Scapholunate Reconstruction Research Articles

Cadaveric scapholunate reconstruction using the ligament augmentation and reconstruction system.

Background Untreated scapholunate ligament disruption may lead to progressive wrist arthritis. Current techniques used to treat the disruption may not prevent arthritis because of attenuation of a reconstructive ligament substitute or failure to re-establish normal wrist kinematics. Questions/Purposes This study evaluates a combined synthetic-autologous technique for the treatment of scapholunate dissociation. Methods Scapholunate dissociation was created in six cadaveric wrists. The dorsal and volar components of the scapholunate ligament were reconstructed using the Ligament Augmentation & Reconstruction System (LARS; LARS, Arc-sur-Tille, France) and a modified Blatt capsulodesis performed. Reconstructed wrists were subjected to cyclic passive motion. Outcomes were measured radiologically and compared using Student's t-test. Results Carpal alignment was re-established following scapholunate ligament reconstruction. Carpal alignment was maintained after cyclic loading. Conclusions The technique described corrected the carpal malalignment associated with scapholunate dissociation. Corrected positions were maintained after one thousand cycles of flexion and extension without fraying or loosening of the LARS. Clinical Relevance Current popular techniques for scapholunate reconstruction do not address the important dorsal and palmar components of the ligament that control their intercarpal motion. Reconstruction of the dorsal and palmar components of the scapholunate ligament can be achieved through a dorsal approach to the wrist.

EARLY RESULTS OF COMBINED PALMAR-DORSAL SCAPHOLUNATE LIGAMENT RECONSTRUCTION

Isolated dorsal scapholunate reconstruction may be inadequate to stabilize and restore physiological scapholunate kinematics in the setting of combined dorsal and palmar ligamental incompetence. To address this entity, a combined reconstruction that encompass both dorsal and palmar scapholunate reconstruction was performed in 20 patients followed up to 19.8 (6-84) months. Compared to the contralateral wrist, the results were extension (67 ± 1.6 to 85.7%, p < 0.01), flexion (84.5 ± 3.2 to 81 ± 2.3%, p = 0.38), grip strength (62 ± 1.6 to 88.3 ± 1.9%, p < 0.01), and pain score (rest: 1.55 ± 0.26 to 0.2 ± 0.09, p < 0.01; activity: 3.2 ± 0.09 to 0.4 ± 0.17, p < 0.01). Based on Mayo wrist score, five excellent, 13 good, and two fair results were reported.

Scapholunate Ligament Reconstruction

Background Scapholunate reconstruction poses a challenge to orthopedic surgeons. Materials and Methods Prospective cohort. Description of Technique Our technique for scapholunate (SL) reconstruction involves ligament reconstruction utilizing a portion of the flexor carpi radialis tendon rerouted via transosseous tunnels across the scaphoid, lunate, and triquetrum (scapholunotriquetral tenodesis). The tendon graft is secured with interference screw fixation into the triquetrum. The philosophy of this new technique is to reduce subluxation and maintain the relationship between scaphoid and lunate by placing a graft through the center of the SL articulation. This graft is then tensioned by passing it centrally through the lunate and triquetrum and secured using an interference screw in the triquetrum. Secondary stabilizers, including the dorsal intercarpal ligament, are then augmented by passing the graft back to the scaphoid, crossing from the triquetrum over the proximal capitate. This further reinforces the translational relationship between the scaphoid and the triquetrum and, therefore, augments stability of the SL articulation. Results We have utilized this technique successfully in over 40 patients since 2009. We report on a prospective consecutive series of 11 patients with over 12 months follow-up (range 12 to 24 months) demonstrating good early radiological and clinical outcomes. Conclusions In developing this technique, we aimed to take the best features of previously described techniques and address the perceived shortcomings of each. We believe there are several benefits of our technique. Moreover, few other techniques address as many of the aspects of chronic SL instability as our technique does.

Cable-augmented, Quad Ligament Tenodesis Scapholunate Reconstruction

Eight patients underwent scapholunate reconstruction using tensionable suture anchors. Adapted from a modified Brunelli technique, the anchors provide a fixed cable that reduces the scapholunate diastasis and maintains reduction during the healing phase. The flexor carpi radialis tendon graft is advanced through the scaphoid and stabilizes the volar scaphotrapezial ligament, dorsal scapholunate ligament, dorsal intercarpal ligament, and dorsal radiocarpal ligament. The ligament-sparing approach is closed using an ulnar advancement capsulodesis that further reinforces the dorsal intercarpal and dorsal radiocarpal ligament. Good clinical results were obtained. Measured on a visual analog scale (0 to 10), the average pain score improved from 5.8 to 2.1, average patient satisfaction was 7.6, average extension was 56 degrees (91% of contralateral side), flexion was 44 degrees (70% of contralateral side), and grip was strength 41 kg (95% of contralateral side). Radiographic parameters were less favorable. The average scapholunate angle was 71 degrees, radiolunate angle 16 degrees, and scapholunate interval 3.0 mm. The cable-augmented, quad ligament scapholunate ligament reconstruction offers theoretical advantages over previously published techniques, but long-term follow-up is required.

The Use of Temporary Screw Augmentation for the Treatment of Scapholunate Injuries

Injuries to the scapholunate (SL) interosseous ligament can have devastating consequences to carpal stability. The purpose of this study is to provide a technique for screw augmentation to SL reconstruction, while comparing radiographic outcomes to a traditional Kirschner wire fixation cohort. A retrospective review of all patients treated by screw fixation for SL ligament injuries was cross-matched to a cohort of patients treated with pin fixation for age and length of time from the time of injury to surgical fixation. Outcomes were the values of SL gap and SL angle on plain radiographs as averaged between 2 independent reviewers, as well as complications. Seven patients who received screw augmentation had an average follow-up of 8.7 months. When compared with the Kirschner wire cohort, there was improvement of immediate postoperative gap in the screw cohort of 3.1 versus 1.3 mm. There was also better reduction in SL angle in the screw group (22 vs. 10.4 degrees correction). At 4 months follow-up, both the SL gap and SL angle were maintained better in the screw group. There was 1 infection in each cohort, 1 pin migration in a screw/pin combination patient counted in the screw group, and 1 pin migration in the pin cohort. Our study suggests that temporary screw augmentation for SL ligament injuries results in more effective SL gap and SL angle correction both immediately and in short-term follow-up than does pin fixation. Longer follow-up is needed to evaluate longevity of reduction, and larger, prospective studies with clinical outcomes are needed to show statistically significant benefits to screw augmentation.

A New Bone-Ligament-Bone Autograft From the Plantar Plates of the Toes and Its Potential Use in Scapholunate Reconstruction

The study was performed to investigate a new bone-ligament-bone autograft from the plantar plate of the toes. The anatomic properties of the plantar ligaments and the technical feasibility to harvest a bone-ligament-bone graft were examined to evaluate the potential use of this graft for a suitable reconstruction of the scapholunate (SL) interosseous ligament. The plantar plate of the metatarsophalangeal joints of the second to fifth toe and the proximal interphalangeal joints of the second to fourth toe were examined in 20 cadaver feet (15 fresh and 5 embalmed cadavers) and measurements such as length, thickness, and width were taken. The average length of the plantar ligaments of the proximal interphalangeal joint was 0.63 cm (D3) and 0.62 cm (D4). The length of the plantar plates of the proximal interphalangeal joint of the third and fourth toe was found to be similar to that of the SL ligament. In addition to the measurements, a bone-ligament-bone autograft of the plantar plates of the metatarsophalangeal joint was designed as an SL-ligament substitute and successfully transplanted into cadaveric wrists. This new autograft is intercalated between the scaphoid and lunate and, contrary to all previous methods, not simply superimposed upon them. Length of the plantar plates was considered by the authors as the main criteria for selection of the new bone-ligament-bone graft. The plantar plate of the proximal interphalangeal joint of the third and fourth toe showed a similar length compared with the SL ligament. Therefore, it can be concluded from the data that this bone-ligament-bone graft can be a suitable replacement for the SL ligament.

Scapholunate ligament reconstruction using a periosteal flap of the iliac crest: a biomechanical study.

Advances continue to improve direct reconstruction of the dorsal scapholunate (SL) ligament, which is the strongest part of the entire SL ligament and is known as the turning point between the scaphoid and lunate. This study was designed to compare the biomechanical properties of the dorsal SL ligament with those of a periosteal flap of the iliac crest, which is a new graft candidate for dorsal SL reconstruction. A bone-ligament-bone complex was harvested for biomechanical testing from the iliac crest and the dorsal SL complex. Ten specimens could be prepared in each group. After potting the bone blocks in methylmethacrylate for stable fixation, the specimens were tested, using a servohydraulic testing system, at a rate of 10 mm/min. Failure displacement, failure force, failure stress, energy to failure, and stiffness were assessed for both groups. Eight specimens in each group were tested successfully. In the ligament group, six specimens failed at the ligament level, whereas two failed at the insertion of the scaphoid. In the periosteum group, all eight specimens failed at the ligament level. The failure force of the dorsal SL ligament averaged 171.8 N, failure stress was 10.3 N/mm2, and failure displacement amounted to 2.9 mm. Energy to failure was 269.1 N-mm, and stiffness averaged 77.2 N/mm. Failure force of the periosteal flap amounted to 144.3 N, failure stress was 9.9 N/mm2, failure displacement was 3.0 mm, and energy to failure was 217.9 N-mm. Stiffness of the periosteal flap measured 60.5 N/mm. Comparison of the dorsal SL ligament and the periosteal flap of the iliac crest revealed no significant biomechanical differences. Therefore, the biomechanical properties of the periosteal flap recommend its use for reconstruction of the dorsal SL ligament.