Interosseous Ligament Research Articles

Chronic Syndesmotic Injuries and Reconstruction

Chronic instability of the distal tibiofibular syndesmosis is associated with poor functional outcomes and the development of arthritis. Stabilization of the distal tibiofibular joint after a neglected or recurrent diastasis can be accomplished using a variety of surgical procedures; however, no 1 technique has shown clear superiority. Arthrodesis is considered the most reproducible means of restoring stability at the distal tibiofibular joint; however, the limitation of motion can be associated with ankle pain and may exacerbate symptoms from early ankle degenerative disease. This article presents an algorithmic approach using a double limb allograft reconstruction for symptomatic patients with persistent radiographic widening and either subtle syndesmotic instability or significant disruption and lateral talar shift due to attenuated or disrupted syndesmotic ligaments. The technique primarily reconstructs the interosseous ligament and does not attempt to individually recreate each ligament of the syndesmosis to preserve physiological fibula rotation and translation. Early outcomes have been excellent. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Screw in Lisfranc Ligament

Category: Trauma Introduction/Purpose: The Lisfranc ligament is an interosseous ligament connecting the medial cuneiform with the second metatarsal. Current treatment of displaced Lisfranc injury is rigid fixation using a transarticular screw. The purpose of this study was to observe the amount of ligamentous disruption with the placement of a transarticular screw from the second metatarsal to the medial cuneiform. Methods: This cadaveric study included a total of 15 preserved cadavers and 23 feet. Blunt dissection down to bone, with removal of soft tissue, was performed on each foot for visualization of the Lisfranc joint. A guide-wire was inserted in a dorsolateral to plantar medial direction from the base of the second metatarsal into the medial cuneiform. Then over the guide- wire a 40 mm, 4.0 partially threaded, cannulated screw was inserted. The Lisfranc ligament was then carefully identified with more dissection. The screw was then removed. Separation of the second metatarsal from medial cuneiform was performed by transecting the dorsal, Lisfranc (interosseous), and plantar ligaments. Digital photographs of the Lisfranc ligament, medial cuneiform and second metatarsal articular surfaces were recorded and measurements were taken. Results: Of the 23 feet, the screw came in contact with the Lifranc ligament in 20 feet. The screw fully penetrated the ligament in 7 feet, partially disrupted it in 4 feet, and had <1 mm of contact in 9 feet. In 3 feet, there was no contact with the ligament with an average distance of 1.5 mm. Conclusion: Our results reveal the amount of disruption a transarticular screw, placed in a dorsolateral to plantar medial direction, will have on the Lisfranc ligament. Although the screw came into contact with the ligament in 20 out of 23 feet, only 13 feet had partial disruption or minimal contact and 3 feet had no contact at all. This is clinically relevant because ligamentous damage due to insertion and/or presence of screw in anatomic location of the ligament may interfere with its healing.

Association of lunate morphology, sex, and lunotriquetral interosseous ligament injury with radiologic measurement of the capitate-triquetrum joint.

Radiologic presentation of carpal instability at the radial side of the carpus, e.g. scapholunate diastasis following scapholunate interosseous ligament injury, has been studied extensively. By comparison, presentation at the ulnar-sided carpus has not. The purpose of this study was to assess the effects of lunate morphology, sex, and lunotriquetral interosseous ligament (LTIL) status on the radiologic measurement of the capitate-triquetrum joint (C-T distance). Further, we sought to evaluate the diagnostic accuracy of C-T distance for assessing LTIL injuries. We retrospectively identified 223 wrists with wrist radiographs and MR arthrograms with contrast injection. Data collected included sex, lunate morphology and LTIL status from MR arthrography, and C-T distance from radiography. The effects of lunate morphology, sex, and LTIL injury status on C-T distance were evaluated using generalized linear models. Diagnostic performance of C-T distance was assessed by the area under receiver-operator characteristic curve (AUROC). Lunate morphology, sex, and LTIL injury status all had significant effects on C-T distance; wrists with type II lunates, men, and wrists with LTIL injuries had greater C-T distances than wrists with type I lunates, women, and wrists without LTIL injuries, respectively (p<0.01). The diagnostic value of the C-T distance for identifying patients with full-thickness LTIL tears was sufficient for women with type I (AUROC=0.67) and type II lunates (0.60) and good for men with type I (0.72) and type II lunates (0.77). The demonstrated influence of LTIL status on C-T distance supports the use of C-T distance as a tool in assessing for full-thickness LTIL tears.

Surgical Treatment of Chronic Lateral Ankle Instability Using an Inferior Extensor Retinaculum Flap: A Retrospective Study

Chronic lateral ankle instability causes significant problems with physical activity. The purpose of the present study was to evaluate the results of ligamentous retensioning combined with reinforcement using an extensor retinaculum flap. A consecutive series of 38 patients were included with a minimum follow-up duration of 2 years. The functional results were assessed using the Karlsson and American Orthopaedic Foot and Ankle Society scale scores. The pre- and postoperative radiologic assessment was performed using stress radiographs to measure varus tilt and anterior drawer tests. All 38 patients were followed up for 2.5 to 7.2 years, and 35 patients were satisfied. The American Orthopaedic Foot and Ankle Society scale score had improved significantly from 57 (range 20 to 70) points preoperatively to 95 (range 80 to 100) points postoperatively (p < .0001), and 35 patients believed their ankle was more stable after surgery. The patients had returned to their previous sports activities an average of 4.7 (range 2 to 12) months after surgery. On the stress radiographs, the mean talar tilt angle had improved significantly from 15.2° (range 6° to 26°) preoperatively to 3.8° (range 1° to 8°) at the final follow-up visit (p < .001), and the mean anterior talar had improved significantly from 13.2 (range 8 to 18) mm preoperatively to 4 (range 4 to 7) mm at the final follow-up visit (p < .002). Regarding the prognostic factors, a link was found between the functional result and residual radiologic laxity measured on the stress radiographs. Reconstruction of the lateral ligaments for chronic ankle instability combining capsuloligamentous retensioning and reinforcement with an extensor retinaculum flap resulted in successful outcomes, excellent ankle stability, and preservation of ankle joint mobility. This technique addressed both lateral ankle and subtalar instability by developing an extraarticular interosseous ligament.

High-resolution MRI (3T-MRI) in diagnosis of wrist pain: is diagnostic arthroscopy still necessary?

3T MRI has become increasingly available for better imaging of interosseous ligaments, TFCC, and avascular necrosis compared with 1.5T MRI. This study assesses the sensitivity and specificity of 3T MRI compared with arthroscopy as the gold standard. Eighteen patients were examined with 3T MRI using coronal T1-TSE; PD-FS; and coronal, sagittal, and axial contrast-enhanced T1-FFE-FS sequences. Two musculoskeletal radiologists evaluated the images independently. Patients underwent diagnostic arthroscopy. The classifications of the cartilage lesions showed good correlations with the arthroscopy findings (κ=0.8-0.9). In contrast to the arthroscopy, cartilage of the distal carpal row was very good and could be evaluated in all patients on MRI. The sensitivity for the TFCC lesion was 83%, and the specificity was 42% (radiologist 1) and 63% (radiologist 2). For the ligament lesions, the sensitivity and specificity were 75 and 100%, respectively, with a high interobserver agreement (κ=0.8-0.9). 3T MRI proved to be of good value in diagnosing cartilage lesions, especially in the distal carpal row, whereas wrist arthroscopy provided therapeutic options. When evaluating the surgical therapeutical options, 3T MRI is a good diagnostic tool for pre-operatively evaluating the cartilage of the distal carpal row.

Analysis of tenodesis techniques for treatment of scapholunate instability using the finite element method

Chronic scapholunate ligament (SL) injury is a common disorder affecting the wrist. Despite advances in surgical techniques used to treat this injury, SL gap re-emergence may occur postoperatively. This paper presents an investigation into the performance of the Corella, schapolunate axis (SLAM), and modified Brunelli tenodesis (MBT) surgical reconstruction techniques used to treat scapholunate instability. Finite element (FE) models were used to undertake virtual surgery, and the resulting scapholunate (SL) gap and angle obtained using the 3 techniques were compared. The Corella technique was found to achieve the SL gap and angle closest to the intact (ligament) wrist, restoring SL gap and angle to within 5.6% and 0.6%, respectively. The MBT method resulted in an SL gap least close to the intact. The results of our study indicate that the contribution of volar scapholunate interosseous ligament to scapholunate stability could be important.

Dorsal Scaphoid Subluxation on Sagittal Magnetic Resonance Imaging as a Marker for Scapholunate Ligament Tear

To evaluate the diagnostic utility of scaphoid dorsal subluxation on magnetic resonance imaging (MRI) as a predictor of scapholunate interosseous ligament (SLIL) tears and compare this with radiographic findings. Thirty-six MRIs were retrospectively reviewed: 18 with known operative findings of complete Geissler IV SLIL tears that were surgically repaired, and 18 MRIs performed for ulnar-sided wrist pain but no SLIL tear. Dorsal subluxation of the scaphoid was measured on the sagittal MRI cut, which demonstrated the maximum subluxation. Independent samples ttests were used to compare radiographic measurements of scapholunate (SL) gap, SL angle, and capitolunate/third metacarpal-lunate angles between the SLIL tear and the control groups and to compare radiographic measurements between wrists that had dorsal subluxation of the scaphoid and wrists that did not have dorsal subluxation. Interrater reliability of subluxation measurements on lateral radiographs and on MRI were calculated using kappa coefficients. Thirteen of 18 wrists with complete SLIL tears had greater than 10% dorsal subluxation of the scaphoid relative to the scaphoid facet. Average subluxation in this group was 34%. Four of 18 wrists with known SLIL tears had no subluxation. No wrists without SLIL tears (control group) had dorsal subluxation. The SL angle, capitolunate/third metacarpal-lunate angle and SL gap were greater in wrists that had dorsal subluxation of the scaphoid on MRI. Interrater reliability of measurements of dorsal subluxation of the scaphoid was superior on MRI than on lateral x-ray. An MRI demonstration of dorsal subluxation of the scaphoid, of as little as 10%, as a predictor of SLIL tear had a sensitivity of 72% and a specificity of 100%. The high positive predictive value indicates that the presence of dorsal subluxation accurately predicts SLIL tear. Diagnostic II.

Wrist Arthroscopy in Children and Adolescent With Chronic Wrist Pain: Arthroscopic Findings Compared With MRI.

Wrist arthroscopy is a dynamic diagnostic procedure and its indications are growing as a treatment modality in the adult population. The aim of the study was to retrospectively report our series of pediatric and adolescence with chronic wrist pain, with or without wrist instability who underwent wrist arthroscopy after failing at least 4 months of conservative management. Our secondary aim was to report the sensitivity and specificity of clinical examination and magnetic resonance imaging evaluation for various injury subgroups against the gold standard of the arthroscopic findings. Technical challenges, complications, and outcomes are also discussed. A retrospective review of the medical records of 32 pediatric and adolescent patients who underwent wrist arthroscopy was conducted. Preoperative clinical diagnosis, radiographic, and intraoperative findings including classifications of triangular fibrocartilage complex (TFCC) and interosseous ligaments were obtained. Patients were followed up to 1 year postoperatively and were discharged if symptom free. Thirty-three wrist arthroscopies in 32 patients were performed from 1996 to 2004. There were 2 male and 30 female patients. At arthroscopy 16 wrists were found to have TFCC injuries, 11 wrists had scapholunate injuries, and 8 had lunotriquetral (LT) injuries. Clinical examination for diagnosis of TFCC injury was too sensitive and nonspecific; however, clinical diagnosis of scapholunate injury was sensitive and specific. LT injury was under diagnosed clinically. Magnetic resonance imaging was found to have a low sensitivity for diagnosis of LT injury but diagnosis of TFCC was sensitive and specific. The sex ratio of 2 males:30 females was startling. Nevertheless, this therapeutic level 3 study supports a thorough search for pathology in any patient with persistent wrist symptoms because pathology was identified in 32 of the 33 wrists at arthroscopy. Level III-Therapeutic.

The Sacral X Axes: Location, Structure, Movement, Parallel Kinetic Ligamentous Loading, Function, Biotensegrity Technology and Pathology. The Essential Pieces of the Low Back Pain Puzzle.

In the last century much research was accomplished on the pelvis yet the pelvis remains an enigma. Movement was located and measured, but not specified, comprehended or described. An oblique axis was suspected but not identified. Some function of the pelvis is suspected, but it has not been described or understood. Many practitioners suspect the pelvis to be the source of common low back pain, but just as many practitioners believe this not to be true. Ten years ago two separate points were located that looked like they could function as bony transverse sacral X axes providing the pelvis was symmetrical, however, if and when the pelvis is asymmetrical each point could also function with a related pelvic point and act as an oblique axis. The resting pelvis is unmoving and almost immobile, however, the erect and loaded pelvis is dynamic and filled with kinetic energy. Primary sacral loading is on the posterior interosseous ligaments and serve to suspend the sacrum. The primary loading initiates a secondary loading on the sacrotuberous ligaments that balances the primary loading. These two sets of balanced ligaments create two sets of interactive force couples and a trigger for biotensegrity. During normal gait an initial unilateral posterior innominate rotation on the side of the first step causes the ilial tuberosity to push caudad directly on the lateral sacrum causing a lateral sacral flexion with rotation. The trunk is caused to counter rotate thus decreasing loading forces to the femoral head. When loading is shifted to the contra lateral side on the second step the weight shift takes place with biotensegrity mechanics. Movement is through balanced, interchangeable, parallel, kinetically loaded ligaments that create interactive force couples. None of this was possible to determine without the sacral x axes. This is all way beyond conventional biomechanics. Acute and chronic back pain is essentially all caused from an anterior innominate rotation (lifting, bending lowering, shoveling, sweeping, pregnancy or a postural forward head) that causes the innominates to rotate cephalad and laterally at the PIIS. This is a measurable movement that puts a vertical shear on the lateral axis points and separates the sacral origins of both the gluteus maximus and the piriformis from their ilial origins resulting pain in the buttocks, piriformis syndrome and sciatica. Dysfunction is all initiated at the sacral x axes. This is corrected effectively simply with a manual bilateral posterior innominate rotation that reverses all symptoms leaving the patient free of pain.

Anatomical Study of the Cervical and Interosseous Talocalcaneal Ligaments of the Foot with Surgical Relevance.

There is conflicting evidence regarding the morphology and orientation of the cervical ligament (CL) and interosseous talocalcaneal ligament (ITCL). The morphology of the CL and its relationship to the ITCL were studied to obtain an understanding of these structures. Twenty-six feet (13 left, 13 right) were obtained from formalin-fixed cadavers (14 females, four males) with the mean standard deviation (SD) age at death 80.9 (12.9) years. All measurements were made with a digital caliper. The length and width of the foot, the width and height of the talus, were measured. The talus was cut coronally to expose the ITCL and qualitative observations were noted. The mean (SD) heights and widths of the CL at the anterior, posterior, superior, and inferior points were 8.27 (2.52), 13.95 (5.96), 9.15 (2.45), and 11.90 (4.30) mm, respectively. The mean (SD) thicknesses of the CL at the superoanterior, superoposterior, inferoanterior, inferoposterior, and central points were 0.62 (0.24), 1.05 (0.30), 0.70 (0.26), 1.20 (0.34), and 0.97 (0.31) mm, respectively. The fibers of the CL are oriented at a slight superoanterior to inferoposterior angle, whereas the fibers of the ITCL are oriented in a slight superomedial to inferolateral angle. The fibers of the CL and ITCL overlap inside the tarsal sinus with the CL positioned anteriorly, which helps to distinguish the two ligaments. In this study, we identified the morphometrics of the CL and described the CL and ITCL qualitatively. These results are relevant to introducing innovative techniques for reconstructive surgery of the subtalar ligaments in order to repair, for example, subtalar instability.

Arthroscopic Correlates of Subtle Syndesmotic Injury.

Arthroscopic criteria for identifying syndesmotic disruption have been variable and subjective. We aimed to quantify syndesmotic disruption arthroscopically using a standardized measurement device. Ten cadaveric lower extremity specimens were tested in intact state and after serial sectioning of the syndesmotic structures (anterior inferior tibiofibular ligament [AiTFL], interosseous ligament [IOL], posterior inferior tibiofibular ligament [PiTFL], deltoid). Diagnostic ankle arthroscopy was performed after each sectioning. Manual external rotational stress was applied across the tibiofibular joint. Custom-manufactured spherical balls of increasing diameter mounted on the end of an arthroscopic probe were inserted into the tibiofibular space to determine the degree of diastasis of the tibiofibular joint under each condition. A ball 3 mm in diameter reliably indicated a high likelihood of combined disruption of the AiTFL and IOL. Disruption of the AiTFL alone could not be reliably distinguished from the intact state. Use of a spherical probe placed into the tibiofibular space during manual external rotation of the ankle provided an objective measure of syndesmotic instability. Passage of a 2.5-mm probe indicated some disruption of the syndesmosis, but the test had poor negative predictive value. Passage of a 3.0-mm spherical probe indicated very high likelihood of disruption of both the AiTFL and the IOL. The findings challenge the previously used but unsupported standard of a 2-mm diastasis of the tibiofibular articulation for diagnosis of subtle syndesmotic instability.

Ulnar Head Reconstruction with Microvascular Second Metatarsal.

Background:The distal radioulnar joint along with the interosseous ligament of the forearm and the proximal radioulnar joint, form a functionally integrated system responsible for the pronation–supination of the hand. The distal ulna, the so-called ulnar head, is an integral part of this system. Apart from its well-known role in forearm rotation, the ulnar head is essential in transverse load transmission through the distal radioulnar joint upon resisted elbow flexion. Autologous reconstruction of ulnar head would theoretically be beneficial with respect to prostheses.Methods:Three cases of ulnar head reconstruction with microvascular second metatarsal are reported herein including trauma, oncological, and congenital ethiologies.Results:The clinical result was good without complaints of instability.Conclusions:The cases included in this series, although heterogeneous, indicate that this treatment may be feasible also in postoncological resections and in congenital cases.

Novel anatomical reconstruction of distal tibiofibular ligaments restores syndesmotic biomechanics.

To date, there is a paucity of literature on syndesmotic reconstruction techniques that restore both anatomic stability and physiologic syndesmotic biomechanics. In this cadaveric study, (1) a novel syndesmotic reconstruction surgical technique using autogenous peroneus brevis tendon was described and (2) the biomechanical properties of the reconstruction was investigated. Ten fresh-frozen lower extremities were used in this study. Reconstruction of the anterior and posterior, as well as the interosseous tibiofibular ligaments was performed with a halved peroneus brevis tendon. Biomechanics were assessed using foot external rotation torque and ankle dorsiflexion axial loading tests, which were performed in (a) intact, (b) cut, (c) anatomically reconstructed syndesmotic ligaments, and (d) 3.5mm tricortical syndesmotic screw fixation. Medial-lateral and anterior-posterior displacements of the distal fibula were recorded during foot external rotation and fibular axial displacement was recorded during ankle axial loading. The fibula was displaced posteriorly and proximally with respect to the tibia in all specimens during external rotation and axial loading tests, respectively. Significant differences (p < 0.05) were found in distal fibular displacements between anatomically reconstructed ligaments and screw fixation. Tricortical syndesmotic screw fixation resulted in 59% of posterior fibular displacement when compared to intact ligaments. No significant differences (n.s.) in distal fibular displacement were demonstrated between intact ligaments and anatomically reconstructed ligaments. Anatomical reconstruction of the distal tibiofibular ligaments with the peroneus brevis tendon provides stability and recreates the biomechanical properties of an intact syndesmosis. This new surgical technique may be a viable alternative for the treatment of syndesmotic injuries. V.

A different reason for subtalar joint pain

Purpose:Interosseous cysts located in calcaneal sulcus are radiologically diagnosed as ganglion cysts. However there is not enough evidence in the literature about their treatment and how they occur. We think that these cysts may cause hind foot pain by causing peripheral bone edema of the calcaneus or mucoid fluid production which further increases subtalar intra articular pressure.Methods:We performed surgical treatment for calcaneal sulcus cyst to 6 patients in 2015. All patients were evaluated with AP and lateral ankle X-ray and MRI preoperatively.Results:We found that all cysts were arisen from insertion of the interosseous talocalcaneal ligament in calcaneal sulcus by MRI (figure 1). There were accompanying bone edema in 3 patients whose cysts were larger. We performed subtalar arthroscopy with drilling to 2 of the patients whose cysts were small. 3 patients were operated with curettage and grafting (autograft) by lateral approach. Last patient were treated with drilling by lateral approach. We detected the mucoid fluid stretching joint capsule when we reach subtalar joint during open surgery (figure 2). Interosseous talocalcaneal ligament were intact in all patients treated even treated with open surgery or arthroscopy. Therefore cystic changes were not seen. In order to avoid ligament damage, cysts were curated and grafted with spongious bone through a small bone window. In a short follow-up period, complete pain relief without recurrence was observed.Figure 1Figür 2Conclusions:During subtalar arthroscopy we saw that anterior of the posterior talar facet was impinged to talocalcaneal ligament insertion on the calcaneal sulcus. We suggest that cysts might occur as a result of recurrent oscillating trauma as Van der Vis et al. were postulated.

Distal radioulnar joint: functional anatomy, including pathomechanics.

The distal radioulnar joint allows the human to rotate the forearm to place the hand in a desired position to perform different tasks, without interfering with the grasping function of the hand. The ulna is the stable part of the forearm around which the radius rotates; the stability of the distal radioulnar joint is provided by the interaction between ligaments, muscles and bones. The stabilizing structures are the triangular fibrocartilage complex, the ulnocarpal ligament complex, the extensor carpi ulnaris tendon and tendon sheath, the pronator quadratus, the interosseous membrane and ligament, the bone itself and the joint capsule. The purpose of this review article is to present and illustrate the current understanding of the functional anatomy and pathomechanics of this joint.

Analisis Perbandingan Nilai Signal to Noise Ratio (SNR) pada Pemeriksaan MRI Ankle Joint dengan Menggunakan Quad Knee Coil dan Flex/Multipurpose Coil

Background : Research on the difference comparison the value of Signal To Noise Ratio (SNR) at MRI Ankle Joint examination using Quad Knee Coil and Flex/Multipurpose Coil at the hospital's radiology installation Telogorejo Semarang. Quad knee coil is a volume coil, is a coil that can act as a transmitter and receiver at the same RF signal (transreceiver). Flex / Multipurpose Coil is a surface coil which has a high SNR for a superficial examination (a small organ). The purpose of this research is to know comparison the value of signal to noise ratio (SNR) and higher the value of signal to noise ratio (SNR) at MRI Ankle Joint examination using Quad Knee Coil and Flex / Multipurpose Coil.Method : This type of research is quantitative experimental approach. The research data which 6 samples. Rate includes images subjectively talocalcaneal interosseous ligament, talocrural joint, subtalar joint, the calcaneus, tibia, talus, and the Achilles tendon. Then the results of the data in Paired T-Test tested.Results : Test results that there are differences in comparison the value of signal to noise ratio (SNR) at MRI Ankle Joint examination using Quad Knee Coil and Flex / Multipurpose Coil which has a p-value / sig for all of 0.002, and each criterion that have talocalcaneal interoseous ligament p value 0.026, talocrural joint p value 0.017, subtalar joint p value 0.001, calcaneus p value 0.002, tibia p value 0.003, talus p value 0.006, and achilles tendon p value 0.012. This is in accordance with the calculated average value SNR on the use of Quad Knee Coil is higher at 110.67 because the coil acts as transreceiver and has two preamplifier so as to improve the SNRConclusion : There is a differences in comparison the value of Signal To Noise Ratio (SNR) at MRI Ankle Joint examination using Quad Knee Coil and Flex / Multipurpose Coil.

The Anatomy of the Dorsal Capsulo-Scapholunate Septum: A Cadaveric Study.

Background Tears of the dorsal radiocarpal capsule at the level of the scapholunate interosseous ligament (SLIL) have recently been described in association with predynamic scapholunate instability. Purpose The aim of this anatomical study of the dorsal capsulo-scapholunate septum (DCSS) was to examine the connection of the dorsal capsule on the SLIL and dorsal intercarpal ligament (DICL). Methods Fourteen fresh frozen wrists from seven adult cadavers were dissected through a dorsal approach. Any dorsal attachment of the DICL on the dorsal surface of the SLIL, that is, the DCSS, was identified and measured (height and width). Results The DCSS was consistently found connecting the DICL, the dorsal radiocarpal capsule, and the dorsal aspect of the SLIL. It was formed by the confluence of three arches like intersecting ribs in gothic architecture. The mean dimensions of the DCSS were 5.8 mm in height and 4.0 mm in maximum width. Conclusion The DCSS that connects the SLIL with the dorsal capsule and DICL could be a constant structure of dorsal wrist. Further investigation is required to study the histology of the DCSS and its biomechanical properties in isolation to know whether the DCSS can be considered a secondary stabilizer of the scapholunate ligament complex. Clinical Relevance A better anatomical knowledge of scapholunate ligament complex could help understand and manage instability of the wrist.

Clinical outcomes following reduction and pinning of lesser arc injuries without repair of the scapholunate interosseous ligament

BACKGROUND: Purely ligamentous lesser arc, Mayfield grade 3 and 4, perilunate dislocations (PLDs) are uncommon. Current recommendations are for open reduction and repair of the interosseous ligaments to prevent the development of scapholunate dissociation and degeneration to a scapholunate advance collapse (SLAC) wrist. This study proposes a less invasive treatment method which includes closed reduction and pinning alone without repair of the scapholunate interosseous ligament. We propose that most patients will obtain good function and pain scores and the few that develop instability may still have a reconstruction performed through a naive surgical field METHODS: Dislocations were reduced anatomically and held with buried K-wires which were removed at 6 weeks with no specific rehabilitation protocol observed. Subjective assessment included Mayo wrist scoring system, wrist range of movement, instability and grip strength testing. Radiological measurements included scapholunate distance, scapholunate angle, radiolunate angle and osteoarthritis RESULTS: Ten male patients, median age of 35 years, were followed up for a median of 22 months. Seven patients underwent a closed reduction and anatomical pinning while three underwent open reduction due to unachievable reduction by closed means. All of these patients presented at a median of 14 days after the injury occurred. None of the patients had their scapholunate ligaments repaired or reconstructed. Mayo scores included three excellent scores, two good scores and five fair scores. Instability was found clinically in one asymptomatic patient who had a positive Watson shift test. Radiological scores include a median scapholunate distance of 2 mm, a scapholunate angle of 70° and a radiolunate angle of 15°. Osteoarthritis was found in two patients, all of whom were asymptomatic DISCUSSION: Current recommendations in the literature are that PLDs should be reduced via an open surgical technique with repair of the scapholunate interosseous ligament (SLIL) and percutaneous pinning. However, the results of this treatment strategy are not optimal and do not confer uniformly good results. We propose a closed anatomical reduction and percutaneous pinning of the PLD. Our study shows that most patients will demonstrate good function and pain scores when managed this way. A smaller number of these injured wrists will go on to develop instability. However, the advantage of our method over the current recommendations is that when this happens the reconstruction of the SLIL will be made easier through a naive surgical field CONCLUSION: We recommend the closed reduction and anatomical pinning of a purely ligamentous lesser arc injury. This treatment strategy yields good results at medium term follow-up and preserves the option for the reconstruction of the scapholunate interosseous ligament should instability develop

Interosseous Ligament and Transverse Forearm Stability: A Biomechanical Cadaver Study

The interosseous ligament (IOL) is known to be an important longitudinal stabilizer of the forearm. We hypothesize that it may also contribute to transverse stability, with pronosupination tensioning of the radius relative to the ulna. Therefore, when injured, we predict the interosseous space should widen in the transverse plane, enough to be appreciable on plain radiographs. A measurable difference in interosseous space, comparing an injured with an uninjured forearm, can potentially be of diagnostic and clinical value. Ten fresh-frozen cadaver arms (from 5 individuals) were radiographed in 6 different positions of forearm supination, first in an uninjured state and then with the IOL sectioned, both partially (central band only) and completely. The transverse interosseous distance was measured on radiographs using edge detection software and compared using analysis of variance and contrast analysis. The maximum range of pronosupination was also compared before and after injury, using a paired t test. Average maximum supination increased from 84° to 106°, and pronation from 69° to 84°, after the IOL was sectioned completely. Sectioning of the IOL led to a statistically significant increase in the interosseous distance, a minimum of 2 mm, in all but one forearm position. The IOL of the forearm plays an important role in providing transverse stability to the radius and ulna. When the IOL is sectioned, the forearm exhibits increased pronosupination range of motion. Radiographs of bilateral forearms taken in identical rotational position can reliably differentiate between an intact and torn IOL in cadavers. The IOL's stabilizing role during forearm rotation suggests a novel strategy for diagnosing forearm IOL injury using comparative radiographic measurements.

Neglected isolated scaphoid dislocation.

The authors present a case of isolated scaphoid dislocation in a 40-year-old male that was undiagnosed for 2 months. The patient was treated by open reduction, Kirschner wire fixation, interosseous ligament repair using a suture anchor and Blatt's dorsal capsulodesis. At 6 years followup, his radiographs of wrist showed a normal carpal alignment with a scapholunate gap of 3 mm and no evidence of avascular necrosis (AVN) of the scaphoid.