Scapholunate Ligament Rupture Research Articles

Evaluation of a newly designed deep learning-based algorithm for automated assessment of scapholunate distance in wrist radiography as a surrogate parameter for scapholunate ligament rupture and the correlation with arthroscopy

PurposeNot diagnosed or mistreated scapholunate ligament (SL) tears represent a frequent cause of degenerative wrist arthritis. A newly developed deep learning (DL)-based automated assessment of the SL distance on radiographs may support clinicians in initial image interpretation.Materials and MethodsA pre-trained DL algorithm was specifically fine-tuned on static and dynamic dorsopalmar wrist radiography (training data set n = 201) for the automated assessment of the SL distance. Afterwards the DL algorithm was evaluated (evaluation data set n = 364 patients with n = 1604 radiographs) and correlated with results of an experienced human reader and with arthroscopic findings.ResultsThe evaluation data set comprised arthroscopically diagnosed SL insufficiency according to Geissler’s stages 0–4 (56.5%, 2.5%, 5.5%, 7.5%, 28.0%). Diagnostic accuracy of the DL algorithm on dorsopalmar radiography regarding SL integrity was close to that of the human reader (e.g. differentiation of Geissler’s stages ≤ 2 versus > 2 with a sensitivity of 74% and a specificity of 78% compared to 77% and 80%) with a correlation coefficient of 0.81 (P < 0.01).ConclusionA DL algorithm like this might become a valuable tool supporting clinicians’ initial decision making on radiography regarding SL integrity and consequential triage for further patient management.

Arthroscopic Management of the Hamate Proximal Pole Arthrosis.

In this retrospective study, all patients with arthrosis of the proximal pole of the hamate encountered in a 10-year period treated with arthroscopy were reviewed. Patient demographics, arthroscopic details, associated injuries, and procedures were reviewed. Functional and patient-reported clinical outcomes after arthroscopic osteochondroplasty were analyzed. An analysis of 39 patients who underwent arthroscopic osteochondroplasty showed a type II lunate prevalence of 87.2%. On wrist arthroscopy, a triangular fibrocartilaginous complex tear was the most common diagnosis (64.1%), followed by scapholunate ligament tear (61.5%) and lunotriquetral ligament tear (35.9%). All patients were managed arthroscopically with 100% procedural success. Average follow-up of 42.8 ± 37.7 months showed statistically significant improvements in the visual analog score and Mayo wrist score postoperatively (P < 0.01). Three patients (7.7%) failed the procedure at a mean of 23 ± 31.4 months. Risk factors for salvage operations were nondominant wrist involvement 100% (P = 0.04), lunotriquetral ligament injury 100% (P = 0.04), the absence of triangular fibrocartilaginous complex injury 100% (P = 0.04), and the presence of scapholunate advanced collapse 100% (P < 0.01). Wrist arthroscopy is valuable for accurately diagnosing and treating hamate arthrosis and identifying a wide variety of pathologies associated. This study showed arthroscopic osteochondroplasty produced satisfactory clinical results. Furthermore, the presence of scapholunate advanced collapse wrist offers its prognostic value in determining treatment failure.

Bilateral Ulnar Deviation Supination Stress Test to Assess Dynamic Scapholunate Instability

We describe a new radiologic test to assess the integrity of the scapholunate ligament in dynamic scapholunate dysfunction. A bilateral forearm-holding device was designed to perform a comparative radiographic assessment of the scapholunate joint gap during resisted isometric contraction of the extensor carpi ulnaris muscle with full supination of the forearm. The concept is based on the known scaphoid pronation effect of this muscle. Clinical data from 12 patients were collected retrospectively and used to analyze the patients' symptomatic and asymptomatic (contralateral) wrists with a newly developed test called the Bilateral Ulnar Deviation Supination (BUDS) test. A wrist arthroscopy was performed in all cases as a reference standard for the radiologic test. The test was positive in 7 patients, with a mean scapholunate joint gap of 4.8 mm. The mean differences in the scapholunate joint gaps between both wrists were 2.6 mm in BUDS-positive patients and 0.2 mm in BUDS-negative patients. A Geissler stage III or IV scapholunate ligament rupture was confirmed in all BUDS-positive patients; by contrast, BUDS-negative patients exhibited either no lesion or a Geissler stage I injury. The BUDS test is a new radiologic test based on proven biomechanical effects that is able to accurately assess dynamic scapholunate dysfunctions. The analysis carried out found a correlation between radiographic and arthroscopic findings. Further research is needed to confirm the validity and reliability of the test. Therapeutic III.

Total Wrist Arthroplasty for Posttraumatic Wrist Osteoarthritis: A Cohort Study Comparing Three Indications.

Scapholunate ligament ruptures and scaphoid nonunion with consecutive advanced collapse (SLAC and SNAC wrists) as well as intra-articular distal radius fractures (DRF) are prone to cause posttraumatic wrist osteoarthritis. The aim of this study was to compare the outcomes of these indications for total wrist arthroplasty. We included 13, 11, and 8 patients with an overall mean age of 60 ± 9 years in the SLAC, SNAC, and DRF cohort, respectively. After an average follow-up period of 6 ± 3 years, we found no difference between our groups regarding pain levels and functional scores, although these parameters significantly improved compared to preoperative parameters. Complication and revision rates revealed no significant difference. However, significantly higher extension, arc of range of motion values in the flexion-extension, as well as in radial-ulnar deviation plain were detected in the SLAC compared to the DRF group. Finally, TWA proved to show a beneficial performance in all three investigated indications.

Four-corner arthrodesis of the wrist using Variable Angle Locking Compression Intercarpal Fusion Plate (VA LCP ICF Plate; Synthes®): pre- and postoperative radiological analysis and clinical outcome in long-term evaluation.

Long persisting scaphoid non-unions or scapholunate ligament ruptures can lead to carpal collapse.The resulting clinical symptoms are restrictions in the range of motion, pain, and loss of grip strength. The symptomatic treatment so far offers different options. In our study, the Variable Angle Locking Compression Intercarpal Fusion Plate (VA LCP ICF Plate) by Synthes® was used in 11 cases of advanced carpal collapse for a four-corner fusion of the wrist. The intra- and postoperative as well as follow-up results have been assessed and compared with those of current literature.The results of the Manchester-Modified Disability of the Shoulder, Arm and Hand Score (M²-Dash) showed an average of 41.5 points (MD=44/SD=16.62/MIN=21/MAX=65).One of the re-evaluated patients complained about pain at rest. One patient stated pain after mild strain; 4 patients complained pain after heavy burden (e.g. boxing, weight lifting).Measuring the range of motion, the operated hand showed a maximum in dorsal extension of 78.31% and in flexion of 57.89% compared to the contralateral, non-operated hand. In performance testing the fist clenching sign as well as pinch grip were complete and void of pain in 100%, whereas opposition (dig. man. I to V) was complete in five patients (83.33%), with moderate pain in one patient (16.67%) and a persisting gap of 0.2 cm in n=1 (16.67%). In comparison with the current literature regarding healing rates, complications, and follow-up results, we recommend the Synthes® VA LCP ICF Plate as a good surgical option in patients suffering from advanced carpal collapse.

Scanning the wrist for ligament injuries

To understand the pathology which may occur following an injury to the wrist, this presentation will review the anatomy and biomechanics of this joint. The biomechanics of wrist injuries are as follows Weightbearing injuries which may be sustained weightlifting or in gymnastics where there is increased axial loading or where the wrist is extended and radially deviated, may result in volar carpal ligament injuries. Twisting injuries during wrestling and again gymnastics where there is excessive pronation or supination of the wrist may affect the TFCC. Impact injuries such as a fall onto the outstretched hand - FOOSH - can result in scapho-lunate, lunotriquetral and or palmar radiocarpal ligament rupture, a TFCC tear or a strain of the dorsal radiocarpal ligament. (Anderson, Read, 2008) All these ligaments which have been listed are easily seen with ultrasound. A detailed history is imperative prior to scanning the wrist. Specific tests can also be useful determining which ligaments may be injured prior to scanning such as Watsons test. Injuries to intrinsic ligaments such as the scapholunate ligament can be classified into 3 different grades. Grade 1 is a stable injury with only mild stretching of the joint from radial to ulnar deviation. Grade 2 is a tear of the central and dorsal components of the ligament leading to widening of the joint from radial to ulnar deviation. Grade 3 is a tear of all 3 regions of the ligament leading to not only widening of the joint but malalignment of the joint. A partial tear or strain of an extrinsic ligament will appear as a thickened, hypoechoic, but in tact ligament. A full thickness tear will appear as an anechoic defect in the ligament. The ultrasound appearances and technique for scanning these ligaments as well as ligamentous pathology will be reviewed in this presentation.

Scapholunate instability: improved detection with semi-automated kinematic CT analysis during stress maneuvers.

To evaluate the diagnostic performance of radioulnar deviation (RUD) and clenching fist (CF) maneuvers for the evaluation of scapholunate dissociation (SLD) using quantitative kinematic CT. Thirty-seven patients with suspected scapholunate instability were prospectively evaluated with kinematic CT. Two radiologists independently evaluated the SLD during RUD and CF maneuvers. Various dynamic parameters describing SLD were compared (maximal value, variation coefficient and range) in patients with and without scapholunate ligament ruptures confirmed by CT arthrography. SLD in CF varied from 3.17 ± 0.38 to 3.24 ± 0.80 mm in controls and from 4.11 ± 0.77 and 4.01 ± 0.85 mm in patients with scapholunate ligament ruptures for reader 1 and 2 (p < 0.009). SLD in RUD varied from 3.35 ± 0.51 and 3.01 ± 0.78 mm in controls and from 4.51 ± 1.26 to 4.42 ± 1.75 mm in patients with scapholunate ligament ruptures for reader 1 and 2 (p varied from 0.001 to 0.002). The inter-observer variability was better for RUD (ICC = 0.85 versus 0.6 for RUD and CF respectively). Analysis of SLD using kinematic CT has shown significant measurement differences between the groups with or without scapholunate instability with good diagnostic performance. • Kinematic CT can quantitatively assess scapholunate dissociation. • SLD analysis on kinematic CT has excellent reproducibility with radioulnar deviation maneuver. • Scapholunate dissociation was significantly different in patients with and without instability. • Diagnostic performance for scapholunate instability identification was better with radioulnar deviation.

Histopathological Analysis of the Lunate in Rheumatoid Disorders

Introduction: Avascular necrosis of the lunate in Systemic Lupus Erythematous (SLE) and rheumatoid arthritis (RA) are not rare. Our study aimed to describe the histopathology of the lunates after removing them in the operating room in patients with rheumatoid diseases and lunate palmar dislocation. We correlated the histopathological findings with magnetic resonance imaging (MRI), radiological parameters, and blood test parameters. Methods: From January 2006 to January 2015, 12 patients were operated for rheumatoid disorders, 8 RA, 1 SLE, and 3 psoriatic arthritis (PA). There were 8 female and 4 male with a mean age 65 (53-79) years. Antinuclear antibodies and other relevant tests were performed. Anticardiolipin antibody, anti-double-stranded DNA, and anti-β-2 glycoprotein I were measured by enzyme-linked immunosorbent assay (ELISA). All patients underwent MRI study. T1-weighted images were evaluated for bone necrosis of the lunate. In the operating room, we excised whole lunates and we studied the macroscopical aspect inside and outside. We evaluated the size, cartilage surfaces, number of foraminas, and ligament insertions. After that, we cut the bone and showed the bleeding bone and collapse areas. Histopathological analysis was performed with lunate sections. The lunates were fixed in formalin, decalcified, embedded in paraffin, and cut in 5 microm sections, and stained with hematoxylin and eosin. We visualized lunates sections by microscope. The surgical treatment was a wrist arthrodesis in 8 cases and wrist arthroplasty in the other 4 cases. We evaluated x-rays data such as lunate morphology, Stahl Index, Carpal Height ratio (CHR), and Carpal Ulnar distance ratio (CUDR). We correlated preoperative x-rays and MRI data with histopathological findings. We correlated blood test parameters with the histology. Statistical analysis of data was performed with chi-square test (significance level P &lt; .05). Results: In 2 cases, we showed a lunate flattening associated with a partial hypointensity in coronal sections in T1-weighted images in MRI. Microscopic analysis showed synovial hyperplasia, fatty marrow, and fibrovascular tissue. We did not find avascular necrosis in any complete lunate but we found a focal necrosis (empty lacunae) in 2 cases. Mean CHR was 0.385, CUDR 0.301, Index Stahl 56.95, and radio-scaphoid angle 76°. We showed more ulnar translation in RA than in other rheumatoid disorders (CUDR P = .002). The correlation focal lunate necrosis with MRI was P = .371. The correlation focal lunate necrosis with scapholunate ligament rupture was P = .640. We showed 2 blood test parameters statistically significant with focal lunate necrosis (C reactive Protein P = .046 and Rheumatoid Factor P = .053). Conclusion: Neoangiogenesis and wrist synovitis in rheumatoid disorders, with an increased number of synovial cells and vessels, seem to contribute to the progression of autoimmune diseases. It is possible that the patients with rheumatoid wrists have hypervascularity and therefore a chronic adaptation to a decrease number of vessels in the lunate and to ligament injuries. This could avoid to have Kienböck disease in a chronic palmar lunate dislocation in rheumatoid disorders.

Posterior Radioscaphoid Angle as a Predictor of Wrist Degenerative Joint Disease in Patients With Scapholunate Ligament Tears.

The purpose of this study is to determine whether the posterior radioscaphoid angle, a marker of posterior displacement of the scaphoid, is associated with degenerative joint disease in patients with scapholunate ligament tears. Images from 150 patients with wrist pain who underwent CT arthrography and radiography were retrospectively evaluated. Patients with and without scapholunate ligament ruptures were divided into two groups according to CT arthrography findings. The presence of degenerative changes (scapholunate advanced collapse [SLAC] wrist) was evaluated and graded on conventional radiographs. Images were evaluated by two readers independently, and an adjudicator analyzed the discordant cases. Posterior radioscaphoid angle values were correlated with CT arthrography and radiographic findings. The association between posterior radioscaphoid angle and degenerative joint disease was evaluated. Scapholunate and radiolunate angles were considered in the analysis. The posterior radioscaphoid angle was measurable in all patients, with substantial interobserver agreement (intraclass correlation coefficient, 0.75). The posterior radioscaphoid angle performed better than did the scapholunate and radiolunate angles in the differentiation of patients with and without SLAC wrist (p < 0.02). Posterior radioscaphoid angles greater than 114° presented an 80.0% sensitivity and 89.7% specificity for the detection of SLAC wrist. Posterior radioscaphoid angles were strongly associated with degenerative wrist disease, with potential prognostic implications in patients with wrist trauma and scapholunate ligament ruptures.

Mid-term results of ligament tenodesis in treatment of scapholunate dissociation: a retrospective study of 20 patients.

The purpose of this retrospective study was to assess the modified Brunelli technique for the treatment of chronic irreparable complete scapholunate ligament rupture, causing a reducible carpal malalignment without secondary osteoarthritis. A total of 20 patients were treated using this technique. At a mean follow-up period of 24 months (range 6-53, SD 15), pain on a visual analogue scale had improved from 6 (range 3-10) to 3 (range 0-7). Function measured with the DASH score had improved from 37 (range 11-90) to 20 (range 0-53). Range of motion was reduced in flexion by a mean of 19° (range 10-45), and in extension by a mean of 14° (range 0-35). Mean grip strength at last follow-up was 81% of the uninjured hand (range 50-100%) Three patients developed scapholunate advanced collapse (stage II) requiring salvage surgery. Scapholunate ligament reconstruction with the modified Brunelli technique showed satisfactory results in this study. Extended studies are needed to determine the long-term benefits of this reconstructive procedure. IV.

Combined Volar Hamate Dislocation and Scapholunate Ligament Rupture: A Case Report.

A twenty-two-year-old male patient presented to our trauma center after a motor-vehicle accident in which he sustained multiple injuries, including a volar dislocation of the hamate and ipsilateral scapholunate dissociation. Following closed reduction of the hamate dislocation, open reduction and stabilization of these carpal injuries was undertaken two days post-injury via a dorsal approach. Percutaneous Kirschner wires were used as well as two mini suture anchors to repair the scapholunate ligament. The patient was immobilized for six weeks and Kirschner wires were removed at twelve weeks postoperatively. To our knowledge, hamate dislocation with scapholunate dissociation and its surgical treatment have not previously been described. Successful surgical treatment for this injury pattern may be performed dorsally via direct reduction and repair of the scapholunate ligament with percutaneous pinning of the affected carpal bones.

The Value of 3.0-Tesla MRI in Diagnosing Scapholunate Ligament Injury

Objective To determine the sensitivity and specificity of 3.0-tesla (T) magnetic resonance imaging (MRI) and a dedicated hand coil in diagnosing scapholunate ligament (SLL) injury compared with intraoperative findings. Methods From January 2006 until September 2010, 3.0-T MRI scans were performed on 38 wrists (37 patients) with clinically unclear but suspected lesions of the SLL. These scans were evaluated by two experienced radiologists. Radiological findings were compared with intraoperative findings during arthrotomy. Sensitivity, specificity, accuracy, and positive and negative predictive value were calculated. Results An SLL lesion was identified during arthrotomy in 37 wrists. The first radiologist identified an SLL lesion on MRI in 26 wrists, all of which were confirmed intraoperatively. The second radiologist identified SLL lesions in 31 patients; however, intraoperatively it was found that there was no lesion of the ligament in one patient. Sensitivity ranged from 70 to 81% with a specificity of 100% and a positive predictive value of 97 to 100%. Accuracy measured 71 to 79%. Conclusions 3.0-T MRI of the wrist is moderately sensitive and very specific for detection of SLL lesions. However, if there is a high clinical suspicion of an SLL rupture, a 3.0-T MRI does not often have an additional value. Level of Evidence Diagnostic, level II.

Paper 177: Arthroscopic Repair Of Combined TFCC Tears: A New Clinical Entity with Long Term Follow up

In recent years, appreciation for the role of triangular fibrocartilage complex tears in ulnar sided wrist pain has significantly increased (TFCC - triangular fibrocartilage complex). The TFCC functions as the major stabilizer of the distal radioulnar joint. It is the focal point that allows the carpus to rotate with the radius around the ulna. As a stabilizer of the ulnar carpus, the TFCC transmits 20% of an axially applied load from the ulnar carpus to the distal ulna. Severe twisting and loading injuries of the wrist are commonly responsible for tears of the TFCC. These patients will not only present with ulnar sided wrist pain, but pain with the extremes of supination and pronation as well as repetitive activity. Injuries to the TFCC have presented a challenge in regards to treatment. We have previously reported on a successful technique for arthroscopic repair of peripheral TFCC tears. The technique involves the use of spinal needles placed percutaneously through the safe zone and the use of a Shuttle relay (Linvatec) and absorbable braided suture to create a mattress type repair. Follow up for a minimum of 24 months has produced excellent results when evaluated using the Mayo Modified wrist score. As our series of patients has grown, we have noted an interesting subset of patients that have had not only peripheral TFCC tears, but central tears as well. To the best of our knowledge, lesions of the TFCC involving both central and peripheral tears have not previously been described. Past studies have demonstrated successful outcomes with debridement of central lesions and repair of peripheral lesions. Both arthroscopic as well as open techniques have been described. However, when we first encountered a TFCC tear with both a central and a peripheral component; what we have termed a Combined TFCC lesion, we were perplexed as to how to approach the problem. We ultimately did a thorough debridement of the central component and a secure arthroscopic repair of the peripheral component and then treated the patient post-operatively as we would any other peripheral repair. This first patient post operatively had and excellent outcome with a Modified Mayo wrist score of 100. Since that first patient, review of our series of TFCC repairs has yielded thirty three additional patients with combined lesions of the TFCC. This report is an evaluation of these thirty four patients with combined TFCC lesions. There were twenty four males and ten female patients. Their average age was thirty-three years old. There were twenty right wrist injuries and fourteen left wrist injuries. The dominant wrist was injured 28/34 times. Mechanism of injuries included thirty one sports related injuries (baseball, american football, hockey and tennis), two MVA's and one assault. Associated pathology involved one scapholunate ligament rupture and four ECU sling ruptures. Follow up ranged from 48 to 110 months and averaged 72 months. Average Mayo Modified wrist score was 90. This compared favorable with our previous series of peripheral TFCC repairs where the average score was 92.5 We believe that debridement of the central portion of a Combined TFCC lesion in conjunction with repair of the peripheral portion can lead to good and excellent results. Without repair of the peripheral portion of the combined lesion, the laxity caused by the tear of the central portion would lead to biomechanical instability. Despite the lack of continuity of the central portion of the TFCC, repair of the peripheral portion leads to increased stability by creating a suspension bridge type configuration. Burkhart popularized this concept in regards to partial repair of massive rotator cuff tears and we believe this biomechanical theory is applicable for Combined lesions of the TFCC as well. Debridement of the central portion in conjunction with repair of the peripheral portion of a combined TFCC lesion gives the surgeon a viable surgical option, that withstands the test of time, when faced with this difficult variant of TFCC pathology.

The Incidence of Intrinsic and Extrinsic Ligament Injuries in Scaphoid Waist Fractures

To determine the incidence of associated intrinsic and extrinsic ligament injuries in patients with a nondisplaced or displaced scaphoid waist fracture. During a 3-year period, a study of all scaphoid fractures was performed at our institution. Diagnosis was confirmed by plain radiographs, computed tomography, and magnetic resonance imaging. A 3-part anatomic classification was used to categorize the scaphoid fractures. The study population comprised 40 patients with 41 scaphoid waist fractures who had wrist arthroscopy for treatment and evaluation of the scaphoid fracture and associated carpal injuries. We observed fresh intrinsic ligament injuries in 34 of 41 wrists. In 29 cases, the scapholunate ligament was injured, with complete rupture occurring in 10 wrists. The lunotriquetral ligament was injured in 8 wrists, and the triangular fibrocartilage complex was injured in 11 wrists. Statistically, the number of intrinsic ligament injuries did not differ between nondisplaced and displaced scaphoid fractures (p> .30). In this study of acute scaphoid waist fractures, the overall incidence of associated ligament injuries was surprisingly high, at 34 of 41 wrists. Complete scapholunate ligament rupture was found in 10 of 41 wrists. This incidence is higher than previously reported and emphasizes the need for careful assessment of the intrinsic and extrinsic ligaments, particularly the scapholunate ligament, before deciding on treatment.

Treatment of acute scapholunate ligament injuries with bone anchor

Scapholunate instability is the most common form of carpal instability. Repair or reconstruction of the scapholunate interosseus ligament is advocated to reduce symptoms, stabilize the scapholunate joint and avoid the progression of carpal degeneration. Aim of this study is to evaluate the results (clinical and radiographic) obtained in 18 patients treated in our department for acute lesions SLIL from 2003 to 2008. Patients were 16 males and 2 females with an average age at the time of the trauma of 33.8 years old (min 17 and max 68 years). The diagnosis of scapholunate dissociation relies on a through history and physical examination and imaging studies. Early surgical repair of the torn schapolunate ligament was performed in all the patients. The method used for the treatment of these lesions was open reduction and direct ligament reinsertion through a minianchor MITEK. In our surgical experience in 3 cases we have found a combination between an isolated scaphoid fractures and a scapholunate ligament rupture without carpal dislocation. We reviewed all patients treated with an average follow-up of 32 months (range 9-68 months). The review was carried out both clinically and radiographically (static and dynamic). We achieved 13 excellent results (Mayo score average 94,77), 3 good results (Mayo score average 84), 1 sufficient results (Wrist score 72) and 1 bad result (Wrist score 35). From the radiographic evaluation we found a loss of reduction in the two cases identified clinically as sufficient and bad. One patient after an optimal ligament healing, underwent to a recurrence of the lesion SLIL 2 years from surgery. Open reduction and direct bony fixation of the torn scapholunate ligament using a suture anchor is generally successful in restoring scapholunate stability and has produced good functional mid-term results. At an average follow up of 32 months excellent or good functional outcomes were reported in 88% of the patients despite a large number of cases with a high energy trauma and other associated injury. The association between an isolated scaphoid fracture and a SLIL lesion is rare but not impossible in presence of a scapholunate instability we recommend the immediate reconstruction of the torn ligament.

Dorsal Capsulodesis for the Treatment of Scapholunate Instability

To regain stability of the proximal carpal row after scapholunate ligament rupture in order to avoid osteoarthritis and carpal collapse. As additional therapy in scapholunate ligament repair especially in patients with static, but reducible scapholunate malalignment. Fixed scapholunate malalignment. Osteoarthritis of the radiocarpal or the midcarpal joint. Dorsal approach to the carpal joint with release of the second, third and fourth extensor compartment and resection of the dorsal interosseous nerve. Opening of the radiocarpal joint for inspection of the chondral surfaces and the scapholunate ligament for possible repair. If needed, reduction of scaphoid and lunate. Repair of the scapholunate ligament. If a reduction of scaphoid and lunate is necessary, temporary Kirschner wire fixation of the scaphoid to the capitate and the lunate. The dorsal intercarpal ligament is identified and its middle third is dissected and elevated from the triquetrum remaining attached to the distal scaphoid pole. The ulnar end of the elevated part of the dorsal intercarpal ligament is pulled through a split in the dorsal radiotriquetral ligament and fixed to itself. Closure of the proximal and distal third of the dorsal intercarpal ligament. Management Immobilization in a below-elbow cast including the metacarpophalangeal joint of the thumb for 6 weeks. Removal of the Kirschner wires, if used, 8 weeks postoperatively. Physiotherapy to improve wrist motion. Most of the reports in the literature show an improvement of pain. The effect on radiologic parameters and the development of osteoarthritis remains uncertain.

Diagnostic accuracy of plain radiographs and cineradiography in diagnosing traumatic scapholunate dissociation

Missed tears of the scapholunate ligament (SLL) and scapholunate dissociation (SLD) after wrist injuries pose a high risk of post-traumatic osteoarthritis of the carpus. Plain X-rays and dynamic radiographic studies are frequently used for initial diagnostic work-up. Given the limited evidence of their accuracy, we retrospectively compared the radiographic findings of patients with suspected traumatic SLD with wrist arthroscopy as the accepted reference standard. During a 6-year period, plain radiographs and DSA cineradiography scans were obtained from 198 patients who had sustained a hyperextension injury to their hand. Of those, 102 (72 men, 30 women, mean age of 42+/-12 years) subsequently underwent diagnostic arthroscopy. Digital images were reevaluated by experienced radiologists unaware of the arthroscopic findings for the presence or absence of SLD. We calculated the sensitivity (SN) and specificity (SP) with 95% confidence intervals (CI), and computed areas under the receiver operating characteristic curves (AUC/ROC). Arthroscopy revealed 42 SLL ruptures, 13, 10, and 19 of which were classified as grade I (partial), II (complete with dynamic instability), or III (complete with static instability) respectively. Plain radiographs correctly identified 24 injuries (SN 57.1%, 95% CI 41.0-72.3%), and produced 1 false-positive result (SP 98.3%, 95% CI 91.1-100.0%). The scapholunate distance and the SL angle contributed independently to the diagnostic variance, with an AUC/ROC of 85.7% (95% CI 76.8-92.2%). Cineradiography had a sensitivity of 36 out of 42 (85.7%, 95% CI 71.5-94.6%), and a specificity of 57 out of 60 (95.0%, 95% CI 86.1-99.0%). Pathological results on plain radiographs and cineradiography reliably indicate the presence of SLD after wrist trauma. Although non-conclusive, a negative dynamic study markedly reduces the pre-test probability of disease. Both methods remain key elements of primary diagnostic strategies for suspected traumatic SLD, and may facilitate the selection of additional tests.

Sonographic evaluation of scapholunate ligament: Value of tissue harmonic imaging

The aim of this study was to compare tissue harmonic imaging (THI) and conventional (fundamental) sonography in the evaluation of the scapholunate ligament (SLL). The bilateral SLL of 3 patients with unilateral SLL rupture and the bilateral SLL of 20 volunteers without history of trauma were examined. THI findings were compared with conventional sonographic findings. On conventional sonographic evaluation of 43 normal wrists, the dorsal component of the SLL was partially visible in 10 of the 43 normal wrists (23%) and was completely visible in 33 of 43 (77%) normal wrists. Using THI, the SLL was visible in its entirety in 39 of 43 normal wrists (91%) and was partially visible in 4 of 43 normal wrists (9%). The mean scapholunate distance was 3.3 mm (range, 2.9-4.5 mm) in normal wrists. THI improved visualization of SLL continuity and demonstration of its fibrillar echotexture. In the 3 wrists with clinical and/or radiological evidence of SLL rupture, the SLL was not visible with conventional sonography nor THI; the mean scapholunate distance was 6.1 mm (range, 5.6-6.8 mm). THI improves visualization of the SLL.

Three-Ligament Tenodesis for the Treatment of Scapholunate Dissociation: Indications and Surgical Technique

Different surgical techniques have been proposed to treat traumatic scapholunate instability. Deciding which treatment is best for each individual case is not easy. In this article we report an algorithm of treatment based on a number of prognostic factors that may help in this matter. We also report on the promising results obtained using a new technique, the 3-ligament tenodesis, for the treatment of nonrepairable complete scapholunate ligament rupture, causing a reducible carpal malalignment without secondary osteoarthritis. This technique incorporates features from 3 previously described techniques.

Scapholunate dissociation. Results of ligament suture and ligament-plasty

The diagnosis of scapholunate ligament rupture is frequently missed. Untreated, it will lead to carpal collapse and arthrosis of the wrist, and ultimately to scapholunate advanced collapse (SLAC-wrist). We report the results of 20 patients treated either by direct suture or reconstruction of the ligament with a follow-up of three to five years after surgery. The operation was performed between 0.5 and 120 months (suture 2.6 months, reconstruction 28 months) after the original trauma. The results of direct repair were superior to ligament reconstruction. In our experience, direct ligament repair was only possible up to four to six months after trauma, this study emphasizes the importance of early diagnosis and treatment by anatomical reposition of scapholunate ligament rupture.