Scapholunate Angle Research Articles

Outcome After Repair of the Scapholunate Interosseous Ligament and Dorsal Capsulodesis for Dynamic Scapholunate Instability Due to Trauma

To retrospectively assess outcomes in 17 patients treated with scapholunate (SL) interosseous ligament repair and capsulodesis for dynamic SL instability due to trauma. A retrospective review of 17 consecutive patients included clinical and radiographic examinations to determine outcome after SL interosseous ligament repair and dorsal capsulodesis. The average age at the time of surgery was 36 years, and the postoperative follow-up period averaged 66 months. Outcome measures included the Mayo wrist evaluation system and Disabilities of the Arm, Shoulder, and Hand questionnaire scores. Pain complaints were measured on a 10-point visual analog scale. Preoperative and postoperative measurements, respectively, for all patients were obtained as follows: SL gap, 2 versus 3 mm; stress views of the SL gap, 3 versus 4 mm; SL angle, 49 degrees versus 54 degrees ; capitolunate angle, 4 degrees versus 7 degrees . Grip strength was 82% of the uninjured side at the final follow-up evaluations. Pain averaged a 3 out of 10 before and after surgery. Surgery was completed an average of 22 weeks from injury. Disabilities of the Arm, Shoulder, and Hand questionnaire scores averaged 31, indicating wrist impairment. Three patients developed degenerative changes noted on postoperative x-rays. When patients were evaluated based on daily job requirements (strenuous vs nonstrenuous) there were statistically significant differences. Nonstrenuous job requirements had lower pain scores; better Disabilities of the Arm, Shoulder, and Hand questionnaire scores; better Mayo outcomes; better grip strength; and decreased SL gap on stress views. Flexion and extension of the wrist were better in the nonstrenuous group but did not reach statistical significance. Prior reports evaluating patients for SL ligament repair appeared to be favorable in short-term (1- to 2-y) follow-up periods. In the present report, for patients followed up for an average of 66 months after surgery, the results, clinically and radiographically, appear to deteriorate in those who place high demands on the wrists on a daily basis. Although the numbers in the present study are small, they indicate that SL ligament repair with dorsal capsulodesis may have a place for patients who have normal preoperative static unloaded x-rays and sufficient ligament for repair and who do not place high demands on the wrists on a daily basis. The ideal procedure for this difficult problem continues to remain elusive. Therapeutic IV.

Ligamentous reconstruction of scapholunate dislocation through a double dorsal and palmar approach

Six patients were treated for scapholunate dissociation by reconstruction of both the palmar and dorsal parts of the scapholunate interosseous ligament through a combined palmar and dorsal approach. The mean active range of motion of the wrist at final follow-up was 44 degrees of flexion and 58 degrees of extension and the mean hand grip strengths was 88% of that of the contralateral hand. The average time to return to work was 105 days and the mean DASH score at a mean follow-up of 32 months was 18. At follow-up, radiographs showed maintenance of the anatomical reduction of the scapholunate articulation in all cases and the scapholunate angle was normal in five patients.

Arthroscopic Resection in the Management of Wrist Ganglion

Purpose : To analyze the results of an arthroscopic resection of a wrist ganglion. Materials and Methods : Seventeen cases were analyzed. Eleven cases were treated by arthroscopic resection and 6 cases were treated by an arthroscopic resection and a pull out extracapsular sac. For the functional evaluation, the level of pain, grip strength, range of motion and patient's satisfaction were analyzed. The average follow-up time was 22 months (10-38). Results : In all patients, the functional results improved and all patients returned to work. No recurrence was noted. A ganglion stalk was identified in 14 cases, including 8 cases (scapholunate ligament), 3 cases (midcarpal joint), 1 cases (dual stalk), 1 case (lunotriquetral ligament) and 1 case (carpometacarpal joint). There was no case of Scapholunate instability and the scapholunate angle and gap were within the normal limits. Conclusion : An arthroscopic resection of a wrist ganglion is a safe and reliable alternative to an open resection.

THE ASSOCIATION OF SCAPHO-TRAPEZIO-TRAPEZOID OSTEOARTHROSIS AND SCAPHOLUNATE DISSOCIATION

There are two parts to this paper. In the first part we report 18 cases of bilateral scapho-trapezio-trapezoid osteoarthrosis associated with uni- or bilateral scapholunate dissociation. This case series was followed prospectively using repeat clinical assessments and radiographs. We were able to document the progression of both the clinical manifestations and radiographic features of the scapholunate dissociation in these patients. In the second part of the paper we compared the radiographic indices of scapholunate dissociation seen in our series, that is, the scapholunate angle and interval, with those of a control group over time, to determine if there was a significant difference. The control group differed from our series principally by being devoid of any clinical or radiographic evidence of scapho-trapezio-trapezoid osteoarthrosis. We found that our case series already had some radiographic evidence of scapholunate attrition at presentation and that at follow-up the scapholunate dissociation became more pronounced both clinically and radiographically relative to the controls. The authors propose a theory to explain the association and temporal relationship between the two conditions.

Assessment of four midcarpal radiologic determinations

Several radiologic measurement methods have been described for determining static carpal alignment of the wrist. These include the scapholunate, radiolunate, and capitolunate angles. The triangulation method is an alternative radiologic measurement which we believe is easier to use and more reproducible and reliable than the above mentioned methods. The purpose of this study is to assess the intraobserver reproducibility and interobserver reliability of the triangulation method, scapholunate, radiolunate, and capitolunate angles. Twenty orthopaedic residents and staff at varying levels of training made four radiologic measurements including the scapholunate, radiolunate and capitolunate angles as well as the triangulation method on five different lateral, digitized radiographs of the wrist and forearm in neutral radioulnar deviation. Thirty days after the initial measurements, the participants repeated the four radiologic measurements using the same radiographs. The triangulation method had the best intra-and-interobserver agreement of the four methods tested. This agreement was significantly better than the capitolunate and radiolunate angles. The scapholunate angle had the next best intraobserver reproducibility and interobserver reliability. The triangulation method has the best overall observer agreement when compared to the scapholunate, radiolunate, and capitolunate angles in determining static midcarpal alignment. No comment can be made on the validity of the measurements since there is no radiographic gold standard in determining static carpal alignment.

Chronic Asymptomatic Contralateral Wrist Scapholunate Dissociation

The authors report a series of six patients who presented with scapholunate dissociation, with no significant contralateral antecedent trauma and no rheumatoid arthritis or congenital ligamentous laxity. Such patients may present with pain or a snapping/popping sensation in one wrist, undergo radiographs of both wrists, and are discovered to have scapholunate gapping bilaterally. The literature contains few reports of this condition, and this series of six is a relatively large one for this infrequently reported condition. The six charts were reviewed retrospectively; each patient was asked to return for follow-up and radiographic examination and each participated in a telephone questionnaire about pain, activity changes, new treatments, and exacerbation of wrist problems. The average follow-up was 39 months, with a range of 6 months to 13.5 years. One patient with severe unilateral instability and persistent pain underwent soft-tissue surgical repair (Blatt reconstruction); another demonstrated unilateral dorsal intercalated segment instability with moderate pain symptoms but declined surgical reconstruction. The other 10 wrists, despite radiographically demonstrated widened scapholunate angles and rotatory subluxation of the scaphoid, had mild or no pain and no dorsal intercalated segment instability deformity. The evolution of the bilateral form of scapholunate dissociation seems to be benign unless dorsal intercalated segment instability deformity is present, which may then rapidly progress to degenerative arthritis and scapholunate advanced collapse wrist. Severe or minor repetitive trauma, inflammation, infection, tumors, and congenital ligamentous laxity have been etiologically implicated in scapholunate dissociation. The natural history of scapholunate dissociation involves volar rotation of the scaphoid and dorsal rotation of the lunate, progressing to malalignment and eventual arthrosis between the scaphoid and radius, the capitate and lunate, and the lunate and hamate bones.

Partial Scapholunate Ligament Injuries Treated With Arthroscopic Debridement and Thermal Shrinkage

To present the early results of arthroscopic debridement and thermal shrinkage using radiofrequency probes for partial (Geissler grades I and II) scapholunate (SL) interosseous ligament injuries of the wrist. Sixteen patients with a mean age of 34 years (range, 18-54 y) presenting with chronic dorsoradial wrist pain unresponsive to initial conservative treatment for a mean period of 12 weeks were included in this study. No patient showed radiologic signs of static dissociation (SL interval, <3.5 mm; mean SL angle, 49 degrees ) before surgery. Diagnostic arthroscopy showed a partial SL tear in 14 patients and redundancy of the ligament in 2. Partial SL tears involved the membranous (proximal) and volar part of the ligament. All lesions were debrided and treated with thermal shrinkage using a bipolar radiofrequency probe. The mean follow-up period was 19 months (range, 9-34 mo). Fourteen patients experienced substantial pain relief whereas in 2 the pain remained unchanged. Eight patients were completely pain free. The mean flexion-extension arc was 142 degrees and the mean grip strength was 78% that of the unaffected side. No patient showed radiologic signs of arthritis or static or dynamic instability after surgery (SL interval remained <3.5 mm; mean SL angle, 53 degrees ). Based on the modified Mayo wrist score there were 8 excellent, 6 good, 1 fair, and 1 poor result. Partial SL ligament tears can be a source of radial-sided wrist pain. Scapholunate ligament debridement and thermal shrinkage effectively provided pain relief for most of the patients treated. Stability was maintained radiographically. No complications were noted from the use of radiofrequency probes. These reasonably favorable short-term results should be viewed cautiously. A longer follow-up study is necessary to determine the ultimate efficacy of this procedure.

Ergebnisse der skapholunären Bandplastik zur Therapie der fortgeschrittenen skapholunären Dissoziation

Scapholunate dissociation is one of the most common disorders of the wrist. Untreated it might lead to osteoarthrosis (scapholunate advanced collapse, SLAC wrist). Choosing the best surgical treatment option is still challenging, especially in cases of carpal collapse in combination with beginning osteoarthrosis of the radial styloid and the proximal pole of the scaphoid. We report the results of a homogenous group of eight patients with reducible carpal collapse and beginning arthrosis treated by reconstruction of the scapholunate ligament. The operation was performed 66 (range: 20 to 252) months after trauma. The average length of follow-up was two years. Five patients stated general improvement, while three reported a change for the worse. At follow-up, the average total range of motion of the operated wrist was decreased by 16 % compared to the unaffected side. The average grip-strength (measured with a Jamar dynamometer) was 77 % of the uninvolved wrist. The DASH score was 43 +/- 25. In three cases the Martini score showed a good or an excellent result. The average scapholunate angle was 72.3 degrees preoperatively and decreased to 61.0 degrees at follow-up. At follow-up as well as pre- and postoperatively the carpal height ratio showed pathologic mean values. Therefore, reconstruction of the carpal alignment was not achieved in most of the cases. Progression of the osteoarthrosis has to be expected. Reconstruction of the scapholunate ligament for treatment of carpal collapse with beginning osteoarthrosis therefore remains an unsolved problem.

Development of degenerative changes in the wrist with nonunion oh the scaphoid bone

In patients with symptomatic scaphoid nonunion there was an increased evidence of progessive osteoarthrosis expressed as instability of the wrist; it is defined as a scapholunate angle more than 70 degrees or a radiolunate angle of more than 10 degrees. We tried to determine the factors of risk and prognostic indicators of degenerative arthritis. In this study 40 patients with painfull nonunion of the scaphoid were analysed. Duration of nonunion was not in correlation with development of osteoarthritic changes (p=0,644; p>0,05). Progessive degenerative changes correlated well with radiolunate angle (p=0,398; p<0,05), kapitolunate angle (p=0,381; p<0,05) and carpal index (p=0,392; p<0,05). The average values of intercarpal angles increased with progression of osteoarthritic changes. There was a statistically strong corelation between location of fracture in proximal third and presence of degenerative changes (p=0,341; p<0,01). Intesity of arthritic changes showed no statistically significant correlation regarding untreated fractures (p=0,665; p>0,05). We recommend that a scaphoid nonunion associated with carpal instability should be operated before degenerative changes develop.

Capsulodesis for the treatment of chronic scapholunate instability

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

Treatment of isolated perilunate and lunate dislocations with combined dorsal and volar approach and intraosseous cerclage wire

Purpose To determine the clinical outcome of patients with perilunate and lunate dislocations treated with a combined dorsal and volar approach and intraosseous cerclage wire. Methods A combined dorsal and volar approach with an intraosseous wiring technique was used to treat 22 isolated perilunate and lunate dislocations. The mean interval between injury and surgery was 3 days. Outcome was assessed after an average of 49 months. Patients were assessed subjectively with a Disabilities of the Arm, Shoulder, and Hand questionnaire and were asked to rate their overall satisfaction, pain relief, problems with activities of daily living, and return to work and previous activity status. Results were assessed objectively by range of motion and grip-strength measurements and initial postsurgical radiographs were compared with final radiographs with regard to scapholunate angle and gap. Results Patient satisfaction was high in 15 of 22 patients. Seven patients stated they had problems with activities of daily living after their injury. Only 10 patients returned to the same job they had before their injury; however, all 22 patients were able to return to some type of work. Sixteen of the patients stated they were able to return to their previous level of activity. The wrist flexion-extension arc and grip strength averaged 80% and 77%, respectively, compared with the opposite side. Follow-up radiographs showed no significant change in scapholunate angle or gap with time. As expected the scapholunate cerclage wire broke frequently. The cerclage wire was removed in 16 patients, 12 because of broken hardware and 4 because of pain. Conclusions Our results show that a combined dorsal and volar approach with an intraosseous wiring technique can restore effectively normal intercarpal relationships, providing acceptable pain relief, functional motion, and grip strength.

Dorsal scapholunate ligament reconstruction using a periosteal flap of the iliac crest.

To report a new technique for scapholunate ligament reconstruction, using a periosteal flap of the iliac crest. In 12 patients with static SL instability, a periosteal flap was harvested from the anterior portion of the iliac crest. Following repositioning of the carpals, the flap was fixed to the scaphoid and lunate between an incompletely osteotomised scale at the dorsal horn of the scaphoid and lunate. Pin fixation of the scapholunate (SL) and CL interval secured postoperative reduction for 8 weeks. A forearm plaster cast was worn for 12 weeks. Eleven patients, all male, were available for follow-up at an average of 29 months. The interval between trauma and surgery averaged 15 months. The preoperative SL angle measured 77 deg, CL angle was -10 deg, and SL gap amounted to 5.2 mm. At follow-up, SL angle was 59 deg, CL angle measured -2 deg, and SL gap was 2.1 mm. SL gap, SL angle, and CL angle improved significantly from preoperative to follow-up values. According to the clinical grading system of Green and O'Brian, 6 patients scored in the excellent and good category and 5 in the fair category. Using the radiologic grading system of Gickel and Millender, 9 patients scored as excellent and good, whereas the 2 poor results were due to failure of the technique. The technique enables reduction of the SL angle and SL gap in patients with static reducible scapholunate instability. The initial results are quite encouraging.

Scapholunate Dissociation Associated with Distal Radius Fracture

Purpose: To analyze the relationship of fracture patterns in cases diagnosed as scapholunate dissociation after treatment for distal radius fracture. Materials and Methods: Forty-six cases were analyzed clinically and radiographically. Twenty-four cases were treated by closed reduction and percutaneous k-wire fixation, twelve cases by closed reduction, k-wire and external fixator application, and ten cases by open reduction and plate fixation. For radiological evaluation, scapholunate gap, scapholunate angle, and radiolunate angle were analyzed to detect scapholunate dissociation and dorsal intercalated segmental instability. Results: In the 7 cases with a borderline scapholunate gap (>2 mm), 3 cases with an initial fracture line involving the interfacet prominence progressed to static scapholunate dissociation. Conclusion: Initial scapholunate gap and fracture line geometry of the distal radius were helpful for predicting progression to static scapholunate dissociation.

Treatment of scapholunate dissociation: ligamentous repair associated with modified dorsal capsulodesis.

We previously reported that our repair and/or reconstruction of the scapholunate interosseous ligament reduced the scapholunate dissociation and improved the clinical results. Re-evaluation of these patients after three years revealed that malrotation of the scaphoid advanced significantly although the clinical results declined only slightly. To prevent progression of scaphoid malrotation, a modified dorsal capsulodesis was subsequently added to the ligamentous repair of scapholunate dissociation. The records of 17 patients were available for this study. The time lapse from injury to surgical treatment ranged from four days to one year and six months. All but three patients were operated less than two months after the injury. All patients were followed for more than one year, with an average of 49 months. Clinical results were expressed by a modification of the point score method of Green and O'Brien. Scapholunate angles were measured on lateral X-ray films with the wrist in neutral position. Overall clinical results averaged 83 points (range: 25-100). The scapholunate angles averaged 49 degrees (range: 45-60). In the three patients, in whom the operation was performed more than 11 months after the injury, the clinical results averaged 38 points and scapholunate angles averaged 54 degrees, respectively. These clinical and X-ray results suggest that early repair of the scapholunate interosseous ligament along with a modified dorsal capsulodesis is a useful procedure in the treatment of scapholunate dissociation.

Carpal instability in rheumatoid wrists

This study was conducted to identify patterns of carpal instability in the rheumatoid wrist. One hundred patients with proven rheumatoid arthritis were randomly chosen, and posteroanterior and lateral radiographs of right wrists were taken. The most common isolated pattern was volar intercalated segmental instability, apparent in 16 wrists, while nine wrists had scapholunate dissociations. Larsen grading scores revealed a correlation between disease duration, carpal height ratio, and ulnar translocation index. In the early stages of disease, the scapholunate angle was significantly increased and the lunate rotated volarly due to loosening of the intrinsic carpal ligament. In later phases, the capitolunate angle significantly increased and the capitate rotated dorsally. Patterns of carpal instability in rheumatoid wrists seem to be complicated, involving combined laxity of the intrinsic and extrinsic carpal ligaments.

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.

Change of carpal alignment under anaesthesia: role of physiological axial loading on carpus

Objective. to study the effect of physiological axial loading on the carpal alignment. Design. Patients with distal radial fracture undergoing general anaesthesia for management of their injury were employed for the present study. The contralateral normal wrist was assessed for any change in carpal alignment following the elimination of the physiological axial load under anaesthesia with complete muscle relaxation. Background. Axial load across the wrist is known to affect carpal alignment. Axial compression is known to dorsiflex the lunate due to its dorsally thinned wedge shape. However, cadaveric experiments have also shown the axial compression to flex the whole proximal carpal row. Methods. Lateral radiographs of the uninjured wrist joint were performed in twenty patients with distal radial fracture. Radiographs were taken before and after giving general anaesthesia along with muscle relaxants and were repeated after applying the traction in line with the long axis of the radius. Results. Anaesthesia caused scaphoid and lunate to dorsiflex with no change in scapholunate angle while, traction caused scaphoid to rotate further dorsally. Conclusions. Physiological axial loading due to the normal tone of the forearm muscles tends to flex the scaphoid and the lunate. This is contrary to the lunate’s classical description of its tendency to dorsiflex under axial loading. Our results also failed to support the view that scapholunate interosseous ligament is in continuous tension due to the tendency of the scaphoid and lunate to move in the opposite directions. Relevance. A dorsiflexed lunate need not be considered the hallmark for diagnosing the scapholunate dissociation.

Die Behandlung der Kahnbeinpseudarthrose des mittleren Drittels durch palmare Knochenspanplastik und Schraubenfixation

Between 1984 and 1998, 178 scaphoid nonunions were treated with iliac crest bone grafting and the Herbert-screw.125 patients were followed between one and ten years with an average follow-up period of 4 years. Bony union was achieved in 89% of the patients with improvement of range of motion and grip strength. In 13 patients with DISI-defomity and SL-angle > 70°, the angulation deformity was improved with 11° average reduction of the scapho-lunate angle. At follow-up, limited athritic changes at the radial styloid were noted in 53%, compared with 33% preoperatively. Most frequent reasons for persistent nonunion were sclerosis of the proximal scaphoid fragment, technical problems related to the Herbert-screw and bone graft placement.

Scapholunate dissociation: treatment by dorsal capsulodesis

Between December 1994 and December 1996, 26 patients with a scapholunate ligament injury (three with SLD 1. degrees, 16 with SLD 2. degrees and 7 with SLD 3. degrees ) underwent an operation for dorsal capsulodesis in the Klinik für Handchirurgie, Bad Neustadt/Saale. Mean follow-up was 24 months (16 to 37 months). Follow-up criteria were range of motion, grip strength, pain relief, and X-ray findings. Clinical outcome was evaluated using a personal questionnaire, the DASH- and a modified Cooney-Score. Although significant reduction of joint mobility compared to the opposite site was found in all cases (E/F 32 %, U/R 19 %), the reduction of pain was 30 %. Grip-strength was not altered. Thus, 86 % of the patients were satisfied with the result obtained. On X-ray, the scapholunate angle was raised in the SLD 3. degrees -group by 12 degrees postoperatively; in the group with dynamic instability, X-ray findings were normal. Overall, 19 % (5/26) needed further operations due to persistent pain.

Bone-Ligament–Bone Reconstruction for Scapholunate Disruption

Bone-Ligament–Bone Reconstruction for Scapholunate Disruption