Treatment Of Chronic Scapholunate Instability Research Articles

Ligamentoplasty in scapholunate instability: short-term results of the "all dorsal scapholunate repair" technique.

Injury to the scapholunate complex is the cause of scapholunate instability which can lead to radiocarpal and medio-carpal osteoarthritis. Several ligamentoplasty techniques have been reported for the treatment of chronic scapholunate instability before the osteoarthritis stage. The objective of this study was to assess the short-term results of an "all dorsal scapholunate repair" ligamentoplasty. We report the clinical, radiological and functional results of a retrospective study including 21 patients, operated between June 2019 and December 2020 for a stage 3 or 4 scapholunate instability according to the Garcia Elias classification. With a follow-up of 14.2months, the pain was 0.1/10 according to the VAS at rest and 4/10 during exercise. Wrist strength was measured at 65% of the opposite side. The flexion-extension range of motion was 105°. Radiologically, there was a reduction of the diastasis and scapholunate angle. Osteolysis areas around the anchors were described in 47% of patients. The mean QuickDASH was 29.2/100, PRWE 24/100 and Mayo wrist score 67.8/100. Eighty-one percent of patients were satisfied. Seventeen patients had returned to work 5.2months postoperatively. In the case of work-related injury, the functional scores were poorer, with a delayed return to work. This technique provides encouraging results in the short term. Most patients were improved compared to preoperative state. The work-related injury appears to be a poor prognostic factor. A longer-term study is imperative to confirm the maintenance over time of the correction of carpal malalignment and the evolution of the osteolysis areas.Level of evidence: Level IV Retrospective study.

Double Dorsal Capsulodesis in the Treatment of Chronic Scapholunate Instability: Description of a New Surgical Technique and Case Report

Introduction: The scapholunate ligament (SLL) injury can cause wrist pain and instability. There is a wide variety of surgical techniques used for the treatment of this lesion, such as dorsal capsulodeses, tenodeses with flexor or extensor tendons, and bone-ligament-bone graft.
 Objective: To describe a new technique for the treatment of SLL injury aiming to stabilize the dissociated carpus with a double dorsal capsulodesis.
 Materials and methods: By presenting the case of a 36-year-old male security officer who injured his left wrist in a motorcycle accident, a procedure to align the carpus is proposed. The long-term outcome of this procedure is also described
 Results: The proposed surgery was successfully performed; it had excellent clinical and functional results, with no complications. Long-term restoration of carpal alignment observed in wrist radiographs was evidenced after two years of follow-up, the patient was asymptomatic and with full functional recovery.
 Conclusion: The proposed technique appears to be reproducible, effective and easy to perform. Unlike the technique described by Blatt, the aim of this one is to restore the physiological position of the lunate bone by adding a second capsulodesis, as it is believed to be an essential factor in the maintenance of carpal kinematics.

Treatment of chronic scapholunate instability: Results with three-ligament tenodesis vs. scapholunate and intercarpal ligamentoplasty

In this retrospective case control/comparison study, we compared the clinical and radiological outcomes in patients with chronic scapholunate dissociation treated with three-ligament tenodesis (3 LT) versus scapholunate and intercarpal ligamentoplasty (SLICL). Twenty patients with a mean age of 43 years were treated with the 3 LT procedure and 26 patients with a mean age of 44 years with the SLICL procedure. All patients had chronic reducible scapholunate dissociation without chondral lesions. The two groups of patients were operated on by senior surgeons, at the same facility, over two different time periods. All patients were evaluated (pain, motion, strength, function, X-rays) with a mean follow-up of 28 months (12–49) in the 3 LT group and 36 months (12–54) in the SLICL group. In the both groups, we found a significant improvement in pain levels, grip strength and functional scores (DASH and PRWE). The SLICL group had significantly less pain and greater grip strength than the 3 LT group. Patients in the SLICL group had a greater improvement in their DASH and PRWE Scores. The mean range of motion in flexion–extension was 82° (102° preoperative) in the 3 LT group and 113° (115° preoperative) in the SLICL group. In the 3 LT, there was no significant improvement in the mean static and dynamic scapholunate gaps (3.6 and 4.8 mm postoperatively versus 3.9 and 4.9 mm preoperatively), or the scapholunate angle (75° versus 72°). In the SLICL group, the mean static and dynamic gaps improved significantly (2.3 and 3.0 mm postoperatively versus 3.2 and 4.6 mm preoperatively), as did the scapholunate angle (62° versus 73°). In the 3 LT group, 4 patients developed osteoarthritis. In conclusion, the SLICL procedure for scapholunate ligament reconstruction led to better clinical and early radiological results than the 3 LT technique.

Arthroscopic Reduction-Association of the Scapholunate with an Absorbable Screw.

Background The treatment of chronic scapholunate instability is yet a controversial topic. Arthroscopic reduction-association scapholunate technique is a minimally invasive option in which a stable pseudoarthrosis at the scapholunate joint is obtained, allowing some degree of movement while maintaining the normal alignment of the wrist. The purpose of this study was to review the results of arthroscopic reduction-association scapholunate with an absorbable screw. Methods We retrospectively evaluated patients with dynamic or static, but reducible, chronic scapholunate instability who underwent arthroscopic reduction-association scapholunate between 2012 and 2015. An absorbable headless compression screw was used in the technique. Results A total of 33 patients (21 males, 12 females) were included. Average follow-up time was 17 months. At final follow-up, the average postoperative Disabilities of the Arm, Shoulder and Hand (DASH) score was 18 (range, 8-46). The average postoperative grip strength was 30 kg, 73% of the uninjured side. The average extension-palmar flexion arc was 112 degrees, 79% of the uninjured side. The scapholunate angle decreased from 70 degrees preoperatively to 52 degrees postoperatively. In the cases of static lesion, the scapholunate interval decreased from 4.1 mm preoperatively to 2.8 mm at final follow-up. One patient had a breakage of the screw at 4 months, four developed a complex regional pain syndrome, one had a prominence of the screw at the waist of the scaphoid, and four maintained symptoms of instability. From these 10 patients, 5 were submitted to revision surgery. Conclusion The arthroscopic reduction-association technique is capable of maintaining the reduction of the scapholunate joint and of improving symptoms, while preserving range-of-motion. The use of an absorbable screw is an option in this technique, and may diminish screw-related complications.

Equivalent Clinical Outcomes Following Favored Treatments of Chronic Scapholunate Ligament Tear.

Optimal treatment of chronic scapholunate (SL) instability remains controversial. Many surgical techniques have been proposed with varied results in subsequent case series; however, there is limited evidence demonstrating the relative effectiveness of the different treatment options. We conducted a systematic review of the English literature to compare outcomes from capsulodesis and ligament reconstruction for treatment of chronic scapholunate instability. An electronic database search using keywords associated with scapholunate ligament instability was performed. A total of 511 studies were identified. All studies with scapholunate ligament tears >4weeks after the initial injury were included in the review. Data extracted included patient demographics, wrist range of motion, and radiographic outcome measures. A total of 308 patients from 11 studies met the inclusion criteria and were included in the study. The average time to surgery from initial injury was 11months. There was no significant difference in wrist flexion or extension after capsulodesis or reconstruction. The weighted mean for postoperative wrist extension/flexion was 56°/45.6° in the capsulodesis group and 40.9°/47.3° in the reconstruction group. Pooled means of SL angle and SL gap were 60.3° and 3.44mm after capsulodesis and 56.5 and 2.72mm after reconstruction, respectively. This systematic review failed to demonstrate any significant difference in outcomes from capsulodesis or reconstruction for treatment of chronic scapholunate instability. However, the retrospective studies examined were notably heterogeneous in design with high estimates of variance. Further prospective trials are necessary to determine an ideal treatment strategy.

Scapholunate Temporary Screw Fixation for the Treatment of Chronic Scapholunate Instability: Level 4 Evidence

For chronic scapholunate ligament instabilities, it is not uncommon to see the loss of reduction on radiological images at intermediate to long term follow-up. We propose the use of scapho-lunate temporary screw fixation to provide a more stable mechanical environment for soft tissue healing after primary repair or late reconstruction of the scapholunate ligament.

Scaphocapitate Arthrodesis for Treatment of Scapholunate Instability in Manual Workers

To assess the long-term efficacy of scaphocapitate arthrodesis for treatment of chronic scapholunate instability in high-demand patients. We retrospectively analyzed the clinical and radiographic results of 20 manual workers who underwent scaphocapitate arthrodesis for chronic scapholunate instability at a mean follow-up of 10 years (range, 1-23 y). We measured range of motion and grip strength; pain on a scale of 0 to 5; Quick Disabilities of the Arm, Shoulder, and Hand score; and ability to return to work. We assessed radiographs for union, carpal height and alignment, signs of ulnar translation or radiocarpal arthritis, and hardware problems. At most recent follow-up, the arc of motion averaged 87° for flexion-extension and 41° for the radioulnar deviation. The postoperative average maximum grip strength was 21 kg, which was 60% of the opposite, normal wrist. Pain was significantly reduced. The average postoperative Quick Disabilities of the Arm, Shoulder, and Hand score was 19, and the return-to-work rate was 90%. Radiographic analysis showed union in all patients, improvement of carpal height and scaphoid angle, no evidence of ulnar translation, and a 30% rate of radiocarpal osteoarthritis. This report of long-term results demonstrates the efficacy of scaphocapitate limited carpal arthrodesis for the treatment of chronic rotatory subluxation of the scaphoid. We conclude that continued use of this procedure is warranted. Therapeutic IV.

The role of three-ligament tenodesis in the treatment of chronic scapholunate instability

Restoring ligamentous control in dissociative carpal instability is a major issue in protecting against osteoarthritis. We present clinical and radiological results for 20 patients who underwent flexor carpi radialis three-ligament tenodesis and were prospectively reviewed at a mean follow-up of 25.1 months. Three-ligament tenodesis significantly relieved pain and increased grip strength, wrist function at the expense of joint stiffness. This improvement was not seen in cases of dynamic instability. However, ligamentous loosening did result in rapid recurrence of radiological anomalies and frequent complications. This study challenges the long-term benefit of three-ligament tenodesis in both dynamic and static chronic scapholunate instability.

Long-term results of dorsal intercarpal ligament capsulodesis for the treatment of chronic scapholunate instability

The purpose of this study was to assess the clinical and radiological outcomes of dorsal intercarpal ligament capsulodesis for the treatment of static scapholunate instability at a minimum follow-up of four years. A total of 59 patients who underwent capsulodesis for this condition were included in a retrospective analysis after a mean of 8.25 years (4.3 to 12). A total of eight patients underwent a salvage procedure at a mean of 2.33 years (0.67 to 7.6) and were excluded. The mean range of extension/flexion was 88° (15° to 135°) and of ulnar/radial deviation was 38° (0° to 75°) at final follow-up. The mean Disabilities of the Arm Shoulder and Hand (DASH) score and Mayo wrist scores were 28 (0 to 85) and 61 (0 to 90), respectively. After significant improvement immediately post-operatively (p < 0.001 and p=0.001, respectively), the mean scapholunate and radiolunate angles deteriorated to 70° (40° to 90°) and 8° (-15° to 25°), respectively, at final follow-up, which were not significantly different from their pre-operative values (p = 0.6 and p = 0.4, respectively). The mean carpal height index decreased significantly from 1.53 (1.38 to 1.65) to 1.48 (1.29 to 1.65) indicating progressive carpal collapse (p < 0.001); 40 patients (78%) had radiological evidence of degenerative arthritis. Capsulodesis did not maintain carpal reduction over time. Although the consequent ongoing scapholunate instability resulted in early arthritic degeneration, most patients had acceptable long-term function of the wrist.

Chronic scapholunate instability treated by scaphocapitate fusion: A midterm outcome perspective

Chronic scapholunate instability can lead to functional deficits and radiocarpal osteoarthritis. A number of procedures, namely scapho-trapezio-trapezoid (STT) fusion, scaphocapitate (SC) fusion or soft tissue reconstruction procedures, aim to improve function while protecting the wrist from osteoarthritis. Define the role of scaphocapitate fusion in comparison to STT fusion and capsulodesis and ligament reconstruction. A clinical, radiographic and functional evaluation was performed on 31 SC fusion cases with an average follow-up of 5 years. Range of motion was 41° in flexion and 39° in extension. Radial-ulnar deviation was 43°. Strength was 32.5 kgf (Jamar). The DASH was 27% and the PRWE was 25%. Fifty percent of the wrists were pain-free at rest. Ninety-four percent of patients were satisfied with the procedure. Seventy-eight percent of patients had returned to their occupation. Radiographic analysis revealed that consolidation was obtained at 10.1weeks. The postoperative radioscaphoid angle was 55° with good radioscaphoid congruence. There was no osteoarthritis in the radioscaphoid joint in 84% of the cases. The non-union rate was 13%. These data are similar to the few series that exist. STT fusion leads the same clinical results, but it is technically more difficult and has a higher rate of complications. Capsulodesis and ligament reconstruction provide the same functional results as SC fusion, but with slightly less stiffening. However, these techniques do not seem to protect the wrist from arthritic degeneration at longer follow-up. SC fusion is superior to STT fusion for the treatment of chronic scapholunate instability. This is a pain-relieving intervention with good clinical results and preservation of scaphoid stability. As a component of the surgeon's armamentarium, it can be held in the same regard as capsulodesis and ligament reconstruction for cases of chronic scapholunate instability with a non-reducible scaphoid, or after failure of a soft tissue reconstruction procedure. Level 4, retrospective study.

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.

Scaphoid-trapezium-trapezoid fusion in the treatment of chronic scapholunate instability

Limited intercarpal arthrodesis for chronic scapholunate instability has been the subject of several recent publications. We have followed nine patients, who had scapho-trapezio-trapezoidal (S-T-T) fusion for scapholunate instability. All nine patients were re-examined recently after an average follow-up period of 19 months (range, 12 to 25 months). Six of the nine patients believed that their symptoms were significantly improved. The postoperative range of wrist motion (ROM) was decreased in all directions of motion. The pinch strength averaged 86% on the treated side and the grip strength averaged 74% of the unoperated side. Review of follow-up x-ray films showed radiographic evidence of union in eight of nine patients. We conclude that, with careful patient selection and close attention to operative detail, S-T-T fusion can be an effective treatment for scapholunate instability. However, the results are not uniformly predictable, and neither range of motion nor strength is normal after the procedure.