Scapholunate Ligament Repair Research Articles

Medium-Term Patient-Reported Outcomes after Surgical Management of Perilunate Injury: A Multiinstitutional Experience

Abstract Background There is a lack of consensus on the optimal treatment of perilunate injuries (PLIs). Open reduction with internal fixation with scapholunate (SL) ligament repair is recommended; however, procedures such as lunotriquetral (LT) ligament repair, carpal tunnel release (CTR), proximal row carpectomy, denervation, and arthrodesis may also be used. Purpose The purpose of this study was to assess patient-reported outcomes (PROs) after surgical management of PLIs. Methods A retrospective review of surgically treated PLIs at two institutions in a major metropolitan city from 2014 to 2020 was conducted. Demographics, radiographic data, and details of surgical management were reviewed. PROs were prospectively collected and analyzed. Results Eighty-seven patients with surgically managed PLIs were identified. The average time to surgery was 4 ± 7days. Twenty-six percent of patients presented with acute median neuropathy. Thirty-seven patients provided PROs for analysis. Patient-Rated Wrist Evaluation scores were 22 ± 12.9, 14.4 ± 11.3, and 37 ± 22 for pain, function, and total scores, respectively. Satisfaction was 7 ± 3 Sixteen percent of patients were unable to maintain employment due to their injury. The interval to return to work was 6.3 ± 7.7 months. Conclusion PLIs cause significant morbidity and affect patients' ability to return to work. While open reduction with SL repair is routinely performed to treat PLIs, additional procedures may be considered. Undergoing concurrent CTR in the absence of neurological symptoms showed no differences in outcomes. Level of Evidence Level III, retrospective cohort study.

Adjunctive Dorsal Spanning Plate Fixation in the Stabilization of Perilunate Dislocations

To compare the biomechanical properties of adjunctive dorsal spanning plate (DSP) fixation with traditional K-wire fixation of perilunate dislocations in a cadaveric model. Fourteen fresh-frozen cadaveric wrists underwent simulated perilunate injury. The specimens were randomly allocated to either K-wire fixation versus K-wire and DSP fixation. Scapholunate (SL) ligament repair was performed in all specimens. The constructs were tested using a robot cyclically and to failure. Fluoroscopic images were obtained of the specimens prior to simulated injury, after fixation, after 10 and 100 loading cycles, and at construct failure. Differences in carpal alignment parameters (SL interval, SL angle, lunotriquetral interval, and capitolunate angle) and load to failure were recorded. There were no statistically significant differences between the two group's carpal alignment parameters after fixation. Specimens fixated with K-wires and DSP required significantly higher loads to achieve construct failure. The only significant difference between the two groups' carpal alignment parameters was SL interval change at failure. Compared with K-wire fixation alone, adjunctive DSP fixation resulted in significantly increased loads to failure and decreased change in SL interval at the time of failure. Adjunctive DSP may be a useful technique in the polytraumatized patient in whom providing back a weight-bearing extremity may be advantageous in the rehabilitation process.

Surgical repair of posttraumatic injuries of the scapholunate ligament: A literature study.

Scapholunate interosseous ligament rupture can cause wrist issues like pain, strength loss, and cartilage degeneration. While various surgical treatments exist, it's unclear which method is optimal. This study aims to determine the superior treatment approach for scapholunate dissociation. In Pubmed, Embase, Scopus and Web of Science was searched for articles reporting results of surgical repair of scapholunate dissociation. Additional inclusion criteria were English- and Dutch-language articles published between January 2000 and December 2022 with at least 8 patients and at least 1 year of follow-up. Seventeen articles were included, 9 covered tenodesis repair, 2 focused on capsulodesis, 3 on direct scapholunate ligament repair using bone anchors, and 3 on a combination of tenodesis and capsulodesis. No difference could be found between the types of surgical techniques in wrist mobility and grip strength. The Disability of Arm, Shoulder, and Hand score, Visual Analogue Scale for pain and Mayo wrist scores showed no clinically relevant difference. With all methods, normal radiological values were obtained after surgery. The mean scapholunate angle was less than 60° and the scapholunate gap less than 3 mm. However, at longer follow-up an increase in this angle and gap was seen again. This review did not allow to conclude that one technique was better than another to treat scapholunate dissociation because of poor quality of the included studies. Pre- and postoperative values were not always reported, there were insufficient comparative studies, and randomized prospective studies were missing.

Description of WALANT technique in open bone and ligament wrist surgery

The gold-standard for bone, ligament and joint surgery in the wrist is locoregional anesthesia in most countries. Wide-Awake Local Anesthesia No Tourniquet (WALANT) is commonly used for simple soft-tissue hand surgery procedures such as carpal tunnel or trigger finger release, and can now also be safely used in procedures such as proximal row carpectomy, scapholunate ligament repair or partial wrist fusion, to name but a few. This article describes the use of WALANT for complex surgery in the wrist. WALANT surgery offers many known benefits, such as enhanced patient safety and comfort, simplified perioperative process and avoidance of anesthesia-related risks, and also allows the surgeon to perform intraoperative testing of the repaired structures. Thus, the surgeon can tailor the rehabilitation program and shorten recovery time. We describe detailed guidelines for performing WALANT procedures safely and effectively, making it a favorable option for complex surgeries in the wrist.

Influence of forearm rotation on the kinetic stabilizing efficiency of the muscles that control the scapholunate joint. Clinical application in proprioceptive and neuromuscular rehabilitation programs

BackgroundThis study focuses on the relationship between forearm muscles, carpal ligaments, and their impact on scapholunate joint stability across varying forearm rotations. This is crucial for optimizing pre and postoperative rehabilitation strategies for scapholunate joint dysfunction. PurposeOur study aims to understand the kinetic influence of forearm muscles on scapholunate joint instability. We emphasize the significance of forearm rotation to enhance treatment efficacy. Study DesignWe conducted an experimental study to understand how forearm muscles contribute to the stability of the scapholunate joint during different degrees of forearm rotation and we focused on the joint effect of muscle groups rather than individual muscles for treatment protocols. ResultsOur findings shed light on the conservative treatment of dynamic scapholunate instability and the postoperative rehabilitation of scapholunate ligament repair. We found that the effect of forearm muscles significantly contributes to preserve stability in the scapholunate joint across various forearm rotational positions. These insights have practical implications for hand therapists, offering innovative strategies to enhance clinical practice. ConclusionsThis research underscores the importance of considering forearm rotation when developing rehabilitation protocols for scapholunate joint instability and provides a valuable perspective in line with current rehabilitation principles.

Arthroscopic scapholunate ligament repair and dorsal capsulodesis with suture anchor in acute and subacute scapholunate dissociation

PurposeThe objective of this study was to investigate the potential of arthroscopic scapholunate ligament repair and dorsal capsulodesis with suture anchor as a treatment option for patients experiencing symptomatic acute and subacute (< 3 months) scapholunate instability.MethodsFrom Jan. 2017 to Jan 2020, 19 wrists with acute or subacute tears of the SL ligament with symptomatic instability were treated with arthroscopic SL repair and dorsal capsulodesis with a suture anchor. The average time from injury to operation was 8.8 weeks (range, 4–11 weeks) and the regular follow-up mean duration at our clinic was 26.5 months (range, 24–32 months). The pain score according to the visual analog scale, wrist range of motion, grip strength, radiographic outcomes and functional outcomes according to the Modified Mayo Wrist Score (MMWS) were evaluated preoperatively and postoperatively during the follow-up period.ResultsAll 19 patients had rupture and dissociation of the SL ligament in the radiocarpal joint. The total arc of wrist motion in the flexion–extension plane loss averaged 5.1° (P > .01).The Wilcoxon signed-rank test was used to compare the results: grip force improved significantly with 14.7% improvement of that on the normal side (P < .01); the postoperative MMWS was significantly better than the preoperative scores (P < .01). Of 19 patients of the series, 18 patients (94.7%) achieved good or excellent results according to the MMWS and 16 patients (84.2%) resumed their previous activities. Only one patient (5.3%) had residual laxity of the scapholunate ligament joint at 15 months of follow-up.ConclusionsAt a minimum of two years of follow-up, patients with acute or subacute symptomatic dissociation of scapholunate ligament instability who underwent arthroscopic scapholunate ligament repair and dorsal capsulodesis with suture anchor treatment had satisfactory results.Level of EvidenceLevel IV, case series.

Combined repair of scapholunate ligament (SL) and triangular fibrocartilage complex (TFCC) lesions in chronic trauma of the wrist: surgical treatment of 14 patients.

Injuries of the scapholunate ligament (SL) and of the triangular fibrocartilage complex (TFCC) represent the main ligament injuries of the traumatic wrist. A double injury of the SL and TFCC ligaments is quite common in the trauma setting, and clinical examination is fundamental. MRI allows to detection of a TFCC and SL ligament injury, but wrist arthroscopy is still the gold standard for diagnosis. We present the clinical results of the combined reconstruction of chronic scapholunate ligament and TFCC injury. Fourteen patients were treated at our hospital with a combined scapholunate ligament and TFCC complex repair. All patients were surgically treated by the same senior author, after a diagnostic arthroscopy that revealed a lesion of both structures. A comparison between the pre-operative and post-operative pain and function was carried out using VAS, Disability of Arm, Shoulder and Hand score (DASH) and Patient-Related Wrist/Hand Evaluation score (PRWHE). Wrist range of motion and strength were also compared following surgery. All patients had a mean follow-up of 54months. A statistically significant improvement was observed both with the reduction in pain (VAS from 8.9 to 5) and with the improvement of functionality scores (DASH from 63 to 40 and PRWHE from 70 to 57) and with the increase in ROM and strength. In only one patient (7%), because of pain and instability, a supplement operation was needed (Sauve-Kapandji procedure) 3months after the initial surgery. The simultaneous repair of the SL and TFCC complex has shown a good success rate in both decreasing pain and regaining functionality.

Evaluation of treatment results of perilunate dislocation by open reduction and repair of the scapholunate ligament

The study aims to evaluate the treatment results of perilunate dislocations treated with open reduction and scapholunate ligament (SLL) repair. The results showed that the majority of patients had no pain and wrist function was restored well. After surgery, the majority of patients (29 out of 32) had relief from pain. The average wrist motion was 77.93o extensions, 73.69o flexions, and the mean grip strength was 41.35±5.15 kg. which was 93.56% of the normal side. There was 26 excellent, 1 good, and 5 satisfactory results. The average follow-up time was 32.35 months. Surgical procedures included open reduction and SLL repair. The average functional score is 81.30 (very good). Thus, open reduction and SLL repair gave satisfactory results to subacute and acute perilunate dislocations of the wrist. This technique achieved a relatively pain-free wrist with good grip strength and average SL distance.

SHOULD ALL ISOLATED RADIAL STYLOID FRACTURES BE ASSESSED ARTHROSCOPICALLY FOR CONCOMITANT SCAPHOLUNATE LIGAMENT INJURY?

Chauffeur fractures or isolated radial styloid fractures (IRSF) are known to be associated with scapholunate ligament (SL) injuries. Diagnosis without arthroscopic confirmation is difficult in acute fractures. Acute management of this injury with early repair may prevent the need for more complex reconstructive procedures for chronic injuries. We investigated if all IRSF should be assessed arthroscopically for concomitant SL injuries.We performed a prospective cohort study on patients above the age of 16, presenting to the Gold Coast University Hospital with an IRSF, over 2 years. Plain radiographs and computerized tomography (CT) scans were performed. All patients had a diagnostic wrist arthroscopy performed in addition to an internal fixation of the IRSF. Patients were followed up for at least 3 months post operatively. SL repair was performed for all Geissler Grade 3/4 injuries.10 consecutive patients were included in the study. There was no radiographic evidence of SL injuries in all patients. SL injuries were identified arthroscopically in 60% of patients and one third of these required surgical stabilisation. There were no post operative complications associated with wrist arthroscopy.We found that SL injuries occurred in 60% of IRSF and 20% of patients require surgical stabilisation. This finding is in line with the literature where SL injuries are reported in up to 40-80% of patients. Radiographic investigations were not reliable in predicting possible SL injuries in IRSF. However, no SL injuries were identified in undisplaced IRSF. In addition to identifying SL injuries, arthroscopy also aids in assisting and confirming the reduction of these intra-articular fractures.In conclusion, we should have a high index of suspicion of SL injury in IRSF. Arthroscopic assisted fixation should be considered in all displaced IRSF. This is a safe additional procedure which may prevent missed SL injuries and their potential sequelae.

Outcomes of Acute Versus Subacute Scapholunate Ligament Repair

PurposeThis study investigated the long-term outcomes of direct scapholunate ligament (SLL) repairs with or without dorsal capsulodesis performed within 6 weeks (acute repair) of a SLL tear versus 6 to 12 weeks following injury (subacute repair).MethodsA review of medical records from April 1996 to April 2012 identified 24 patients who underwent SLL repair (12 acute, 12 subacute). Patients returned to the clinic for radiographic examinations of the injured wrist, standardized physical examinations, and validated questionnaires.ResultsThe mean follow-up times for the acute and subacute groups were 7.2 and 6.2 years, respectively. At the final examination, patients with acute surgery regained more wrist extension (acute = 55°, subacute = 47°). The total wrist flexion-extension arcs, grip strengths, pinch strengths, and patient-rated outcome scores were found to be similar between groups. The final scapholunate gap, scapholunate angle, and the prevalence of arthritis were also found to be similar between the acute and subacute groups.ConclusionsAlthough SLL repair is more commonly recommended for treatment of acute SLL injuries, there were no significant long-term differences between acute and subacute SLL surgeries (repair ± capsulodesis).Type of study/level of evidencePrognostic III.

Is the Dorsal Fiber-Splitting Approach to the Wrist Safe? A Kinematic Analysis and Introduction of the “Window” Approach

To compare the kinematic effects of the dorsal fiber-splitting approach for scapholunate ligament repair to a dorsal "window" approach that spares all ligaments. We randomized 24 fresh-frozen paired cadaveric forearms to either the dorsal fiber-splitting capsulotomy approach (FSC) or the dorsal window approach (window) following scapholunate interosseous ligament(SLIL) division. Loaded fluoroscopic radiographs were obtained after each of the 4 testing conditions following cyclic loading (200 cycles; 71 N): (1) intact SLIL, (2) SLIL-division, (3) surgical approach, and (4) closure. FSC specimens were randomly allocated to 2 subgroups for closure with either a suture anchor (n= 6) or a simple running suture closure (n= 6). Radiographic parameter measurements included the scapholunate gap, radiolunate angle, scapholunate angle, and dorsal scaphoid translation. Following the FSC, there were significant alterations in all radiographic parameters when compared with the intact and SLIL-division conditions. The window approach did not result in significant changes in any radiographic parameter. When compared to the window approach, all radiographic parameters of the FSC approach were significantly altered. Following closure with suture anchors in the FSC group, radiographic parameters improved, whereas with standard closure they failed to do so. Despite anchor closure, dorsal scaphoid translation, radiolunate angle, and scapholunate angle all remained elevated compared with scapholunate-divided wrists. The FSC produced significant changes in carpal posture under load, including scapholunate diastasis, dorsal intercalated segment instability, and dorsal scaphoid translation in SLIL-deficient wrists. The window approach preserved the critical dorsal ligament stabilizers and did not produce changes in carpal posture. The FSC may create iatrogenic changes in carpal posture that cannot be fully corrected with standard or anchor closure. The window approach does not alter carpal posture and should be considered when performing surgical procedures on the scaphoid or lunate.

Long-term Outcomes of Delayed Scapholunate Ligament Repair After Complete Rupture of the Ligament.

Treatment of isolated complete tear of the scapholunate ligament is challenging. The purpose of this study was to determine (1) whether delayed repair of only scapholunate ligament is an option without other reconstruction procedures and (2) whether functional outcomes are possible despite radiographic presence of arthritis. This study included patients who had complete ligament tear at exploration and underwent only scapholunate ligament repair without capsulodesis or tenodesis. Fifteen patients returned for clinical and radiographic examinations. Preoperatively, mean scapholunate gap was 2.9 mm and 4.58 mm on posteroanterior and tangential posteroanterior views, respectively. Postoperatively, the final mean gap was 2.5 mm and 3.9 mm on the posteroanterior and tangential posteroanterior views, respectively. The mean preoperative and final scapholunate angles were 74° and 72.6°, respectively. Seven patients had radiographic arthritis at final follow-up. Delayed scapholunate repair is possible after complete ligament tear. At long-term follow-up, clinical functional outcomes may not correlate with radiographic presence of degenerative arthritis. [Orthopedics. 2021;44(3):e446-e453.].

Early Outcomes of Scapholunate Injuries With Concomitant Distal Radius Fractures.

Background: There is limited literature regarding the treatment of concomitant scapholunate ligament (SL) injuries in acute distal radius fractures (DRFs). We hypothesized that surgical treatment of SL injuries in adult patients with DRFs leads to improved functional outcomes. Methods: A retrospective review was made of 42 adult patients who underwent surgical treatment of a DRF with a SL injury between 2005 and 2013. In all, 39 of the 42 patients sustained an intra-articular DRF (AO B or C). SL injury was diagnosed by SL diastasis > 3 mm on posteroanterior (PA) radiographs, magnetic resonance imaging, or with wrist arthroscopy. Patients were divided into 3 groups: 23 had a SL repair and were treated within 21 days of injury (acute), 8 underwent SL repair greater than 21 days from injury (subacute/chronic), and 11 did not undergo repair (non-operative). Median overall time to clinical follow-up was 5.1 years. Mayo Wrist Scores (MWS) and Disabilities of the Arm, Shoulder and Hand (DASH) scores were used to evaluate functional outcome. Results: Clinical outcomes measured by the MWS at final follow-up (6 months-12 years) showed no significant differences between the 3 groups. Of patients treated acutely, 17.3% had good to excellent MWS. MWS at 1-year follow-up was 68.4, 70, and 64 in the acute, subacute/chronic, and non-operative groups, respectively. DASH scores were 16.7, 14.3, and 11.8 in the acute, subacute/chronic, and nonoperative groups, respectively, at a mean of 7.8 years. Conclusions: At mid-term follow-up, all 3 treatment groups had similar DASH scores to the general population. There were no statistical functional differences between any of the groups based upon MWS or DASH scores.

Clinical application of Acutrak screws in the treatment of fresh scaphoid fractures

Objective To investigate the method and short-term effects of Acutrak screws in the treatment of fresh scaphoid fractures. Methods From January 2011 to January 2015, 11 cases of scaphoid fractures were treated by Acutrak headless compression screws. According to Herbert's classification, one case was type B1, 6 cases were type B2, 2 cases were type B3, and 2 cases were type B4. Volar approach was used in 7 cases, dorsal approach in 3 cases, and combined approach in 1 case. Two cases of type B4 had scapholunate dissociation and were treated by open reduction and fixation with simultaneous repair of scapholunate ligament. After the operation, short arm plaster fixation was used and exercises were gradually carried out after immobilization for 2 to 3 weeks. Results Postoperatively all the patients were follow-up for 12 to 24 months with an average of 16.5 months. The time of fracture healing was 7 to 15 weeks with an average of 11.4 weeks. According to the Mayo scoring system, wrist function at the final follow-up was rated as excellent in 6 cases, good in 3 cases and fair in 2 cases. Conclusion Acutrak headless compression screws can achieve reliable fixation and satisfactory treatment results. Key words: Scaphoid bone; Fractures,bone; Internal fixation; Screw

Indications, techniques, and outcomes of arthroscopic repair of scapholunate ligament and triangular fibrocartilage complex.

This review includes updated understanding of the roles of intrinsic and extrinsic carpal ligaments in scapholunate instability and details the author's experience of indications, arthroscopic repair methods, and outcomes of treating the instability. A classification on triangular fibrocartilage complex injuries is reviewed, followed by author's indications, methods, and outcomes of arthroscopic repair of triangular fibrocartilage complex injuries.

Outcomes of Acute versus Subacute Scapholunate Ligament Repair: Level 3 Evidence

Hypothesis: It is currently unknown whether time from injury affects outcomes following repair of dorsal scapholunate ligament (SLL) tears. We tested the null hypothesis that the outcomes of SLL repair are similar when performed within 6 weeks of injury (acute repair) versus when repaired from 6 to 12 weeks following injury (subacute repair). Methods: This case-control study examined 22 patients (12 acute repair, 10 sub-acute repair) who underwent dorsal SLL repair for isolated complete tears of the SLL, with or without supplementary capsulodesis. Patients who underwent SLL repair for complete rupture of the dorsal SLL between 1996 and 2012 were identified from an electronic billing database. Demographic data (age, sex, BMI, occupation, tobacco use) was recorded and radiographic measurements (SL angle and SL gap) were determined from preoperative radiographs. All patients returned to clinic for a study-related visit including radiographic examination of the injured wrist (PA, lateral, supinated PA grip view), physical examination (wrist range of motion, strength testing) and standardized questionnaires (Michigan Hand Questionnaire, VAS-function and pain, SF-12). Analyses were performed on all categorical and continuous data to compare acute and subacute repair groups (P < 0.05). Results: The median length of follow-up for the acute and sub-acute groups were 5.5 and 6.1 years, respectively (Table 1). There was no significant difference in any of the variables between the two groups. The groups were near identical with regard to final SL angle (acute: 66 , subacute: 65 ), final SL gap (3.0 mm, 2.9 mm), and proportion of cases that progressed to scapholunate-advanced collapse (2/12, 2/10). Patient-rated outcomes were not different between patient groups (Table 2). Wrist motion (P 1⁄4 0.20) and forearm motion (P 1⁄4 0.21) were also comparable for the acute and subacute repairs. Both acute and subacute repairs demonstrated well-preserved grip strength (98% of unaffected versus 90%) (P 1⁄4 0.29). Summary Points: At a median follow-up of 5.5 and 6.1 years, respectively, no statistically significant or clinically relevant differences were found when comparing radiographic findings, patient rated outcomes and wrist motion following acute and subacute SLL repair. Acute and subacute repairs of the SLL demonstrate similar rates of progression to end-stage arthritis. Whether treated within 6 weeks or 12 weeks of injury, SLL repair may produce a similar outcome when reparable ligamentous tissue exists. REFERENCES

Scapholunate instability after distal radius volar plating.

Prior to volar locked plating and early motion protocols, ligamentous injuries incidentally associated with distal radius fractures may have been indirectly treated with immobilization. Our goal was to determine the prevalence of scapholunate instability in our population, while identifying those who may have had progression of instability. We retrospectively reviewed 221 distal radius fractures treated with a volar locking plate during a 6-year period. Average patient age was 59years. Standard posteroanterior and lateral radiographs from the first and last postoperative visits were analyzed for scapholunate instability, using the criteria of scapholunate gap ≥3mm and scapholunate angle ≥60°. Six patients (3%) met neither or only one criterion for instability at the first postoperative visit and did not have ligament repair and then went on to meet both criteria at the last postoperative visit after an early motion protocol. Seven patients (3%) met both criteria at the first and last postoperative visits and did not have ligament repair. Five patients (2%) underwent primary scapholunate ligament repair at the time of distal radius fixation. In our representative population, scapholunate instability was uncommon, either from initial injury or possible progression of occult ligament injury, despite early motion without operative treatment of the ligament. Thus, we did not find strong evidence for routinely delaying motion or pursuing further workup. When early radiographs clearly demonstrate acute scapholunate instability, more aggressive treatment may be appropriate for selected patients.

The role of arthroscopy for treatment of perilunate injuries.

Background Open reduction with internal fixation (ORIF) is currently the gold standard treatment of acute perilunate injuries (PLIs). Less invasive surgery, including arthroscopic techniques, has recently emerged in the hope that results similar to those of ORIF could be obtained with less tissue disturbance. Our purpose was to review retrospectively a series of selected PLIs treated with arthroscopic assistance over the past 10 years. Materials and Methods Between 2004 and 2014, a total of 135 acute PLIs were surgically treated in our unit. A total of 27 patients were treated with arthroscopic assistance, among whom 18 were reviewed clinically and radiologically. Description of Technique After an initial closed gross reduction, radio- and midcarpal arthroscopy were performed to clean up the debris and assess the cartilaginous, bony, and ligamentous damage. In 22 cases arthroscopy was followed by either radiolunate and lunotriquetral pinning, scapholunate ligament repair, and SL joint pinning or ORIF of a scaphoid fracture through a mini-invasive dorsal approach. In the remaining six cases, fixation of the ligamentous and/or bony injuries was done using arthroscopy alone. Results Arthroscopic findings are presented as well as the clinical results in a subgroup of patients. At final follow-up, visual analog scale (VAS) pain was rated 18/100 on average (minimum 0, maximum 50). If we consider only the patients without reflex sympathetic dystrophy (RSD; n = 14), the average active wrist flexion-extension was 87° (58% of the normal contralateral side) and the average grip strength was 30 kg (71% of the normal contralateral side). Conclusions Although no statistical comparisons were made, we found that the results were similar to those of ORIF. The results of our study suggest that the use of arthroscopy to treat selected PLIs may be a reliable adjunct either alone or in combination with a dorsal mini-open approach.

Treatment of an unusual trans-scaphoid perilunate avulsion fracture dislocation: a case report.

We describe an unusual case of trans-scaphoid perilunate injury where the proximal half of the scaphoid avulsed from all attaching ligaments and extruded into the forearm. Treatment involved anatomic reduction and internal fixation of the fracture, scapholunate (SL) ligament repair, temporary K-wire fixation, and prolonged immobilization. At 19-month follow-up, the fracture healed, SL ligament remained intact, and the patient recovered much of his hand function.

Scaphoid Overstuffing: The Effects of the Dimensions of Scaphoid Reconstruction on Scapholunate Alignment

Osteochondral replacement of the proximal scaphoid has been reported using a vascularized flap from the medial femoral trochlea. A concern with this technique is the loss of stability of the scapholunate relationship with resection of the scaphoid proximal pole. Overexpansion of the scaphoid dimensions (overstuffing) during scaphoid reconstruction with the osteochondral flap may play a role in maintaining scapholunate alignment. Our purpose was to determine if overstuffing the scaphoid can correct rotatory carpal instability in a cadaveric model studied radiographically. The radiolunate angle and scapholunate interval were measured for 5 fresh cadaver wrists. We completely incised the scapholunate interosseous ligament and performed an osteotomy to excise the proximal third of the scaphoid to simulate a proximal pole deficiency nonunion and create a dorsal intercalated segmental instability deformity. Radiographic measurements were repeated. The proximal pole of the scaphoid was replaced with its original piece of bone; radiographic measurements were repeated without scapholunate ligament repair. The osteotomy site was overstuffed with a 4-mm sawbone spacer without scapholunate ligament repair, and radiographs were obtained. Sectioning of scapholunate ligaments and proximal pole excision successfully created carpal instability demonstrated by abnormal radiolunate angles. Without ligament repair, proximal pole replacement did not restore normal radiolunate angles. Expansion of the scaphoid dimensions corrected radiolunate angles on lateral unloaded radiographs and improved scapholunate intervals on clenched fist radiographs. These findings were statistically significant compared with the unexpanded (replaced) scaphoid. These findings suggest that scaphoid reconstruction that results in expansion of the scaphoid's normal dimensions will restore carpal alignment without scapholunate ligament reconstruction. Osteochondral reconstruction of difficult proximal pole nonunions may not require any preservation or reconstruction of scapholunate integrity if the reconstruction expands the normal dimensions of the native scaphoid. Scapholunate interval and carpal alignment may be restored by scaphoid over stuffing. The effects on increased contact pressure and range of motion require further investigation.