part 2 of a presentation that summarizes the injury patterns of scapholunate ligament and treatment options including the reconstruction options and salvage procedures

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Scapholunate Injuries
Part II
Hussain Algawahmed, MBBS, FRCSC
Consultant Orthopedic Surgeon
Riyadh Care Hospital

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① Is the dorsal scapholunate ligament intact?
② Does the dorsal scapholunate ligament have sufficient tissue
to be repaired?
③ Is the scaphoid posture normal?
④ Is any carpal malalignment reducible?
⑤ Is the cartilage on radiocarpal and midcarpal surfaces
normal?

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 Systematic review: treatment of SL injuries w/o arthritis
 38 studies included

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Stage I:
Occult Instability/Pre-dynamic
 Cast/splint, NSAID and physio
 Lindau 1997
 Forward 2007
 Wrist re-education of proprioception
 Arthroscopic debridement:
 Weiss et al 1997:
11 out of 13 pts had their symptoms resolved or improved with an average
f/up of 27 months
 Ruch and Poehling: satisfactory in 7/7 with no progression
 Arthroscopic electrothermal shrinkage:
 Darlis et al., 2005
 Hirsh et al., 2005
 Shih et al., 2006

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Stage I:
Occult Instability/Pre-dynamic
 Cast/splint, NSAID and physio
 Lindau 1997
 Forward 2007
 Wrist re-education of proprioception
 Arthroscopic debridement:
 Weiss et al 1997:
11 out of 13 pts had their symptoms resolved or improved with an average
f/up of 27 months
 Ruch and Poehling: satisfactory in 7/7 with no progression
 Arthroscopic electrothermal shrinkage:
 Darlis et al., 2005
 Hirsh et al., 2005
 Shih et al., 2006

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Stage I:
Occult Instability/Pre-dynamic
 Cast/splint, NSAID and physio
 Lindau 1997
 Forward 2007
 Wrist re-education of proprioception
 Arthroscopic debridement:
 Weiss et al 1997:
11 out of 13 pts had their symptoms resolved or improved with an average
f/up of 27 months
 Ruch and Poehling: satisfactory in 7/7 with no progression
 Arthroscopic electrothermal shrinkage:
 Darlis et al., 2005
 Hirsh et al., 2005
 Shih et al., 2006

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Stage I:
Occult Instability/Pre-dynamic
 Cast/splint, NSAID and physio
 Lindau 1997
 Forward 2007
 Wrist re-education of proprioception
 Arthroscopic debridement:
 Weiss et al 1997:
11 out of 13 pts had their symptoms resolved or improved with an average
f/up of 27 months
 Ruch and Poehling: satisfactory in 7/7 with no progression
 Arthroscopic electrothermal shrinkage:
 Darlis et al., 2005
 Hirsh et al., 2005
 Shih et al., 2006

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Stage II:
Dynamic Instability
Repairable ligament:
 Direct SL repair for the Coronal displacement
 Capsulodesis for the sagittal malalignment
 Blatt  decreased wrist flexion
 Modified DIC
 Stabilization:
 K wires
 Temporary Screw fixation

13. + A Nathan and Blatt,
B Linscheid and Dobyns
C Filan and Herbert

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 Different than the RASL procedure described by Rosenwasser
 Indications: dynamic and static SL instability undergoing surgical repair
 3.0 mm synthes headless screw is used to achieve compression followed
by SL ligament repair +/- capsulodesis
 Splint/Cast for 6 wks  Dart throwers AROM protocol
 4 months post op  screw removal +/- arthroscopic capsular release

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Stage II - III:
Dynamic/Static Instability
No repairable ligament
 Capsulodesis
 Luchetti 2010: 18 pts followed up at 34 months showed improvement in pain in grip
strength
 Megerle 2012: long term study, DIC capsulodesis did not maintain carpal height or SL
relationship
 Tenodesis
 Four ligament reconstruction
 Tri-ligament reconstruction:
 Classic Brunelli
 Modified Brunelli
 Bone-ligament-Bone reconstruction
 Weiss: bone-retinaculum-bone from the 3rd dorsal compartment
 RASL

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Stage II - III:
Dynamic/Static Instability
No repairable ligament
 Capsulodesis
 Luchetti 2010: 18 pts followed up at 34 months showed improvement in pain in
grip strength
 Tenodesis
 Four ligament reconstruction
 Tri-ligament reconstruction:
 Classic Brunelli
 Modified Brunelli
 Bone-ligament-Bone reconstruction
 Weiss: bone-retinaculum-bone from the 3rd dorsal compartment
 RASL

23. + A-Almquist and associates
B- Linscheid and Dobyns
C-Brunelli and Brunelli

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 38 patients
 21 were stage 3
 17 were stage 4
 Ave f/up: 46 months
 Complete pain relief in 28/38
 Ave Grip strength: 65%
 ROM:
 51 flexion
 52 extension

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 28 yrs male presents 22 weeks post injury
 Scapholunate dissociation with 5.5 mm gap
 Modified Brunelli:
 Berger Capsulotomy with no further scaphoid dissection
 3.2 mm drill from the the waist to the distal pole
 Volar Russe approach
 2 anchors, scaphoid and lunate

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 Patient returned to sports and activities at 4.5 months
 70 degrees extension, 40 degrees flexion
 30 kg grip (vs 42 kg)
 No pain
 Patient didn't’t attend the 6 and 12 months f/up
 Presented at 14 months with increased pain

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 Potential causes:
 Dorsal dissection
 Size of the drill
 Tunnel orientation
 SC k-wire
 Modifications adopted by the author:
 Smaller drill (2 – 2.5 mm)
 More perpendicular tunnel

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Stage II - III:
Dynamic/Static Instability
No repairable ligament
 Capsulodesis
 Luchetti 2010: 18 pts followed up at 34 months showed improvement in pain in
grip strength
 Tenodesis
 Four ligament reconstruction
 Tri-ligament reconstruction:
 Classic Brunelli
 Modified Brunelli
 Bone-ligament-Bone reconstruction
 Weiss: bone-retinaculum-bone from the 3rd dorsal compartment
 RASL

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 14 pts underwent the procedure for dynamic SL instability
 6 returned for f/up
 3 reached by phone
 2 lost to f/up
 3 had salvage surgery (2 arthrodesis, 1 PRC)
 Ave f/up: 11.9 years

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Stage II - III:
Dynamic/Static Instability
No repairable ligament
 Capsulodesis
 Luchetti 2010: 18 pts followed up at 34 months showed improvement in pain in
grip strength
 Tenodesis
 Four ligament reconstruction
 Tri-ligament reconstruction:
 Classic Brunelli
 Modified Brunelli
 Bone-ligament-Bone reconstruction
 Weiss: bone-retinaculum-bone from the 3rd dorsal compartment
 RASL

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 retrospective analysis
 dorsal capsulodesis vs. tenodesis for chronic SL instability
 29 pts included:
 14 capsulodesis
 15 tenodesis
 f/up: 36-38 months
 Results:
 ROM: 64% in capsulodesis vs 63% in tenodesis
 Grip: 91% in capsulodesis vs 87% in tenodesis
 Mayo wrist score: 77 in capsulodesis vs 74 in tenodesis

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Stage II - III:
Dynamic/Static Instability
No repairable ligament
 Capsulodesis
 Luchetti 2010: 18 pts followed up at 34 months showed improvement in pain in
grip strength
 Tenodesis
 Four ligament reconstruction
 Tri-ligament reconstruction:
 Classic Brunelli
 Modified Brunelli
 Bone-ligament-Bone reconstruction
 Weiss: bone-retinaculum-bone from the 3rd dorsal compartment
 RASL

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 21 patients
 Mean of 32 months f/up
 ROM preserved
 95% returned to their occupations and activities
 SL angle and Gap corrected
 1 patient failed due to screw migration
 Another patient needed the screw removed for radial
impengement

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Stage IV:
DISI without Arthrosis
Reducible
 Tri-ligament tenodesis
 RASL
 Partial Arthrodesis

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Stage IV:
DISI without Arthrosis
Irreducible
 Partial Arthrodesis
 STT fusion
 Scaphocapiate arthrodesis: 50% ROM loss
 Avoid over reduction of the scaphoid
 Add radial styloidectomy

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Thank You