early anatomic reduction and repair, functional results may be good to excellent. However, if this ligament is not addressed acutely then an overall carpal malalignment may seem progressively as a result of failure of the secondary scaphoid stabilizers. Chronic SLD will lead to scapholunate advanced collapse and progressive painful arthritis of the wrist. Although most surgeons agree that operative intervention is indicated, no clear consensus exists on the best treatment for patients with chronic SLD. Several procedures have been described that include some sort of partial fusion, capsulodesis, tenodesis, or bone-ligament-bone graft. If there is no evidence for arthrosis, soft-tissue procedures using either capsulodesis or tenodesis may be carried out in an attempt to preserve radiocarpal and intercarpal motion whereas avoiding fusion. This article describes a scapholunate ligament reconstruction combining a new dorsal extensor carpi radialis longus tenodesis and a dorsal capsulodesis for the treatment of chronic SLD.     

Scapholunate ligament repair with capsulodesis reinforcement

The typical presentation of an acute scapholunate dislocation is swelling, pain, and deformity following acute trauma to the wrist. Radiographs corroborate a gross disturbance of carpal relationships. In a dorsal perilunate dislocation, the lateral radiograph shows the longitudinal axis of the capitate dorsal to the longitudinal axis of the radius and the proximal pole of the scaphoid rotated dorsally. A scapholunate angle of greater than 70 degrees on the lateral view is 1 accepted radiographic criterion for identifying an acute scapholunate dissociation. In the posterior-anterior (PA) projection, the carpus is foreshortened. A scapholunate interval of >2 mm is seen on the PA x-ray (Terry Thomas sign). The lunate is triangular instead of quadrangular in shape. Although closed reduction is possible, maintaining an anatomical reduction is extremely difficult. Therefore, all of these injuries require open reduction and internal fixation and repair of the scapholunate interosseous ligament. Although originally advocated for the treatment of some forms of chronic scapholunate dislocations (>3 months old), dorsal capsulodesis can be useful to reinforce the scapholunate interosseous ligament repair in the subacute setting (>3 weeks old).     

Scapholunate ligament injuries: a review of current concepts

Injuries to the scapholunate ligament are common, especially among young active individuals. Surgeons are faced with a difficult problem because of imperfect surgical outcomes and the high demands of this patient population. Here, we review the current concepts and newest literature on scapholunate ligament injuries as well as the classification and treatment options for each stage of scapholunate instability. Emphasis is on stages in which reconstructive rather than salvage procedures can be performed. The natural history is poorly understood; it is unknown which and how many scapholunate injuries lead to wrist arthritis (SLAC wrist). Partial injuries are rare and in small studies did well with arthroscopic treatment. Complete injuries are graded based on the acuity of the injury, the presence and reducibility of scapholunate malalignment, and, finally, cartilage status. In acute injuries, anatomic repair usually leads to satisfactory results, and many authors augment the repair with a capsulodesis technique. In chronic injuries, the presence of static malalignment usually leads to inferior outcomes. Various techniques have been devised and improved over the years. These techniques appear to provide a more anatomic reconstruction, with less loss of motion; motion is 60–80 % of the contralateral side and grip strength averages 65–90 %. Once there is cartilage loss, the surgeon only has salvage procedures to choose from, tailored to the degree of arthritis.     

Capsulodesis of the wrist for scapholunate dissociation

We have had favorable results with our early experience using the Mayo modification of the dorsal intercarpal ligament capsulodesis. Our early experience with this technique has shown improvement in carpal alignment and pain relief with the tradeoff of a mild loss of wrist flexion. These results compare with reported results of the various capsulodesis techniques in evolution. Attention must also be paid as to the stage of dissociation at time of surgery. Dynamic dissociation has been treated with capsulodesis alone, whereas a combination of ligament repair in conjunction with dorsal intercarpal ligament capsulodesis is used to treat both dynamic and static variants. Many other investigators report improvements in scapholunate alignment and improvement in pain relief and function with a loss of wrist flexion as a tradeoff. However, despite technical advances in surgical technique and intraoperative improvement of alignment and gapping, these results may diminish by the 2- to 3-year postoperative period. Scapholunate interosseous injuries remain a challenging problem to even experienced hand and upper extremity surgeons. The Mayo modification of the modified dorsal intercarpal ligament capsulodesis is a technique that may be added to the armamentarium of treatment of this pathologic entity.     

Désaxation scapholunaire : physiopathologie et orientations thérapeutiques

The interosseous scapholunate ligament (IOSLL) is the main stabilizer of the scapholunate (SL) couple but a static instability can appear only in the event of an associated injury of the extrinsic ligaments. Thus, SL dissociation covers a broad spectrum in which only static instability leads with certainty to osteoarthritis. Classically described as a rotatory subluxation of the scaphoid with DISI collapse, static SL instability manifests itself as a complex deformity with dorsolateral subluxation of the unit formed by the scaphoid and the distal carpal row. This deformity explains the dorsolateral radioscaphoid conflict and capitolunar decentering that is the origin of the radioscaphoid and midcarpal osteoarthritis that later appears. It is only within the first 4 to 6 weeks that a repair of the IOSLL, possibly associated with a capsulodesis, makes it possible to expect a good result and can prevent osteoarthritis. Beyond that time, no soft tissue procedure will modify the natural history of the condition. For us, surgery is indicated only for acute injuries and for symptomatic chronic instabilities. Before the occurrence of osteoarthritis, with newfound knowledge of the medium-term results of capsulodesis, it seems reasonable to favour a limited fusion. But in the event of failure, the patient is likely to remain in pain even after a total fusion. It is thus not aberrant to perform a capsulodesis in a sedentary person but it is necessary to inform the patient that osteoarthritis will occur. After occurrence of osteoarthritis, if it is symptomatic, proximal row carpectomy, SLAC procedure, total wrist fusion and denervation, can be considered, depending on the stage, the mobility of the wrist and the wishes of the patient. Denervation of the wrist can give good results with few risks, and does not jeopardize the results of a subsequent procedure.     

Scaphotriquetral capsulodesis for scapholunate instability

Objectives

Scapholunate ligament injuries may lead to scapholunate instability and wrist osteoarthritis. Many surgical techniques have been described to repair these injuries. The goal of our study is to assess the clinical results after capsulodesis with the scaphotriquetral ligament for scapholunate instabilities.

Methods

Twenty-eight patients, 22 men and six women, were operated for scapholunate instability between January 2006 and December 2008. The average age was 37, 8 years, and the average time between trauma and surgery was 9,9 months. The scaphoid shift test was present in 26 patients. All patients underwent static and dynamic X-rays of the wrist and scan. A capsulodesis with scaphotriquetral ligament was performed in all patients.

Results

At 24 months follow-up, a 13° significant decreased of wrist range-of-motion was noted. The strength was significantly improved after surgery. The wrist stability was improved in 26 patients. Concerning pain, a significant reduction was noted with Analogical Visual Scale after surgery (p < 0.005). Twenty-one patients returned to their previous work. Complications were reflex dystrophy in one patient and wrist infection in one patient.

Conclusion

Many techniques were described for treatment of scapholunate injuries, from the simple scapholunate ligament suture to partial wrist arthrodesis. Capsulodesis with scaphotriquetral ligament improves grip strength, decreases wrist instability and pain with a slight lost of range-of-motion.     

Dorsal intercarpal ligament capsulodesis for chronic,static scapholunate dissociation: clinical results

The purpose of this study was to review and report the results of using a new procedure, the dorsal intercarpal ligament capsulodesis (DILC), to treat a group of patients with chronic flexible scapholunate dissociation. This was a prospective study of 21 patients (22 wrists), ranging in age from 16 to 62 years followed up for 1 to 4 years. For this study all patients returned to complete a questionnaire and have a physical examination performed by physicians and therapists independent of the treating surgeons and to obtain standardized radiographs of the wrists. Patient demographics, mechanism of injury, range of motion, and grip strength were recorded. Patients completed the Mayo wrist, Short-Form (SF)-12, and Disabilities of Arm, Shoulder and Hand (DASH) questionnaires. Results showed there were significant improvements in scapholunate angle and scapholunate gap at final follow-up examination, with minor loss of range of motion and grip strength. Patients were satisfied with the outcomes, showing an average score of 17 on the DASH and 83 on the SF-12. The DILC procedure is a reasonable option for treating chronic scapholunate dissociation. The procedure has conceptual advantages to recommend it: it avoids a tether between radius and scaphoid and keeps the proximal carpal row linked as a functional unit. It reduces the scapholunate angle and gap. Overall the results to date are quite encouraging.     

Outcomes of dorsal capsulodesis and tenodesis for treatment of scapholunate instability

PURPOSE: The ideal treatment for scapholunate (SL) instability has not yet been established. This study examined the results of 2 procedures for the primary treatment for chronic SL dissociation of dorsal capsulodesis and flexor carpi radialis tenodesis. METHODS: A retrospective analysis was conducted that examined dorsal capsulodesis and tenodesis procedures performed for chronic SL instability between January 1995 and February of 2003. Twenty-nine patients were identified with isolated chronic SL instability. Of the 29 patients, 14 had a dorsal capsulodesis procedure and 15 had a tenodesis procedure. The follow-up period averaged 38 months in the capsulodesis group and 36 months in the tenodesis group. Results were reviewed clinically and radiographically. Groups were compared with a Student t test. RESULTS: Postoperative wrist motion decreased in both groups after surgery. Final wrist range of motion was 64% of the unaffected side in the capsulodesis group and 63% of the unaffected side in the tenodesis group. Postoperative grip strength remained unchanged in both groups; grip strength measured 91% of the unaffected side in the capsulodesis group and 87% of the unaffected side in the tenodesis group. The average Mayo wrist scores were 77 in the capsulodesis group and 74 in the tenodesis group. One frank failure occurred in the tenodesis group resulting in a wrist fusion. There was no statistical difference in the overall wrist motion, grip strength, or wrist scores between the capsulodesis and tenodesis groups. CONCLUSIONS: Dorsal capsulodesis and tenodesis provided improvement in symptoms for patients with chronic SL instability. Both procedures appear to provide similar results in the treatment of this difficult problem.     

Extensor carpi radialis brevis ligamentoplasty and dorsal capsulodesis for the treatment of chronic post-traumatic scapholunate instability

ObjectivesTo present a novel surgical technique that includes both extensor carpi radialis brevis (ECRB) ligamentoplasty and dorsal capsulodesis for the treatment of chronic post-traumatic scapholunate instability.MethodsWe performed a retrospective review of 32 patients with chronic post-traumatic scapholunate instability (stage 4 or 5 according the Garcia-Elias’ classification) who were treated with this technique. Pre- or intraoperative arthroscopic evaluation was carried out in all cases.ResultsThe postoperative wrist range of motion was generally improved except for wrist flexion. In 20 patients out of 29, the DISI deformity was corrected. Grip strength and pain was also improved postoperatively. Based on the Mayo wrist scoring, 16 patients had excellent results, eight patients had good results, three patients had fair results, and five patients had poor results.ConclusionOur technique which combines ECRB ligamentoplasty with dorsal capsulodesis is a reliable option for the surgical treatment of chronic postchronic post-traumatic scapholunate instability.     

Current innovations in wrist arthroscopy

It has become clear that the stability of the scapholunate joint does not depend wholly on the scapholunate interosseous ligament, but rather on both primary and secondary stabilizers, which form a scapholunate ligament complex. Each case of scapholunate instability is unique and should be treated with tissue-specific repairs, which may partly explain why one procedure cannot successfully restore joint stability in every case. Wrist arthroscopy has a pivotal role in both the assessment and treatment of the scapholunate ligament complex derangements. Tears of the foveal attachment of the triangular fibrocartilaginous complex can be an underdiagnosed cause of distal radioulnar joint instability, because the foveal fibers cannot be visualized using the standard radiocarpal arthroscopy portals. Distal radioulnar joint arthroscopy allows for direct visualization and assessment of these fibers, which in turn has spawned a number of open and arthroscopic repair methods. Wrist arthroscopy has gained wider acceptance as a method to fine-tune articular reduction during open and percutaneous fixation of distal radius fractures, and simplifies intra-articular osteotomies for malunion. It can facilitate percutaneous bone grafting of scaphoid nonunions and has a role in the diagnosis and treatment of associated soft tissue lesions. These and other recent developments will be discussed in the following article.     

Current status of scapholunate interosseous ligament injuries.

Injuries to the scapholunate complex present the surgeon with both diagnostic and treatment dilemmas. The anatomic features, biomechanical properties, radiographic appearance, and surgical treatment algorithms of this small but structurally and kinematically important joint continue to be refined. A thorough history and physical examination, combined with a radiographic evaluation that can include plain radiographs, tomography, motion studies, arthrography, or MRI, usually will define the nature of the ligament injury. Arthroscopy is considered the gold standard for complete evaluation of scapholunate interosseous ligament injury and often is performed as a first step before repair or reconstruction. Procedures such as carpal fusions or capsulodesis can limit excessive scaphoid motion, promote wrist stability, and potentially prevent arthritis, but advances continue to be made in direct scapholunate interosseous ligament reconstruction. Challenges for the future involve improving noninvasive evaluation, defining the degree of extrinsic ligament injury, and improving direct repair and reconstruction.     

Blatt's capsulodesis for chronic scapholunate instability

Nineteen patients underwent a scapholunate interosseous ligament repair combined with a Blatt's capsulodesis for scapholunate instability between 1994 and 1999. The diagnosis was based on clinical, radiographic and arthroscopic assessments. Mean follow-up was 22 months (range: 8 months to 5 years). Fifteen patients were available for follow-up. Most (13 of 15) of the patients presented with predynamic or dynamic instability. Results were analysed clinically and radiologically. Thirteen patients showed good or excellent clinical result. There was statistically significant improvement in pain relief (VAS scores) and grip strength (58% of the opposite side). Mean extension and ulnar deviation were significantly improved (62% and 53% of the opposite side respectively) and there was significant reduction in wrist flexion (49% of the opposite side). Thirteen patients returned to their original level of activity. There was no significant change in the mean scapholunate gap and angle after surgery. Thirteen patients would recommend this operation. We believe that this procedure can produce encouraging results in cases of predynamic and dynamic instability in a patient population with low-demand wrists. Larger caseloads and more complete follow-ups would be desirable to derive strong evidence-based conclusions.     

Occult scapholunate ganglion: a cause of dorsal radial wrist pain

There are multiple causes for chronic dorsal wrist pain over the scapholunate ligament, including occult dorsal carpal ganglion cyst, scaphoid impaction syndrome, dorsal carpal capsulitis, distal posterior interosseous nerve syndrome, and dynamic scapholunate ligament instability. Patients with such pain often have normal x-rays. A retrospective study of 21 patients undergoing surgical exploration for chronic dorsal radial wrist pain who had no palpable cyst and normal x-rays revealed that 18 of the patients had occult scapholunate ganglion cysts or myxomatous degeneration within the scapholunate ligament. All had failed long-term conservative management. Surgery involved an approach through Langer's lines, resection of a large triangular portion of the capsule between the dorsal intercarpal and radiotriquetral ligaments, and tangential debridement of the area of myxoid degeneration proximal to the distal 2 to 3 mm of dorsal scapholunate interosseous ligament. None of the patients had scapholunate instability or scaphoid impacting syndrome. Of the 18 patients with histologically confirmed myxomatous changes in the scapholunate ligament, 16 had an excellent outcome as defined by rigorous criteria; 1 had a good outcome. There was 1 patient with a poor result. A compelling argument is made for surgical exploration of the scapholunate joint in patients with persistent dorsal radial wrist pain and scapholunate point tenderness.     

Bandnaht und/oder Kapsulodese bei skapholunärer Instabilität

We have reviewed 37 patients with scapholunate instability, operated in Paris between 1979 and 1995 7 months after the injury. There were 12 partial and 18 complete ligament ruptures, but also 4 distensions. The repair was a secondary suture in 16 cases (7 direct, 1 transosseous, 1 combined, 5 anchor, 2 transosseous with anchor). A capsulodesis was performed 7 times as an isolated and 8 times as a combined procedure. 6 previous cases have been treated by ligamentoplasty. We present the results after a mean postoperative follow-up of 27 months, with good results on pain and grip, maintaining a satisfactory range of motion.     

Surgical technique for the treatment of radial wrist pain.

Chronic radial wrist pain with no radiographic evidence of scapholunate instability or other wrist disease can be difficult to diagnose and treat. Our purpose was to evaluate the results of an operation to treat chronic radial or periscaphoid wrist pain that has failed to respond to conservative treatment. We examined the scapholunate ligament and performed a dorsal capsulodesis. One hundred-and-two patients were reviewed retrospectively. Casenotes were available for 88 patients. Function, pain, range of movement (ROM), and grip and pinch strengths were evaluated. Twenty (23%) of the patients were found to have a scapholunate ligament tear of 0-30%, 55 (61%) had a tear of 30%-60%, and 14 (16%) had a tear of 60%-100%. Mean postoperative grip strength was 29.5 kg (80% of the normal side). Postoperative range of movement was significantly limited in flexion compared with the normal side. All patients returned to their previous employment. Seventy (80%) of the patients described improvement in pain and function. Twenty-two (25%) required further operation on the same wrist. This procedure may be indicated in patients with chronic radial wrist pain and no overt instability that is resistant to conservative treatment. It has minimal morbidity and gives good results.     

创伤性腕关节不稳定手术治疗

目的 报道创伤性腕不稳定的手术方法。方法 16例腕不稳定中,表现为舟月骨分离6例,以腕背侧镶嵌不稳定(DISI)为主10例。对于舟月骨分离及DISI采用舟月骨间韧带重建手术6例,舟月头骨固定手术3例;对于DISI采用背侧关节囊固定术3例,桡骨远端截骨矫正术4例。结果 术后观察1至2年患者疼痛明显缓解,手握力提高,日常生活满意度改善,功能较术前恢复。结论积极采取手术治疗腕不稳定,重建损伤韧带或纠正畸形,是治疗腕关节不稳定有效的方法。