Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

283. Arthroscopic Evaluation and Treatment of Scapholunate and Lunotriquetral Ligament Disruptions

Alexander H. Payatakes, Alex M. Meyers, and Dean G. Sotereanos

DEFINITION

images Scapholunate and lunotriquetral interosseous ligament tears are common wrist injuries occurring in isolation or as part of the perilunate injury pattern.

images Interosseous ligament injuries are being diagnosed with an increased frequency as a result of recent advances in imaging and arthroscopy.

images Management of these injuries has proven to be a difficult clinical problem. Surgical management has been more reliable in pain relief than in altering the natural history.

ANATOMY

images The scapholunate complex is subject to significant loads, since the scaphoid is the only carpal bone to span from the proximal to the distal carpal row.

images The proximal carpal row flexes with radial deviation and extends with ulnar deviation.

images The scaphoid “wants” to flex and the triquetrum “wants” to extend.

images The lunate (the intercalated segment) is tethered between the scaphoid and triquetrum. A large amount of potential energy exists in the proximal carpal row.

images Stability is provided to the scapholunate complex by the intrinsic scapholunate interosseous ligament (SLIL) as well as extrinsic capsular ligaments, especially the dorsal radiocarpal (DRC), dorsal intercarpal (DIC) ligament, and volar radioscaphocapitate (RSC) and scaphotrapezium-trapezoid (STT) ligaments.

images The SLIL is a C-shaped structure consisting of a stronger dorsal ligamentous portion (2 to 3 mm thick), a volar ligamentous portion (1 mm thick), and a proximal fibrocartilaginous (membranous) portion.2

images Isolated injuries to the SLIL appear to be associated with dynamic instability, whereas static instability usually indicates additional injury to the secondary ligamentous stabilizers, including the DIC ligament.16

images The lunotriquetral complex is also stabilized by an intrinsic lunotriquetral ligament (LTIL) and extrinsic (volar and dorsal) capsular ligaments.

images The LTIL is C-shaped, analogous to the SLIL, consisting of dorsal and volar ligamentous portions and a membranous proximal portion. In contrast to the SLIL, the volar ligamentous portion of the LTIL is stronger and more significant functionally.12

images As with the scapholunate complex, isolated injuries to the LTIL are usually insufficient for the development of static instability. Presence of a static deformity indicates additional injury to extrinsic ligamentous structures (volar ulnotriquetral, ulnolunate, and ulnocapitate ligaments or the dorsal radiocarpal and intercarpal ligaments).7,20

PATHOGENESIS

images Mayfield et al9 postulated that scapholunate disruption is the initial component of the lesser arc perilunate injury pattern, which occurs when force is applied to the thenar area with the wrist in extension, supination, and ulnar deviation.

images Depending on the amount of kinetic energy involved, the injury may or may not extend to the ulnar side of the wrist.

images SLIL injuries can be sprains, partial tears, or complete tears (with or without injury to the extrinsic ligament stabilizers).

images With complete SLIL tears the scaphoid flexes and the lunate is pulled by the triquetrum into extension (dorsal intercalated segment instability [DISI] pattern).

images With complete SLIL tears the ligament usually fails at the bone–ligament interface off the scaphoid.

images Arthroscopic evaluation has revealed associated SLIL injuries in up to 30% of intra-articular distal radius fractures.5

images LTIL disruption may be traumatic or atraumatic in origin.

images Traumatic LTIL rupture may occur as the final component of a greater or lesser arc perilunate injury pattern.9

images Isolated LTIL tears may result from a fall on an outstretched hand in extension, pronation, and radial deviation (reverse perilunate injury)11 or from a dorsally applied force on a flexed wrist.25

images Atraumatic ruptures of the LTIL may occur secondary to inflammatory arthritis or ulnar impaction syndrome.18

NATURAL HISTORY

images Tears of the SLIL or LTIL, with or without extrinsic ligamentous injury, may lead to various degrees of carpal instability (predynamic, dynamic, or static), alteration of normal carpal mechanics and kinematics, and early degenerative changes in the radiocarpal and midcarpal joints.

images A complete SLIL tear is associated with the development of a DISI deformity, which may be dynamic or static (indicates additional injury to the extrinsic ligaments).

images As a DISI deformity forms, abnormal radiocarpal contact loading occurs as the proximal carpal bones shift in position and lose congruency.

images Abnormal flexion and hypermobility of the scaphoid over time leads to degenerative changes of the radioscaphoid and capitolunate joints and ultimately collapse, termed scapholunate advanced collapse (SLAC) wrist degeneration.22,23

images These degenerative changes have been documented to begin as early as 3 months after injury.

images A complete LTIL tear is associated with the development of a volar intercalated segment instability (VISI) deformity.

images The natural history of partial tears of the SLIL or LTIL is at present poorly defined.

images Partial scapholunate and LT injuries may cause chronic, activity-related wrist pain in the absence of radiologic findings.23

images Predynamic or dynamic instability may cause attenuation of extrinsic ligaments with progressive development of further instability and static changes.29,30

images There is evidence that this process typically requires many years.10

PATIENT HISTORY AND PHYSICAL FINDINGS

images Dorsoradial or ulnar-sided wrist pain with a history of a fall, sudden loading, or twisting of the wrist should raise suspicion for a SLIL or LTIL tear, respectively. However, it is not uncommon for the patient to deny any significant injury.

images Patients frequently complain of weakness, swelling, and loss of range of motion of the wrist.

images A sensation of instability or “giving way” is often reported, occasionally associated with a painful clunk.

images A detailed physical examination of the wrist may provide significant information for the diagnosis of ligamentous injuries and help to rule out other wrist pathology.

images Examination of the wrist begins with evaluation for any deformity or swelling and determination of wrist range of motion.

images Key tests and maneuvers specifically evaluating the scapholunate and lunotriquetral ligaments are as follows:

images Grip strength and pain: Diminished grip strength correlates with wrist pathology.

images The presence of pain at the central aspect of the wrist with attempted grip has also been associated with scapholunate ligament pathology.

images Deep palpation of scapholunate interval: Point tenderness indicates SLIL injury, scaphoid injury, or ganglion cyst.

images Watson’s scaphoid shift test: Pain with or without a clunk or catch sensation is highly suggestive of scapholunate instability.

images Scaphoid ballottement test: Pain and increased anteroposterior laxity are highly suggestive of scapholunate instability.

images Deep palpation of lunotriquetral interval: Point tenderness indicates LTIL injury or triangular fibrocartilage complex (TFCC) pathology.

images Ulnar wrist loading: A painful snap indicates lunotriquetral instability, midcarpal instability, or TFCC complex pathology. This maneuver will also be painful if ulnar impaction is present.

images Triquetrum ballottement test: Pain and increased anteroposterior laxity are highly suggestive of lunotriquetral instability.

images “Ulnar snuffbox” tenderness: Pain with or without crepitus indicates lunotriquetral instability, TFCC complex pathology, or triquetrohamate pathology.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Initial imaging of the wrist should always include AP and lateral radiographs, combined with special views depending on the suspected pathology. If scapholunate pathology is suspected, a bilateral pronated grip anteroposterior (Mayo Clinic) view should be obtained for comparison to the contralateral side.

images Abnormal findings in static scapholunate instability include:

images AP view: increased scapholunate interval (3 mm or more; comparison to contralateral wrist), scaphoid cortical “ring sign,” and triangular appearance of lunate

images Lateral view: flexion of scaphoid and dorsiflexion of lunate, as determined by increased scapholunate angle (more than 60 degrees) and increased lunocapitate angle (over 10 degrees) with dorsal translation of capitate

images Radiographic findings in patients with lunotriquetral tears are often normal. Abnormal findings in static lunotriquetral instability include:

images AP view: proximal translation of triquetrum or lunotriquetral overlap without gapping, and interruption of Gilula’s arc

images Lateral view: flexion of scaphoid and lunate, as determined by normal or decreased scapholunate angle (less than 45 degrees), increased lunocapitate angle (more than 10 degrees) with volar translation of capitate, and a negative lunotriquetral angle

images Provocative views (radial-ulnar deviation, flexion–extension views) or videofluoroscopy may demonstrate asynchronous scapholunate motion (dynamic scapholunate instability) in cases with suspected SLIL injury and normal standard views. Increased, synchronous mobility of the scapholunate complex with diminished motion of the triquetrum indicate an LTIL injury.

images Wrist arthrography has a sensitivity of only 60% compared to arthroscopy and cannot determine the extent of any tear present.26

images MRI (with or without arthrography) has limited value in evaluating interosseous ligament injuries. Reported sensitivity rates for SLIL injuries range from 40% to 65% compared to arthroscopy.17 MRI is even less reliable in diagnosing LTIL injuries.

images Arthroscopy (radiocarpal, midcarpal with probing) remains the gold standard in evaluation of SLIL and LTIL injuries.

DIFFERENTIAL DIAGNOSIS

images Differential diagnosis of scapholunate injuries and radialsided wrist pain21

images Scaphoid fracture or nonunion

images Scaphotrapezial arthritis

images Radiocarpal arthritis

images De Quervain’s tenosynovitis

images Dorsal ganglion cyst

images Dorsal wrist impaction syndrome

images Perilunate instability

images Isolated DRC ligament tear

images Differential diagnosis of lunotriquetral injuries and ulnarsided wrist pain18

images TFCC injury

images Distal radioulnar joint (DRUJ) instability or arthritis

images Ulnar impaction syndrome or chondromalacia

images Ulnar styloid impingement syndrome

images Extensor carpi ulnaris (ECU) tendon subluxation

images Pisotriquetral arthritis

images Triquetrohamate instability

images Hamate fracture

images Ulnar neurovascular syndromes

NONOPERATIVE MANAGEMENT

images SLIL and lunotriquetral injuries associated with dynamic instability may respond to initial nonoperative treatment for 6 to 12 weeks.

images Conservative management typically includes a combination of the following:

images Splinting

images Nonsteroidal anti-inflammatories

images Intra-articular (radiocarpal) corticosteroid injections

images Occupational therapy and work restrictions

images Re-education of wrist proprioception with flexor carpi radialis strengthening

SURGICAL MANAGEMENT

images The selection of surgical treatment for SLIL and LTIL injuries is based on the severity of symptoms, the degree of instability (dynamic or static), chronicity (acute, subacute, or chronic), arthroscopic findings (Geissler grade; see TECH FIG 1), and reparability of the ligament.

images Dynamic instability (based on positive physical findings with provocative maneuvers, abnormal stress radiographs, arthroscopic findings) that has failed to respond to nonoperative treatment may be treated arthroscopically.

images Arthroscopic options include simple débridement, débridement with thermal shrinkage, and débridement (with or without shrinkage) with percutaneous pinning.

images Static instability and severe dynamic instability are indications for open surgery.

images Surgical options include open repair or augmentation (especially of acute or subacute injuries), capsulodesis, and tenodesis.

images Patients developing carpal collapse with arthritic changes require salvage procedures such as radial styloidectomy, proximal row carpectomy, and limited wrist fusions (eg, STT, scaphocapitate, scaphoidectomy plus four-corner fusion, reduction-association scapholunate [RASL] procedure, lunotriquetral fusion).

images The focus of this chapter is on arthroscopic procedures described for management of dynamic scapholunate or lunotriquetral instability. Newer arthroscopic alternatives advocated for management of more advanced pathology are also described.

Arthroscopic Procedures

images Arthroscopic débridement of SLIL and LTIL injuries

images Indications: Predynamic or dynamic instability; arthroscopic findings of a partial ligament tear with an unstable tissue flap (Geissler grade II); with or without synovitis15,27

images The ideal patient for this technique is one with mechanical symptoms (pain with crepitance or clicking) attributable to impingement of unstable tissue flaps and resulting synovitis.

images Arthroscopic débridement and thermal shrinkage of SLIL and LTIL disruptions

images Indications: Predynamic or dynamic instability; arthroscopic finding of a partial ligament tear (Geissler grade I or II).5,7 The dorsal segment of the SLIL should be intact for this procedure.

images This technique provides an option for the management of lax, redundant ligaments with no frank tear (Geissler grade I) where simple débridement is not an option.

images Thermal shrinkage is performed in an attempt to increase stability and improve long-term outcome compared to simple débridement.

images Radiofrequency probes use a high-frequency alternating current to generate heat. This leads to denaturation (uncoiling) of the collagen triple helix with reduction in overall ligament length.

images Use of this device is contraindicated in patients with pacemakers or other implantable electronic devices.

images Arthroscopic débridement and percutaneous pinning of SLIL and LTIL disruptions

images Indications: Acute or subacute dynamic instability (Geissler grades II and III)3,28

images This technique aims to induce the formation of fibrous union between the two involved carpal bones.

images Arthroscopic radial styloidectomy

images Indications: Early (stage I) scapholunate advanced collapse (SLAC) wrist (ie, radial styloid–scaphoid impingement or arthritis) with focal and reproducible clinical findings of radial styloid pain exacerbated by wrist flexion and radial deviation

images This procedure may provide significant pain relief until a salvage procedure (proximal row carpectomy, scaphoid excision, four-corner fusion) becomes necessary.

images Arthroscopic RASL procedure (see Chap. HA-46) and lunotriquetral fusion

images Indications: Static instability (Geissler grade IV); lunotriquetral arthritis13,14

images Early (stage I) SLAC wrist is not a contraindication.

images The RASL procedure aims to achieve fibrous union while maintaining mild rotation at the scapholunate joint, thus approximating normal wrist kinematics. On the other hand, bony fusion is the goal in the lunotriquetral joint.

Preoperative Planning

images A careful review of the patient’s history, physical findings, as well as static and stress radiographs may provide the surgeon with a reasonable impression of what will be required.

images In most cases, however, a decision on the type of procedure to be performed is made intraoperatively based on the arthroscopic findings and associated pathology.

images Consideration must therefore be given to have the following available: radiofrequency probes, mini C-arm, drills, Kirschner wires of various widths, and headless compression screws.

Positioning

images The patient is placed in the supine position with the extremity on a hand table.

images Any possible donor site for ligament reconstruction or augmentation should also be prepared and draped in a sterile fashion.

images The extremity is placed in a tower distraction device with 10 to 12 lb (5 to 6 kg) of distraction and 12 to 15 degrees of wrist flexion (FIG 1).

images The arthroscope monitor is placed on the opposite side of the hand table from the surgeon.

images

FIG 1 • A. Positioning for arthroscopy of the wrist. B. The monitor should be visible to the surgeon. If use of fluoroscopy is anticipated, the C-arm is placed adjacent to the head of the operating table.

images If percutaneous pinning or use of other implants is anticipated, a small fluoroscopy unit is placed adjacent to the head of the operating table.

Approach

images Arthroscopic evaluation and management of scapholunate and lunotriquetral injuries can typically be performed through standard dorsal wrist portals (3–4, 4–5, 6R, midcarpal).

images The additional use of a radial volar portal through the flexor carpi radialis (FCR) sheath has been advocated for better visualization of the volar portions of the SLIL and LTIL, as well as the DRC and DIC ligaments.1,19

TECHNIQUES

ARTHROSCOPIC EVALUATION

images  An 18-gauge needle is used to distend the radiocarpal joint with 7 to 10 mL of normal saline.

images  A 2.7-mm, 30-degree arthroscope is preferred for wrist arthroscopy.

images  Typical working portals include the 3–4, 4–5, 6R, and midcarpal portals. Outflow is established through the 6U or 6R portal.

images  The entire radiocarpal joint is evaluated in a systematic manner, usually from radial to ulnar.

images  The SLIL is best visualized through the 3–4 portal with probe insertion through the 4–5 or 6R portal. The 4–5 portal is used for instrumentation.

images Occasionally the avulsed portion of the SLIL may make visualization through the 3–4 portal difficult. In this situation, the arthroscope is transferred to the 6R portal and directed radially.

images  The proximal portion of the SLIL is easily visualized by following the radioscapholunate ligament (ligament of Testut) to its insertion. The volar radioscapholunate and long radiolunate ligaments (wider) are visualized radially, and the short radiolunate is located ulnar to the ligament of Testut.

images

TECH FIG 1 • Geissler arthroscopic classification of interosseous ligament injuries of the wrist. The scapholunate joint is depicted here but the classification is also applicable to the lunotriquetral joint. A.Grade I: Attenuation of the scapholunate interosseous ligament as visualized in the radiocarpal joint. No incongruence is noted in the midcarpal joint. B. Grade II: Partial full-thickness tear with unstable flap but minimal joint incongruity. C. Grade III: Complete tear of the scapholunate interosseous ligament with moderate joint incongruity. A 1.5-mm probe can enter the joint (view from midcarpal portal). D.Grade IV: Complete tear with marked incongruity. The 2.7-mm arthroscope can “drive through” the joint.

images  The LTIL is best visualized through the 4–5 or 6R portal, with use of the 3–4 and 6R for instrumentation.

images  Both ligaments should be evaluated in their entirety (dorsal, proximal, and volar portions).

images If visualization of the volar portions of the SLIL and LTIL is inadequate, an additional volar portal through the FCR sheath may be used,1 but this has rarely been necessary in our experience.

images  In patients with gross scapholunate instability, the arthroscope is finally turned toward the dorsum of the scaphoid and lunate to identify possible avulsion of the DIC or DRC ligament.16

images  Evaluation of carpal congruence and stability is incomplete without performance of midcarpal arthroscopy.

images  The midcarpal portals are placed 1 cm distal to the 3–4 and 4–5 portals.

images The 2.7-mm, 30-degree arthroscope is aimed proximal.

images The scapholunate joint is visualized radially and the lunotriquetral joint ulnarly.

images Both joints are evaluated for congruity.

images Stability is evaluated with a 1-mm arthroscopic probe and the 2.7-mm arthroscope.

images A Watson scaphoid shift test may be performed while visualizing the scapholunate joint.

images  The Geissler arthroscopic classification of wrist interosseous ligament tears is shown in Techniques Figure 1.5

ARTHROSCOPIC DÉBRIDEMENT

images  A thorough diagnostic arthroscopy (radiocarpal plus midcarpal) is performed to verify the diagnosis and rule out instability or other associated pathology.

images  The inflamed synovium is excised with a 2.5 or 2.7-mm full-radius resector.

images  Any unstable tissue flaps are resected with a suction punch or synovial resector.

images  Redundant tissue is then resected to a stable rim with the synovial resector or bipolar radiofrequency probe.

images  A probe is then inserted through the 4–5 or 6R portal to reassess stability from both the radiocarpal and midcarpal joint.

images  Débridement should generally be limited to the proximal membranous portion of the SLIL or LTIL.

images  Unwarranted débridement of the dorsal (SLIL) or volar (LTIL) portions of the ligamentous complex may lead to further instability.

images  Carpal stability should be assessed both before and after débridement.

ARTHROSCOPIC DÉBRIDEMENT AND THERMAL SHRINKAGE

images  Diagnostic arthroscopy is performed as previously described.

images  Geissler grade II tears are débrided with a synovial resector to a stable rim (TECH FIG 2A). Thermal shrinkage of the intact portion of the ligament is then performed with a 2.3-mm bipolar radiofrequency probe.

images Attenuated ligaments (Geissler grade I) are treated with thermal shrinkage alone.

images  Thermal shrinkage is performed by applying the radiofrequency probe in a paintbrush fashion (2.3-mm radiofrequency probe [Mitek VAPR®, Westwood, MA]) (TECH FIG 2B). The goal is to evenly distribute the thermal energy throughout the ligament.

images The 4–5 portal is preferred for this procedure for optimal access to the SLIL.

images Ligament shrinkage is visually confirmed by a change in its color and consistency (TECH FIG 2C).

images  Intermittent application of the probe (a few seconds at a time) with adequate outflow prevents ablation of the ligament and overheating of the joint.

images Radiofrequency probes specially designed for thermal shrinkage have recently become available. They offer additional safety by not reaching ablation temperature.

images

TECH FIG 2 • Débridement and thermal shrinkage. A. Geissler grade II scapholunate interosseous ligament tear as seen through 3–4 portal. B. “Paintbrush” technique for thermal shrinkage. The probe is applied intermittently to avoid overheating. C. The same ligament after débridement and thermal shrinkage. Note apparent change in color and consistency.

ARTHROSCOPIC DÉBRIDEMENT AND PERCUTANEOUS PINNING

images  Diagnostic arthroscopy is performed as previously described.

images  All residual tissue of the torn ligament (SLIL or LTIL) is debrided with a 2.5 or 2.7-mm full-radius resector.

images  The cartilage of the apposing surfaces of the involved carpal bones is then débrided to bleeding bone with a 2.5 or 2.7-mm aggressive full-radius resector and a 2.9-mm barrel abrader (TECH FIG 3A).

images  The extremity is then removed from the distraction tower.

images  If necessary, congruity of the joint is improved by external (pressure on the distal pole of scaphoid) or internal maneuvers (percutaneous Kirschner wires used as joysticks).

images  The joint is stabilized by percutaneously inserting three or four 0.045-inch (1.1-mm) Kirschner wires under fluoroscopic control.

images  The scapholunate joint is typically stabilized with two Kirschner wires across the scapholunate joint (radial to ulnar) followed by one or two Kirschner wires across the scaphocapitate joint (TECH FIG 3B).

images  The lunotriquetral joint is similarly stabilized with two Kirschner wires across the lunotriquetral joint (ulnar to radial) followed by one or two Kirschner wires across the lunocapitate joint.

images  The pins are then cut subcutaneously or bent outside the skin per surgeon preference.

images

TECH FIG 3  Débridement and percutaneous pinning. A. Remnants of ligament and articular cartilage of apposing surfaces are débrided to bleeding bone. B. The joint is stabilized with three or four Kirschner wires placed under fluoroscopic guidance.

ARTHROSCOPIC RADIAL STYLOIDECTOMY

images  Diagnostic arthroscopy is initially performed to delineate the chondral lesions and accurately stage the SLAC wrist.22

images  The arthroscope is placed in the 3–4 or 4–5 portal.

images  Excision of the radial styloid is performed through the 1–2 (or 3–4) portal with a side-cutting 3.5-mm sheathed burr.

images  Arthroscopic evaluation of articular cartilage and intraoperative radiographs should be used to determine the extent of resection.

images The origin of the radioscaphocapitate ligament is visualized and preserved during bone resection.

images  Although the tendency is to overestimate the amount of bone resected, excision of more than 4 mm may jeopardize the ligament and result in ulnar carpal dislocation.

ARTHROSCOPIC RASL PROCEDURE AND LUNOTRIQUETRAL FUSION

images  Diagnostic arthroscopy with evaluation of chondral lesions is performed as described previously.

images  The apposing surfaces of the joint to be fused are débrided to bleeding bone with a 2.5 or 2.7-mm aggressive full-radius resector and a 2.9-mm barrel abrader.

images Complete decortication is verified from both the radiocarpal and midcarpal joints.

images  In the case of the RASL procedure, a side-cutting 3.5-mm sheathed burr is then used to perform an arthroscopic radial styloidectomy through the 1–2 (or 3–4) portal as described previously.

images  Kirschner wires (0.062 inch or 1.6 mm) are then inserted percutaneously from the dorsum into the involved carpal bones (distal scaphoid-lunate or lunate-triquetrum). Positioning of the wires should be slightly eccentric to allow for subsequent placement of the screw centrally. The Kirschner wires are used as joysticks to reduce the joint under fluoroscopic (with or without arthroscopic) control.

images It is essential to verify adequate reduction of the capitolunate joint on the lateral view.

images A Köcher clamp may be placed across the Kirschner wires to maintain reduction.

images An additional 0.045-inch (1.1-mm) Kirschner wire may be inserted through the dorsal rim of the distal radius into the lunate for provisional stabilization of the lunate.

images  A 0.035-inch (0.9-mm) guidewire is then placed across the joint (scapholunate or lunotriquetral) under fluoroscopic control.

images  In the case of the RASL procedure, the guidewire should be placed through the 1–2 portal, across the scaphoid waist toward the proximal-ulnar corner of the lunate, thus approximating the normal axis of rotation of the scapholunate joint (TECH FIG 4).

images  A cannulated headless compression screw is then placed across the joint. Length measurement should be reduced by about 4 mm to accommodate for joint compression and to ensure that the screw is completely countersunk into bone.

images  After satisfactory reduction and fixation are verified, the wrist capsule incision is repaired.

images  In patients with lunotriquetral instability as a result of ulnar impaction syndrome, fusion of the lunotriquetral joint must be combined with an arthroscopic wafer procedure or an ulnar shortening.

images

TECH FIG 4 • RASL technique. Scapholunate joint reduction is achieved using two Kirschner wires as joysticks. Optimal positioning of a compression screw is through the scaphoid waist toward the proximal-ulnar corner of the lunate, and fully countersunk.

images

POSTOPERATIVE CARE

images Patients treated with arthroscopic débridement alone are placed in a cock-up wrist splint postoperatively and instructed to initiate range-of-motion exercises at 48 hours.

images Patients treated with arthroscopic débridement and thermal shrinkage are placed in a full-time short-arm splint postoperatively. Range-of-motion exercises are initiated at 2 to 4 weeks, with use of a removable cock-up splint between sessions. Strengthening exercises are initiated at 4 to 6 weeks.

images Patients treated with arthroscopic débridement and percutaneous pinning are placed in a short-arm splint, changed to a short-arm cast after suture removal. The cast is maintained until pin removal, which is performed at 8 to 10 weeks for the scapholunate and at 4 to 6 weeks for the lunotriquetral joint. Range-of-motion exercises are then initiated, with progression to strengthening as tolerated.

images Patients treated with an arthroscopic RASL procedure are placed in a short-arm splint for only 2 or 3 weeks. Range-ofmotion exercises are then initiated, with progression to strengthening as tolerated. Conversely, patients treated with arthroscopic fusion of the lunotriquetral joint are immobilized until radiographic fusion is obtained.

OUTCOMES

images Ruch and Poehling15 reported excellent results with arthroscopic débridement alone in 14 patients with partial SLIL or lunotriquetral tears, or both, and predominantly mechanical symptoms. At a minimum follow-up of 2 years, all patients reported complete relief of their mechanical symptoms, while pain was significantly reduced and grip strength was restored.

images Weiss et al27 have treated both partial and complete SLIL and lunotriquetral tears with arthroscopic débridement alone in an attempt to elicit scar formation with some degree of stabilization. Excellent pain relief and increased strength were achieved in 17 of 19 patients with partial tears, but only in 17 of 24 patients with complete tears. No radiologic progression was noted at 27 months follow-up.

images Darlis et al4 reported substantial pain relief in 14 of 16 patients with Geissler grade I or II SLIL tears treated with arthroscopic débridement and thermal shrinkage. Wrist motion was maintained and there was no radiologic evidence of instability at 19 months of follow-up.

images Hirsh et al6 reported excellent results in 9 of 10 patients with Geissler grade II SLIL tears treated with arthroscopic débridement and thermal shrinkage at 28 months of follow-up.

images Whipple28 reported his results with percutaneous pinning in patients with scapholunate instability. Symptom duration of more than 3 months and a side-to-side gap difference of more than 3 mm were associated with poor outcomes. Pain relief was satisfactory in only 53% of patients with both of these factors.

images Darlis et al3 reported management of chronic (longer than 3 months) dynamic scapholunate instability (Geissler grades III, IV) with arthroscopic débridement and percutaneous pinning in patients who did not wish to undergo open surgery. Results were suboptimal, with significant pain relief and improved grip strength in 6 of 11 patients. At 33 months of follow-up there was no radiologic evidence of progression to static instability, but three patients required additional surgery to address persistent pain.

images Clinical experience with the arthroscopic RASL procedure and lunotriquetral fusion is limited. Rosenwasser et al14reported excellent results using the open RASL technique in 20 patients with static instability. At 54 months of follow-up, patients had achieved 91% of their normal wrist motion and 87% of contralateral grip strength. The authors noted that the procedure may be performed arthroscopically, but thought that experience with the open technique should first be obtained.

COMPLICATIONS

images Injury to branches of superficial radial sensory nerve (especially with use of 1–2 portal) or dorsal branch of ulnar nerve (6R, 6U portals)

images Injury to radial artery (radial volar portal). This portal should be established through the floor of the FCR sheath.

images Persistent pain or instability

images Need for additional surgery (ligament reconstruction, capsulodesis, tenodesis, proximal row carpectomy, partial or complete wrist fusion)

REFERENCES

1.     Abe Y, Doi K, Hattori Y, et al. Arthroscopic assessment of the volar region of the scapholunate interosseous ligament through a volar portal. J Hand Surg Am 2003;28A:69–73.

2.     Berger RA. The gross and histologic anatomy of the scapholunate interosseous ligament. J Hand Surg Am 1996;21A:170–178.

3.     Darlis NA, Kaufmann RA, Giannoulis F, et al. Arthroscopic debridement and closed pinning for chronic dynamic scapholunate instability. J Hand Surg Am 2006;31A:418–424.

4.     Darlis NA, Weiser RW, Sotereanos DG. Partial scapholunate ligament injuries treated with arthroscopic debridement and thermal shrinkage. J Hand Surg Am 2005;30A:908–914.

5.     Geissler WB, Freeland AE. Arthroscopically assisted reduction of intraarticular distal radial fractures. Clin Orthop Relat Res 1996;327: 125–134.

6.     Hirsh L, Sodha S, Bozentka D, et al. Arthroscopic electrothermal collagen shrinkage for symptomatic laxity of the scapholunate interosseous ligament. J Hand Surg Br 2005;30B:643.

7.     Horii E, Garcia-Elias M, An KN, et al. A kinematic study of lunotriquetral dissociations. J Hand Surg Am 1991;16A:355–362.

8.     Mathiowetz V, Kashman N, Volland G, et al. Grip and pinch strength: normative data for adults. Arch Phys Med Rehabil 1985;66:69–72.

9.     Mayfield JK, Johnson RP, Kilcoyne RK. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg Am 1980;5A:226–241.

10. O’Meeghan CJ, Stuart W, Mamo V, et al. The natural history of an untreated isolated scapholunate interosseus ligament injury. J Hand Surg Br 2003;28B:307–310.

11. Reagan DS, Linscheid RL, Dobyns JH. Lunotriquetral sprains. J Hand Surg Am 1984;9A:502–514.

12. Ritt MJ, Bishop AT, Berger RA, et al. Lunotriquetral ligament properties: a comparison of three anatomic subregions. J Hand Surg Am 1998;23A:425–431.

13. Ritt MJ, Maas M, Bos KE. Minnaar type 1 symptomatic lunotriquetral coalition: a report of nine patients. J Hand Surg Am 2001;26A: 261–270.

14. Rosenwasser MP, Miyasajsa KC, Strauch RJ. The RASL procedure: reduction and association of the scaphoid and lunate using the Herbert screw. Tech Hand Up Extrem Surg 1997;1:263–272.

15. Ruch DS, Poehling GG. Arthroscopic management of partial scapholunate and lunotriquetral injuries of the wrist. J Hand Surg Am 1996;21A:412–417.

16. Ruch DS, Smith BP. Arthroscopic and open management of dynamic scaphoid instability. Orthop Clin North Am 2001;32:233–240.

17. Schaedel-Hoepfner M, Iwinska-Zelder J, Braus T, et al. MRI versus arthroscopy in the diagnosis of scapholunate ligament injury. J Hand Surg Br 2001;26B:17–21.

18. Shin AY, Battaglia MJ, Bishop AT. Lunotriquetral instability: diagnosis and treatment. J Am Acad Orthop Surg 2000;8:170–179.

19. Slutsky DJ. Arthroscopic dorsal radiocarpal ligament repair. Arthroscopy 2005;21:1486.

20. Trumble TE, Bour CJ, Smith RJ, et al. Kinematics of the ulnar carpus related to the volar intercalated segment instability pattern. J Hand Surg Am 1990;15A:384–392.

21. Walsh JJ, Berger RA, Cooney WP. Current status of scapholunate interosseous ligament injuries. J Am Acad Orthop Surg 2002;10:32–42.

22. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am 1984;9A: 358–365.

23. Watson H, Ottoni L, Pitts EC, et al. Rotary subluxation of the scaphoid: a spectrum of instability. J Hand Surg Br 1993;18B:62–64.

24. Watson HK, Weinzweig J, Zeppieri J. The natural progression of scaphoid instability. Hand Clin 1997;13:39–49.

25. Weber ER. Wrist mechanics and its association with ligamentous instability. In: Lichtman DM, ed. The Wrist and its Disorders. Philadelphia: Saunders; 1988:41–52.

26. Weiss AP, Akelman E, Lambiase R. Comparison of the findings of triple-injection cinearthrography of the wrist with those of arthroscopy. J Bone Joint Surg Am 1996;78A:348–356.

27. Weiss AP, Sachar K, Glowacki KA. Arthroscopic debridement alone for intercarpal ligament tears. J Hand Surg Am 1997;22A:344–349.

28. Whipple TL. The role of arthroscopy in the treatment of scapholunate instability. Hand Clin 1995;11:37–40.

29. Wolfe SW, Katz LD, Crisco JJ. Radiographic progression to dorsal intercalated segment instability. Orthopedics 1996;19:691–695.

30. Zachee B, De Smet L, Fabry G. Frayed ulno-triquetral and ulnolunate ligaments as an arthroscopic sign of longstanding triquetrolunate ligament rupture. J Hand Surg Br 1994;19B:570–571.



If you find an error or have any questions, please email us at admin@doctorlib.info. Thank you!