Injuries to the scapholunate joint are the most frequent cause of carpal instability and account for a considerable degree of wrist dysfunction, lost time from work, and interference with activities. The complex arrangement and kinematics of the 2 rows of carpal bones allows for an enormous degree of physiologic motion, and a hierarchy of primary and secondary ligaments serves to balance an inherently unstable structure. Although insufficient to cause abnormal carpal posture or collapse on static radiographs, an isolated injury to the scapholunate interosseous ligament may be the harbinger of a relentless progression to abnormal joint mechanics, cartilage wear, and degenerative change. Intervention for scapholunate instability is aimed at arresting the degenerative process by restoring ligament continuity and normalizing carpal kinematics. In this review, we discuss the anatomy, kinematics, and biomechanical properties of the scapholunate articulation and provide a foundation for understanding the spectrum of scapholunate ligament instability. We propose an algorithm for treatment based on the stage of injury, degree of secondary ligamentous damage, and arthritic change.

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Scapholunate Instability: Current Concepts in Diagnosis and Management

Current conceptScapholunate Instability: Current Concepts in Diagnosis and Management

BACKGROUND:Traditionally, acute nondisplaced scaphoid fractures have been treated nonoperatively in a cast, and the expected union rate approaches 90%. Internal fixation of nondisplaced scaphoid fr ...

Nonoperative compared with operative treatment of acute scaphoid fractures. A randomized clinical trial.

Purpose To present a method to perform arthroscopic exploration and instrumentation without infusing any fluid. Methods The hand is suspended from a bow, with traction on all fingers. Portals are developed as in the classic (wet) wrist arthroscopic procedure except that no water is infused to distend the joint and create the optic cavity. For this procedure the joint must be dried; we use suction through the synoviotomes and neurosurgical patties to accomplish this. Results We have performed more than 100 wrist arthroscopies using the dry technique without any undue difficulty. Conclusions The dry technique is as effective as the classic procedure, without the cumbersome leakage of water or the risk of compartment syndrome. It allows some sophisticated arthroscopic procedures to be performed that would be impracticable with water. In addition from these benefits, if open surgery is performed after the arthroscopic exploration then the tissue planes are dry, making surgery much easier. The technique is believed to be inappropriate if thermal probes are used. A learning curve exists.

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Dry Arthroscopy of the Wrist: Surgical Technique

https://link.springer.com/content/pdf/10.1007%2Fs00776-006-1025-x.pdf

Scaphoid fractures and nonunions: diagnosis and treatment.

Different surgical techniques have been proposed to treat traumatic scapholunate instability. Deciding which treatment is best for each individual case is not easy. In this article we report an algorithm of treatment based on a number of prognostic factors that may help in this matter. We also report on the promising results obtained using a new technique, the 3-ligament tenodesis, for the treatment of nonrepairable complete scapholunate ligament rupture, causing a reducible carpal malalignment without secondary osteoarthritis. This technique incorporates features from 3 previously described techniques.

Three-Ligament Tenodesis for the Treatment of Scapholunate Dissociation: Indications and Surgical Technique

Purpose The purpose of this study was to assess wrist pain, range of motion, and the presence of radiographic midcarpal degenerative joint disease (DJD) in patients who had a distal scaphoidectomy in association to a radioscapholunate (RSL) arthrodesis and to compare these findings with prior studies of patients with only an RSL fusion. Methods Sixteen patients with radiocarpal DJD treated by RSL arthrodesis and distal scaphoidectomy were evaluated retrospectively for pain relief and range of motion at an average follow-up period of 37 months (range, 12–84 mo). Radiographs were assessed for the presence of secondary radiographic midcarpal DJD. Results Complete pain relief was obtained in 10 patients, 3 patients complained of slight pain during strenuous loading, and 3 patients had occasional pain with regular activities. The average postoperative ranges of motion were 32° of flexion, 35° of extension, 14° of radial deviation, and 19° of ulnar deviation. Two patients exhibited secondary midcarpal DJD. These results are significantly better compared with those previously published about RSL arthrodesis alone in terms of residual pain and decrease of wrist radial deviation and flexion. Conclusions Patients who require an RSL arthrodesis for the treatment of severe localized radiocarpal DJD appear to have less pain and to retain more flexion and radial deviation if the distal scaphoid is excised concomitantly. This associated procedure also may help prevent secondary midcarpal DJD.

Treatment of radiocarpal degenerative osteoarthritis by radioscapholunate arthrodesis and distal scaphoidectomy.

Purpose We reviewed 21 consecutive patients who underwent a total wrist arthroplasty as a primary procedure between October 2001 and February 2007 The purposes of the present study were to communicate our midterm results and to compare them with previously published series Methods We evaluated all patients clinically and radiologically We used the Patient-Related Wrist Evaluation a primary outcome measure The mean follow-up was 55 years (range, 3–8 years) A total of 14 patients had rheumatoid arthritis, including 1 with juvenile arthritis, and 1 each had psoriatic arthritis, systemic lupus erythematosus, and undifferentiated spondyloarthropathy Of the remaining 4 patients, 2 had grade IV Kienbock disease, 1 had degenerative arthrosis, and 1 had chondrocalcinosis Results Postoperative Patient-Related Wrist Evaluation scores averaged 24 points (SD, 21 pints) out of 100 (worst score) When the patients were specifically asked about pain and function of the arthroplasty, 20 claimed to be satisfied or very satisfied with the procedure Two early and 3 late complications occurred One patient had a wound hematoma and another had a superficial wound infection, both of which resolved with no further complications during the immediate postoperative period In 2 patients, there was some osteolysis around the screw inserted into the medullary canal of the index metacarpal, but not in the trapezoid bone One patient had a slight loosening of the distal component with subsidence on the ulnar side of the carpus There have been no dislocations or surgical revisions of the components Conclusions Based on our study, a total wrist arthroplasty should be considered as a good alternative to arthrodesis for patients who wish to preserve some degree of mobility of the wrist Type of study/level of evidence Therapeutic IV

Universal total wrist arthroplasty: midterm follow-up study.

Partial excision of scaphoid: is it ever indicated?

The width of the carpal arch, represented in this study by the distance between the tips of two Kirschner wires—one inserted into the trapezium and another into the hook of the hamate—was measured with precision calipers in 21 patients with carpal tunnel syndrome, both before and after sectioning of the transverse carpal ligament and in different wrist positions. With the ligament intact, most of the wrists showed a decrease in the distance in both flexion and extension. The distance increased an average of 11% after sectioning of the transverse carpal ligament. The dynamic behavior of the carpal arch, however, was not substantially modified by this procedure.

Alberto L. Lluch

Papers

Three-Ligament Tenodesis for the Treatment of Scapholunate Dissociation: Indications and Surgical Technique

Treatment of radiocarpal degenerative osteoarthritis by radioscapholunate arthrodesis and distal scaphoidectomy.

Universal total wrist arthroplasty: midterm follow-up study.

Partial excision of scaphoid: is it ever indicated?

Dynamic changes of the transverse carpal arch during flexion-extension of the wrist: effects of sectioning the transverse carpal ligament.