SLAC Wrist Research Articles

Identification and treatment of scapho-lunate injuries

Scapholunate tears subsequent to wrist trauma may potentially created carpal instability and lead to degenerative arthritis (SLAC wrist) in the late stages. This is why it is necessary to early identify these injuries and possibly treat them in order to prevent arthritis. Arthroscopic examination of the wrist can directly visualize these injuries and then it is possible to treat them under arthroscopy or open. The Ewas classification, which is an evolution of Geissler Classification, has developed in order to define the type of injuries and to identify the site of anatomical damage, which has occurred in each patient. It also allows to choose the more appropriate treatment in each stage. Materials and methods Twenty-one patients affected by SL ligament injuries were treated and examined under arthroscopy. There were 1 stage I, 3 stage II, 4 stage IIIA, 1 stage IIIB, 7 stage IIIC, 2 stage IV and 3 stage V (static instability). Patient affected by stage I and II were treated by immobilisation alone, patients affected by stage IIIA were treated by pinning (acute and chronic), patients affected by stage IIIB and IIIC were treated by pinning in acute cases and capsulodesis (open or arthroscopic) in chronic cases. In stage IV, patients were treated by tendon reconstruction of SL ligament with a modified Brunelli technique. Patients were aged 16–57-year-old. Patients were reviewed at a mean follow-up of 3 years (6 months–9 years) and evaluated with Mayo score and Dash score. Results Twenty patients obtained an excellent or good clinical result, one fair result was obtained in a patient who had a stage 5 with initial radio-scaphoid osteoarthritis (Slac I–II). We had one case of pin-tract infection treated by oral antibiotic for 1 week. The best results were obtained in the early stages. Discussion and conclusion Early detection of SL injuries is important to prevent developement of arthritis and wrist arthroscopy is mandatory for this purpose. Ewas classification seems effective in guiding the treatment in pre-dynamic cases and dynamic cases has given excellent and good results in the great majority of cases. In later stages (static instability), Garcia-Elias criteria are of utmost importance to guide the treatment.

Dorsal locking plates versus staples in four-corner fusion: A comparative clinical and radiological study

IntroductionFour-corner fusion was described in 1984 by HK Watson for the treatment of SLAC wrist. This intervention has undergone few changes since that description, but the debate on the fixation method is still not resolved. HypothesisDorsal locking plates provide better stability, short immobilization and a quicker return to daily activities than traditional fixation methods such as staples. Materials and methodsThirty-one fusions using the Medartis Aptus Four-Corner Fusion® plate at a mean 13.1months’ follow-up and 35 using staples at a mean 80.4months’ follow-up were reviewed in a clinical and radiographic retrospective comparative study. ResultsResults were comparable between the two groups in terms of range of motion (flexion-extension arc of 67.3° for plates and 60.6° for staples), force (29.6 and 28kg.F), pain and disability (PRWE 34.8/150 and 40.9; QuickDASH 19.83/100 and 30). Mean time off work was significantly shorter in the plate group (4.5 vs. 7.9months). There were no non-unions in the plate group, versus 2 in the staples group. Dorsal impingement implicating hardware was also less frequent in the plate group (2 vs. 11). DiscussionThe dorsal locking plate did not improve final results in four-corner fusion in terms of range of motion, force, pain or function compared to staples. However, it provided stable fixation, allowing a shorter immobilization and a quicker return to work. Although the initial cost is higher, it could allow significant savings on postoperative costs, shifting the technical debate into the field of public health. Level of evidenceLevel IV, retrospective study.

When and which treatment for scapho-lunate ligament lesions?

The lesions of the scapholunate ligament are some of the most frequently encountered in the wrist. Left untreated, the complete rupture of the ligament is followed by degenerative arthritis according to a well-defined pattern of progression through the wrist, eventually leading to multifocal arthrosis, a condition described as scapholunate advanced collapse (SLAC wrist). The scapholunate lesions are classified in stages according to the degree of the lesion established by imaging studies or arthroscopy and to the chronicity of the lesion. Both together essentially determine the healing potential and the prognosis, which rapidly decrease after six weeks from the initial trauma, thus indicating the importance of recognizing the acute or subacute lesion and directing the patient to the hand surgeon early enough. The therapeutic options are notably reduced and often of palliative nature in case of chronic lesions with secondary changes in the wrist mechanics or cartilage damage.

Scapholunate Ligament Injuries: A Review of Current Concepts

Injuries to the scapholunate ligament are common, especially among young active individuals. Surgeons are faced with a difficult problem because of imperfect surgical outcomes and the high demands of this patient population. Here, we review the current concepts and newest literature on scapholunate ligament injuries as well as the classification and treatment options for each stage of scapholunate instability. Emphasis is on stages in which reconstructive rather than salvage procedures can be performed. The natural history is poorly understood; it is unknown which and how many scapholunate injuries lead to wrist arthritis (SLAC wrist). Partial injuries are rare and in small studies did well with arthroscopic treatment. Complete injuries are graded based on the acuity of the injury, the presence and reducibility of scapholunate malalignment, and, finally, cartilage status. In acute injuries, anatomic repair usually leads to satisfactory results, and many authors augment the repair with a capsulodesis technique. In chronic injuries, the presence of static malalignment usually leads to inferior outcomes. Various techniques have been devised and improved over the years. These techniques appear to provide a more anatomic reconstruction, with less loss of motion; motion is 60-80% of the contralateral side and grip strength averages 65-90%. Once there is cartilage loss, the surgeon only has salvage procedures to choose from, tailored to the degree of arthritis.

BONE GRAFTING IN FOUR-CORNER MID-CARPAL FUSION

Four-corner fusion is an accepted surgical treatment for established SLAC and SNAC wrist. We describe a technique of bone grafting to be used in conjunction with any of the standard fusion techniques. A step by step, illustrated approach allows the easy placement of an autograft which is in contact with all surfaces of the bones involved in the fusion.

Arthrodèse médiocarpienne par vis-broches à compression

Indication of midcarpal fusion is SNAC or SLAC wrist grade 3. The main complication of circular plate (most common technique) is non-union. In this context, the purpose of our work was to propose the use of break-away compression screws to decrease the rate of non-union. Our series included ten patients. The fusion was fixed using two break-away compression screws (2mm diameter). No bone graft was used. As assessment, subjective (pain, Quick-DASH) and objective (strength, mobility) criteria were reviewed at follow-up. All the criteria were significantly improved after operation except mobility. Among the complications, we noticed one delayed bone-healing with a good outcome and a radiological consolidation. Midcarpal fusion by dorsal approach using break-away compression screws appears to us a technique of interest, not requiring a bone graft, with good cost effectiveness.

Comparison of Wrist Kinematics and Functional Performance between Surgical Treatments for SLAC Wrist: Level 2 Evidence

Comparison of Wrist Kinematics and Functional Performance between Surgical Treatments for SLAC Wrist: Level 2 Evidence

A new plate for partial wrist fusions: results in midcarpal arthrodesis

Partial wrist fusions are commonly performed for various degenerative conditions. In this series 30 wrists had a scaphoidectomy and midcarpal arthrodesis performed with a new plate. The most common indications were SLAC and SNAC wrists. In 24 cases a four-corner arthrodesis was done and in the other six the triquetrum was not included. Mean follow-up was 3 years. Mean flexion was 31° and extension 35°. Union was achieved in all wrists despite movement being commenced early. The plates proved straightforward to use, allowing some latitude in placement. This series confirms that scaphoidectomy and midcarpal arthrodesis is a useful salvage procedure and that these plates are suitable for that purpose.

Reconstruction radiocarpienne par transfert en îlot de l’articulation radio-ulnaire distale

Introduction We described the island transfer of the DRUJ to reconstruct the radiocarpal joint when the radiocarpal and the mediocarpal joints are destroyed. The objective is to avoid wrist arthrodesis or prosthesis. Patients and method From 1993 to 1997, five patients were operated, five men, the average age was 55 years (36 to 67). The operated side was the dominant side one time. The joint destruction was secondary to: SLAC wrist (stage 3) in two cases, a failure of PRC in two cases and post-traumatic necrosis of the lunatum in one case. Results One failure was resumed by total wrist arthrodesis at 1-year follow-up. Four patients were revised with 11 years follow-up (from nine to 13). Two patients presented a pain-free wrist, two patients complain of barometric pain or after heavy works. The average mobility was: extension 40°, flexion 25°, ulnar deviation 30°, radial deviation −3°, complete pronosupination. The strength was 65% of the opposite side. X-rays showed an important radiocarpal reshaping and ulnar sliding of the carpus. Discussion The island transfer of the DRUJ was possible in every case. The discordance between clinical and radiological results can be explained by joint denervation. We stopped this procedure not to sacrifice any more the healthy DRUJ. Conclusion The island transfer of the DRUJ to reconstruct the radiocarpal joint is a solution to avoid total wrist arthrodesis or prosthesis if we accept the DRUJ sacrifice.

Le fratture-lussazioni trans-scafo perilunari del carpo

Trans-scaphoid perilunate fracture-dislocation is a severe injury caused by a high-energy trauma. Closed or open reduction of the perilunate dislocation and internal fixation of the scaphoid are required. A dorsal approach to the perilunate dislocation allows for a good exposure of the carpal bones and an adequate control of the reduction. Internal fixation of the scaphoid can be done through the same dorsal approach or by a separate volar incision. Screw fixation of the scaphoid is recommended when technically feasible. A delayed treatment is frequent as a result of misinterpretation of the radiographs. Radiocarpal and intercarpal arthrosis (SLAC and SNAC wrist) can be late complications of a trans-scaphoid perilunate dislocation due to residual carpal instability or scaphoid nonunion.

Limited wrist arthrodesis for SLAC wrist

Limited wrist arthrodesis for SLAC wrist

SLAC WRIST IN THE ABSENCE OF RECOGNISED TRAUMA AND CPPD

This comparative cohort study was designed to determine whether non-traumatic SLAC wrist exists, and is associated with abnormal carpal bone kinematics (specifically, decreased lunate flexion). SLAC patients with no recognised history of upper extremity trauma were prospectively compared with an age-matched control group. Thirty-five subjects (69 wrists), included 33 non-traumatic SLAC wrists and 36 control wrists. The non-traumatic SLAC group had significantly different radiographic kinematic analysis compared to the control group. Flexion of the asymptomatic non-degenerative wrist of the non-traumatic SLAC group was distributed 70% through the lunocapitate (LC) joint and only 30% through the RL joint (p < 0.05). Conversely, flexion was more evenly distributed in the control group (48% LC and 52% RL). The non-traumatic SLAC group had abnormal wrist kinematics even in the non-involved side. This study suggests that non-traumatic SLAC does exist. We believe that non-traumatic SLAC begins with abnormal wrist kinematics and that the dorsal radiolunate ligament restricts lunate flexion but not scaphoid flexion, leading to increased SL angles and, with years, eventual attrition of the SL ligament.

Management of Scapholunate Advanced Collapse Pattern of Degenerative Arthritis of the Wrist

A 64-year-old, right-handed banker presents with the insidious onset of pain in his right wrist. He does not recall any specific wrist trauma but remembers “wrist sprains” while playing high school football. His pain has been present for 3 years and has been getting worse. His pain affects sleep and is no longer responsive to anti-inflammatory medication. Wrist extension is limited to 45° and flexion to 60°, and he reports pain at the extremes of motion. Grip strength is 55% that of the opposite side. Radiographs reveal a scapholunate diastasis and complete loss of the joint space between the radius and scaphoid (Fig. 1). The radiolunate joint is unaffected, and the head of the capitate has minimal degenerative changes. The patient's treatment has included wrist splinting and 3 cortisone injections. He is frustrated with his current pain level and wishes to proceed with surgical reconstruction. His goals are to continue home construction projects and tennis with less pain while retaining a stable wrist with some motion. Educational Objectives •State the stages of SLAC wrist •Compare and contrast the differences between PRC and 4-corner fusion •List the complications associated with a 4-corner fusion with the lunate extended •State the various techniques for 4-corner fusion •Describe the role of pinning after PRC Earn up to 2 hours of CME credit per JHS issue when you read the related articles and take an online test. To pay the $20 fee and take this month's test, visit http://www.assh.org/professionals/jhs. •State the stages of SLAC wrist •Compare and contrast the differences between PRC and 4-corner fusion •List the complications associated with a 4-corner fusion with the lunate extended •State the various techniques for 4-corner fusion •Describe the role of pinning after PRC Earn up to 2 hours of CME credit per JHS issue when you read the related articles and take an online test. To pay the $20 fee and take this month's test, visit http://www.assh.org/professionals/jhs.

Long-term results of lunocapitate arthrodesis with scaphoid excision for SLAC and SNAC wrists

When treating the degenerative arthritis that follows scapholunate instability or scaphoid pseudarthrosis, excision of the scaphoid must be combined with a stabilisation of the midcarpal joint. Two alternatives have been proposed for that purpose: fusing the lunate, triquetrum, capitate and hamate (four corner fusion), 4CF; or limiting the arthrodesis to the lunate and capitate, preserving or excising the triquetrum. Previous reports have attributed a high level of complications to lunocapitate arthrodesis, mainly in respect of nonunion. We have reviewed 17 patients who had been treated with a lunocapitate fusion, after an 8 to 12-year follow-up period, and found similar results compared with 4CF, even with a major degree of motion in ulnar-radial deviation. Recent work on the innervation of the radiotriquetral ligaments has given relevance to the preservation of lunotriquetral motion in maintaining proprioception. Also if the triquetrum is excised to gain more motion, the proprioceptive role of the radiotriquetral ligaments is compromised.

Four-corner bone arthrodesis with dorsal rectangular plate: series and personal technique

Controversy exists about the best method to achieve bone fusion in four-corner arthrodesis. Thirty-five patients who underwent this procedure by our technique were included in the study. Surgical indications were stage II-III SLAC wrist, stage II SNAC wrist and severe traumatic midcarpal joint injury. Mean follow-up was 4.6 years. Mean active flexion and extension were 34 degrees and 30 degrees respectively; grip strength recovery was 79%. Radiological consolidation was achieved in all cases. The mean DASH score was 23 and the postoperative pain improvement by visual analogue scale was statistically significant. Return to work was possible at 4 months for the average patient. Complications were a capitate fracture in one patient and the need for hardware removal in four cases. Four-corner bone wrist arthrodesis by dorsal rectangular plating achieves an acceptable preservation of range of motion with good pain relief, an excellent consolidation rate and minimal complications.

Limited wrist arthrodesis for SLAC wrist due to destruction and dislocation of silicone scaphoid implant. Two cases report

Limited wrist arthrodesis for SLAC wrist due to destruction and dislocation of silicone scaphoid implant. Two cases report

舟状骨偽関節による変形性手関節症（SLAC wrist）の治療経験

舟状骨偽関節による変形性手関節症（SLAC wrist）の治療経験

Mittelfristige Behandlungsergebnisse nach Proximal Row Carpectomy und Literaturüberblick

The aim of this study is to evaluate the results after proximal row carpectomy and to compare them with results in the literature. Between 1994 and 2001, 37 patients underwent proximal row carpectomy. 30 patients were available for follow-up. In all cases the proximal row carpectomy was performed through a dorsal approach. Clinical parameters were evaluated by using the conventional wrist score (Krimmer score) as well as the DASH-score. Follow-up examination shows a range of motion (ROM) for wrist extension and flexion of 46 % of the contralateral side. ROM for ulnar and radial deviation is 42 % of the other side, ROM for pronation and supination is equal to the other side. Mean grip strength is determined to be 58 % of the contralateral side. 90 % of the patients are satisfied with the result of the operation. The Krimmer score amounts to 58 and the DASH score to 39 points. We consider proximal row carpectomy to be a good therapeutic option for lunate necrosis stage IIIB or IV or carpal collapse stage II (SNAC or SLAC wrist) with a concomitant lesion of extrinsic ligaments with ulnar translocation. Another indication is the acute, non-reconstructable or the chronic perilunar luxation with arthrosis.

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.

Chondrocalcinosis of the wrist.

Calcium Pyrophosphate Dihydrate Deposition (CPDD) disease has characteristic radiographic features including soft tissue calcification, joint space narrowing, bone sclerosis, subchondral cyst formation without osteophyte formation, and large intraosseous geodes. Triangular fibrocartilage calcification is frequently found and isolated scapho-trapezio-trapezoid (STT) arthritis is specific for CPDD. Distal radio-ulnar (DRUJ), isolated midcarpal joint and piso-triquetral joint involvement also occur. 127 patients were reviewed. Seventy-eight had symptomatic STT joint arthritis, for which 36 underwent surgery. Twenty-two patients had a SLAC wrist deformity for which ten underwent surgery. Eight patients had isolated midcarpal arthritis for which three midcarpal arthrodeses, two four-bone arthrodeses and two carpal tunnel releases were performed. Nineteen patients had a generalized arthritis and seven of the patients underwent surgery: four-corner arthrodesis+scaphoidectomy (one case), carpal tunnel release (two cases) extensor synovectomy (two cases) and trigger finger release (two cases).