SCIENTIFIC ARTICLE
Radiographic Evaluation of the Modified Brunelli Technique Versus a Scapholunotriquetral Transosseous Tenodesis Technique for Scapholunate Dissociation Jennifer W. Hsu, MD, Kathleen M. Kollitz, BS, Mithulan Jegapragasan, MD, Jerry I. Huang, MD
Purpose To compare reduction of the scapholunate articulation using a transosseous tenodesis through the scaphoid, lunate, and triquetrum (SLT) with the modified Brunelli technique (MBT) in a cadaver model, as measured by scapholunate (SL) angle and diastasis on radiographs. Methods Twelve fresh-frozen cadaveric wrists were radiographically examined in a neutral posture, ulnar deviation, and clenched fist position. The SL angle and diastasis were recorded in each position with the SL ligament intact, after sectioning the ligament and secondary restraints, and after reconstruction by either the MBT (6 wrists) or SLT technique (6 wrists). Wrists were cycled through their maximum flexion and extension arc 100 times to simulate wrist motion after ligament sectioning and reconstruction. Results After sectioning and cycling, all wrists demonstrated radiographic evidence of SL diastasis. After ligament reconstruction and cycling, there was no statistically significant difference in diastasis in the MBT reconstructions compared with the SLT reconstructions (3.0 vs 2.4 mm). The SLT group demonstrated better maintenance of the restored SL angle than the MBT reconstructions. Conclusions In this cadaveric model, both MBT and SLT reconstructions restored anatomic parameters in the SL joint, with correction of SL diastasis and SL angle. Future studies to assess the clinical outcomes of SLT tenodesis in patients with chronic SL disruptions are important. Clinical relevance The SLT tenodesis, with a central biologic tether along the SL axis and dorsal reinforcement, may prove clinically useful. (J Hand Surg Am. 2014;-:-e-. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Scapholunate dissociation, reconstruction, tenodesis, Brunelli.
From the Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA. Received for publication December 4, 2013; accepted in revised form March 3, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jerry I. Huang, MD, Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, 4245 Roosevelt Way NE, 2nd Floor, Box 354740, Seattle, WA 98105; e-mail: [email protected]. 0363-5023/14/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.03.005
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(SL) DISSOCIATION is the most common carpal instability, frequently causing wrist pain and weakness.1 When left untreated, SL dissociation results in fixed, altered mechanics between the carpals, likely leading to progressive degenerative changes in the radiocarpal and midcarpal joints.2 Surgical treatment is often recommended to alleviate pain, restore function and grip strength, and prevent the development of progressive SL advanced collapse deformity. Various surgical CAPHOLUNATE
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techniques have been described for treatment of chronic SL injuries, including various dorsal capsulodeses, dynamic tenodeses, boneeligamentebone fixations, and screw reductions.3e12 They have the common goal of restoring intercarpal mechanics by restoring the function of the SL interosseous ligament (SLIL) and secondary stabilizers. The surgical technique of Brunelli and Brunelli6 for SL reconstruction routed a slip of the flexor carpi radialis (FCR) through the distal volar portion of the scaphoid and secured it to the dorsal, ulnar portion of the distal radius, thus correcting scaphoid flexion and providing SLIL, as well as dorsal and volar wrist stabilization. The modified Brunelli technique (MBT), as refined by Garcia-Elias et al,7 Talwalker et al,13 and Van Den Abbeele et al,14 attaches the FCR to the dorsal lunate and avoids tenodesis across the radiocarpal joint, which limits wrist motion. Garcia-Elias et al described the triligament tenodesis, which uses the FCR tendon to stabilize an irreparable chronic SL ligament rupture and correct carpal alignment by restoring the function of 3 ligaments: the scaphotrapeziotrapezoidal ligament, the dorsal portion of the SLIL, and the dorsal radiotriquetral ligament. Recently, Ross et al15 described a technique for SL reconstruction in which the FCR tendon is routed through transosseous tunnels in the scaphoid, lunate, and triquetrum. The tendon is then brought dorsally across the triquetrum, lunate, and scaphoid, where it is secured. In addition to the 3-ligament stabilization described by Garcia-Elias et al,7 this scapholunatotriquetral (SLT) tenodesis provides a central biologic tether through the axis of rotation between the scaphoid and lunate and augments the repair with reconstruction of the dorsal SLIL. In their prospective cohort study, Ross and colleagues reported similar subjective and objective short-term outcomes compared with results after MBT. The purpose of this biomechanical study was to compare the degree of stabilization obtained with the more commonly performed MBT with the SLT tenodesis technique in a cadaver model of complete SL dissociation. We hypothesized that the SLT tenodesis reconstruction would be comparable to the MBT in resisting SL diastasis in our biomechanical study.
or wrist injury, instability, or degenerative changes. The limbs were disarticulated at the elbow and prepared in a manner similar to that described by Pollock et al.16 Midline dorsal and volar forearm incisions were made, and skin flaps were elevated to expose the extensor carpi radialis brevis, extensor carpi radialis longus, and extensor carpi ulnaris tendons and the FCR, flexor carpi ulnaris, flexor digitorum superficialis, and flexor digitorum profundus tendons volarly. We placed number 2 TiCron sutures (Covidien, Inc, Mansfield, MA) into the extensor carpi ulnaris and flexor carpi ulnaris tendons with an interlocking, grasping suture technique. The extensor carpi radialis longus, extensor carpi radialis brevis, 4 flexor digitorum superficialis, and 4 flexor digitorum profundus tendons were sutured side to side into respective bundles. The FCR tendon was split in half longitudinally. Half of the tendon was woven with TiCron suture, which left the remaining half to be used for ligamentous reconstruction. The forearms were then mounted onto a stand consisting of a wooden floor with a vertical wooden support arm. Longitudinal threaded Steinmann pins were placed from the floor of the stand into the medullary canal of the proximal ulna and radius to support the forearm vertically, followed by placement of transverse pins into the distal radius and ulna. Metal S-hooks were used to suspend weights from the prepared tendons to simulate different wrist positions, as described by Slater et al.17 Wrist position was created using 2.3-kg weights on each set of tendons. Wrist flexion was created with the FCR and flexor carpi ulnaris tendons. Extension was created with the extensor carpi ulnaris and combined extensor carpi radialis brevis/extensor carpi radialis longus tendons. Ulnar deviation was created with the extensor carpi ulnaris and flexor carpi ulnaris tendons. Clenched fist stress view was created with 4.6-kg weights attached to the flexor digitorum superficialis and flexor digitorum profundus tendons. With the weights applied, each wrist was allowed to reach its maximum excursion, as dictated by each wrist’s soft tissues, except in the case of the clenched fist position. To ensure that load transferred across the wrist axially rather than causing wrist flexion during application of weights in the clenched fist position, the wrist was manually held in a neutral position. We used fluoroscopy to obtain standard radiographic views of all wrists. Posteroanterior (PA) views were obtained for wrists in neutral, ulnar deviation, and clenched fist positions. Lateral views were obtained for wrists in neutral, flexed, extended, ulnar deviated, and clenched fist positions. For this
MATERIALS AND METHODS Twelve cadaveric upper extremities were evaluated and were found to have no physical examination findings or radiographic evidence of previous forearm J Hand Surg Am.
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initial set of data, the SL ligament remained intact. The limbs were then removed from the frame, and SL dissociation was created in all 12 wrists through a dorsal ligamentesparing capsulotomy. The SLIL was sharply transected with a scalpel blade. Secondary stabilizers were also released with incision through the volar approach with sectioning of the scaphotrapeziotrapezoid joint capsule and the volar radioscaphocapitate ligament. A set of PA and lateral radiographs were obtained for all wrists at this time and referred to as cut. While mounted to the frame, the wrists were cycled 100 times through maximal wrist flexion and extension to simulate repetitive loading of the wrist. Another set of radiographs was obtained for the wrists and referred to as cut-cycled.
ligament-sparing capsulotomy.19 Care was taken to preserve the dorsal radiotriquetral ligament. A 3.2-mm drill hole entering at the insertion of the dorsal SL ligament and aiming toward the tuberosity was made with a cannulated drill. A counter curvilinear incision was made over the scaphoid tubercle. We routed a distally based 10-cm strip of FCR tendon that was the radial 3-mm portion through the scaphoid tunnel using a suture passer. We then passed the FCR slip through a slit in the dorsal radiotriquetral ligament, which acts as a pulley to tension the ligamentous reconstruction (Fig. 1). A 2.2-mm corkscrew suture anchor (Arthrex, Naples, FL) was placed in the lunate and the tendon was secured. The tendon was also sutured to itself over the scaphoid tunnel to reinforce the repair.
Surgical reconstruction Six wrists underwent SLIL reconstruction with the MBT, as described by Garcia-Elias et al.7 The remaining 6 wrists underwent SLT tenodesis as described by Ross et al,15 except for a modification described subsequently. After the reconstruction, each wrist was remounted on the frame, and a set of PA and lateral radiographs was obtained in each wrist position. This data set was referred to as reconstructed. Each wrist was cycled through 100 repetitions of its maximal flexion and extension arc, followed by repeat imaging. This data set was referred to as reconstructedcycled. The digital radiographs were viewed on OsiriX (Pixmeo, Geneva, Switzerland), a Digital Imaging and Communications in Medicine viewer, for measurement of SL intervals on PA views of the wrists. The SL interval was calculated as the distance between the midpoint of the scaphoid and the lunate. To accurately calibrate measurements, a radiopaque metal coin 21 mm in diameter was mounted to the wood frame on all PA views. Pixelstick (Plum Amazing, Princeville, HI) software was used to determine SL angle on lateral views of the wrists. The angle was measured using a line drawn between the most volar point of the scaphoid tubercle distally and the proximal pole and a line perpendicular to the axis between the 2 distal poles of the lunate.18 Means were compared using paired t tests to examine differences in measurements performed within repair groups, and unpaired t tests to examine differences between repair groups.
Scapholunatotriquetral tenodesis: A dorsal ligament-sparing capsulotomy was modified to create a more ulnar flap to allow better access to the triquetrum.15 The volar aspect of the scaphoid exposure and the FCR split were, similar to an MBT reconstruction. A transscaphoid tunnel was drilled dorsally from proximal to distal, from the scaphoid’s lunate articular facet to the volar aspect of the scaphoid tubercle. The dorsal proximal entry point was placed just dorsal to the center point of the scaphoid’s lunate facet and not at the dorsal insertion of the SL ligament, as in the MBT (Fig. 2). A lunotriquetral tunnel was drilled from the ulnar side of the triquetrum and across the lunotriquetral joint to exit the lunate just volar to the midpoint of the lunates’ scaphoid facet. By placing the lunate exit volarly and the scaphoid exit dorsally, tensioning of the obliquely oriented graft allowed for correction of dorsal intercalated segmental instability deformity (DISI). We passed the FCR graft through the scaphoid from volar to dorsal and then through the tunnels in the lunate and triquetrum (Fig. 2). We tensioned the tendon as it exited the triquetrum, which reduced dorsal subluxation of the scaphoid and closed the SL interval. In contrast to the technique of Ross et al,15 an interference screw was not used to secure the tendon graft to the triquetrum in these cadaver wrists owing to concern regarding potential iatrogenic triquetral fracture in the osteopenic cadaveric specimens. The graft was then brought dorsally across the proximal carpal row and secured in the scaphoid waist with a suture anchor to recreate the dorsal SLIL (Fig. 2). When graft length was sufficient, the graft was taken through the base of the capsular graft and sutured in place (Fig. 2). The SLT tenodesis created a tendon tether along the central axis of the scapholunate joint as well as the dorsal
Surgical technique Modified Brunelli technique: We made a longitudinal incision over the dorsal aspect of the wrist and then a
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FIGURE 1: A In the MBT reconstruction, the scaphoid bone tunnel exits dorsally at the insertion of the SL ligament. The FCR graft is brought volar to dorsal through the bone tunnel, across a trough in the dorsal lunate, and through a slit in the dorsal radiotriquetral ligament. The ligament acts as a pulley for the graft B, which is tensioned and sutured over the lunate with a suture anchor C. D Excess graft can be sutured over itself on the scaphoid to reinforce the reconstruction.
then cycled, with the SL interval in the clenched fist position measuring 3.0 mm in the MBT group and 2.4 mm in the SLT group (P ¼ .29). The overall final reductions in scapholunate diastasis (comparing sectioned and cycled specimen with final SL intervals after reconstruction and cycling) were 2.6 mm in the SLT specimens, compared with 1.2 mm in the MBT specimens.
SLIL (Fig. 3). In addition, passing the FCR tendon through the scaphoid tunnel, similar to the MBT, reconstructed the scaphotrapeziotrapezoid ligament, which is an important secondary stabilizer that prevents scaphoid flexion. RESULTS Scapholunate interval In the intact state, the mean SL interval distance was 2.6 mm in the MBT group and 1.8 mm in the SLT group (P ¼ .03). After ligament sectioning and cycling, all wrists demonstrated significant SL diastasis on the clenched fist view compared with the intact intervals, with average distance of 4.3 mm in the MBT and 5.0 mm in the SLT groups (P ¼ .05 and P ¼ .02, respectively) (Fig. 4). The MBT and SLT wrists were not significantly different after cycling (mean, 4.3 and 5.0 mm, respectively; P ¼ .50). After reconstruction, the mean SL interval in the clenched fist position was greater in the MBT group at 2.3 mm, compared to the SLT group at 1.8 mm, although not statistically significant (P ¼ .34) (Fig. 5). Wrists were J Hand Surg Am.
Scapholunate angle The average SL angle was 47 across groups before sectioning, with MBT wrists at an average of 45 and SLT wrists at an average of 49 (P ¼ .41). After ligament sectioning and cycling, the SL angle increased from an average of 47 to 61 in the clenched fist position (P < .001) (Fig. 6). After reconstruction, the SL angle was restored to 47 in the MBT group and 52 in the SLT group (P ¼ .18). Cycling the wrists increased the SL angle in the MBT group by 6 to an average of 53 after cycling (P ¼ .05). The SL angle in the SLT group increased by 2 after cycling to 54 , but this was not statistically significant (P ¼ .41). After SL reconstruction and r
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FIGURE 2: A In the SLT tenodesis, the FCR strip is brought volar to dorsal through a scaphoid bone tunnel, exiting just dorsal to the center point of the lunate facet of the scaphoid. B A bone tunnel is made starting ulnarly through the triquetrum to the lunate, and C the FCR graft is brought through the lunotriquetral tunnel from radial to ulnar. D The graft is tensioned and brought dorsally across the proximal row. E A suture anchor placed into the dorsal portion of the scaphoid secures the graft in position, recreating the dorsal SLIL. F Looking from dorsally onto a flexed wrist after SLT tenodesis, the scaphoid and lunate are in their anatomically restored positions.
identified. The Blatt capsulodesis and modifications such as the Szabo dorsal capsulodesis involve advancement of the dorsal joint capsule and dorsal intercarpal ligament into the scaphoid for static SL instability to prevent scaphoid flexion and progressive DISI.4,20 Moran et al11 presented a series of 31
cycling, the SL angle was similar in the MBT and SLT reconstructions (53 vs 54 ). DISCUSSION Despite numerous surgical options for chronic SL dissociation, a reference standard has not yet been J Hand Surg Am.
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wrist motion to stress the reconstruction. Greatest differences in SL interval and SL angle were noted in the clenched fist position. The MBT reconstructed wrists had better restoration of the SL interval, reduction of the diastasis, and correction of the SL angle compared with the Blatt capsulodesis. The current literature yields conflicting data regarding the long-term efficacy of the MBT in maintaining carpal anatomy and mechanics. In a retrospective analysis of 15 patients after MBT reconstruction at an average follow-up of 36 months, Moran et al23 noted significant improvement in SL angle but not SL intervals with persistent diastasis in patients with static instability. In contrast, Chabas et al24 performed a retrospective analysis of 19 patients with a mean follow-up of 37 months and found improvement of SL interval from 2.8 mm preoperatively to 2.4 mm postoperatively, a correction that was maintained on final follow-up. Recently, Nienstedt25 reported on 12-year follow-up after MBT. Preoperatively, the SL gap was 5.1 mm, which corrected to 2.4 mm after surgery. At final follow-up, this increased to 2.8 mm. The average SL angle improved from 72 to 46 postoperatively and increased again to 63 at final follow-up. Because of concerns regarding progressive SL gapping, several authors recommended screw augmentation in treating chronic SL ligament injuries.12,26 Compared with the K-wire cohort, Larson et al26 demonstrated better improvement in the SL diastasis, correction of the SL angle, and maintenance of the reduction with use of a temporary SL screw. However, iatrogenic fractures of the scaphoid and lunate have been reported.27 One concern with MBT reconstruction is that excessive tightening of the SL joint dorsally may cause a hinge effect with gapping volarly. Berger et al28 demonstrated the importance of the palmar region in its contribution to rotational constraint of the SL joint. Comparatively, the SLT technique offers the advantage of positioning bone tunnels near the center of the axis of rotation between the scaphoid and lunate. This allows even tensioning between the 2 bones and apposition of the facets. Furthermore, passage of the tendon across the lunotriquetral interval provides additional stabilization in settings of perilunate injury. Passage of the tendon dorsally across the proximal row into the scaphoid reinforces the dorsal intercarpal ligament, another important secondary stabilizer of the SL articulation. Ross et al15 reported the average 14-month outcomes of 11 patients after SLT reconstruction and found a reduction in SL interval from an average of 4.2 mm preoperatively to 1.6 mm postoperatively. The
FIGURE 3: Position of the bony tunnels through the scaphoid, lunate, and triquetrum.
patients treated with Blatt or Mayo dorsal capsulodesis. On final follow-up at a mean of 54 months, there was radiographic deterioration with an SL gap increase from 2.7 to 3.9 mm. In a series of direct repair and dorsal capsulodesis, Pomerance21 reported deterioration of clinical and radiographic results in high-demand patients with strenuous jobs. At longterm follow-up after a mean of 66 months, the SL gap was 4 mm, increasing to 6 mm with stress, in the strenuous patient cohort compared with 2 mm, increasing to 3 mm with stress, in the nonstrenuous cohort. The MBT is a popular method that reconstructs the disrupted dorsal SLIL with a strip of the FCR tendon. Garcia-Elias et al7 described the 3-ligament tenodesis as a modification of the Brunelli technique, which further augments the secondary stabilizers. In a cadaveric biomechanical study, Howlett et al22 demonstrated the advantages of distal tunnel placement for more anatomic reconstruction to correct DISI deformity. Pollock et al16 performed a cadaveric study to compare MBT reconstruction with Blatt capsulodesis. Wrists were loaded with weights, and measurements were obtained in different positions after simulated J Hand Surg Am.
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FIGURE 4: Average SL diastasis after SL ligament reconstruction by the A MBT or B the SLT technique, as measured in neutral deviation, ulnar deviation, and clenched fist positions.
FIGURE 5: Anteroposterior fluoroscopic images demonstrating SL diastasis after sectioning of the SL and secondary ligaments and wrist cycling, compared with images taken after reconstruction and cycling. A, B Wrist before and after MBT reconstruction and cycling. C, D Wrist before and after SLT reconstruction and cycling. After MBT reconstruction and cycling, cadaveric wrists on average displayed increased diastasis B, compared with SLT reconstruction D.
SL angle was also reduced from 81 preoperatively to 57 postoperatively. Improvements in Quick Disabilities of the Arm, Shoulder, and Hand scores (mean, 50e21) and Patient-Rated Wrist Evaluation scores J Hand Surg Am.
(mean, 43e19) were found, as were improvements in grip strength. Although follow-up was short, these preliminary clinical and radiographic results are encouraging. r
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FIGURE 6: Average SL angle after ligament reconstruction by A the MBT or B the SLT technique, as measured in neutral deviation, ulnar deviation, and clenched fist positions.
Limitations in our study include those inherent in cadaver-based studies. Cadaver specimens do not allow tissue healing to assess reconstruction durability accurately. Radiographic measurements such as SL interval and SL angle do not comprehensively describe dynamic intercarpal mechanics, and their relationship to long-term clinical outcomes and degenerative changes is unknown. Our technique did not include securing the FCR tendon graft to the triquetrum with a tenodesis screw as described in the original publication of Ross et al.15 Use of a tenodesis screw would have strengthened the construct and possibly further reduced the SL diastasis. Preliminary clinical results and our biomechanical ones of SLT tenodesis suggest that this technique is an effective reconstruction that may lead to restoration and maintenance of intercarpal relationships and mechanics similar to those obtained with the MBT.
7. Garcias-Elias M, Lluch A, Stanley JK. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique. J Hand Surg Am. 2006;31(1):125e134. 8. Harvey EJ, Hanel D, Knight JB, Tencer AF. Autograft replacements for the scapholunate ligament: a biomechanical comparison of hand-based autografts. J Hand Surg Am. 1999;24(5): 963e967. 9. Harvey EJ, Berger RA, Osterman AL, Fernandez DL, Weiss AP. Bone-tissue-bone repairs for scapholunate dissociation. J Hand Surg Am. 2007;32(2):256e264. 10. Szabo RM. Scapholunate ligament repair with capsulodesis reinforcement. J Hand Surg Am. 2008;33(9):1645e1654. 11. Moran SL, Cooney WP, Berger RA, Strickland J. Capsulodesis for the treatment of chronic scapholunate instability. J Hand Surg Am. 2005;30(1):16e23. 12. Rossenwasser M, Miyasajsa KG, Strauch RJ. The RASL procedure: reduction and association of the scaphoid and lunate using the Herbert screw. Tech Hand Up Extrem Surg. 1997;1(4):263e272. 13. Talwalkar SC, Edwards AT, Hayton MJ, Stilwell JH, Trail IA, Stanley JK. Results of tri-ligament tenodesis: a modified Brunelli procedure in the management of scapholunate instability. J Hand Surg Br. 2006;31(1):110e117. 14. Van Den Abbeele KLS, Loh YC, Stanley JH, Trail IA. Early results of a modified Brunelli procedure for scapholunate instability. J Hand Surg Br. 1998;23(2):258e261. 15. Ross M, Loveridge J, Cutbush K, Couzens G. Scapholunate ligament reconstruction. J Wrist Surg. 2013;2(2):110e115. 16. Pollock PJ, Sieg RN, Baechler MF, Scher D, Zimmerman NB, Dubin NH. Radiographic evaluation of the modified Brunelli technique versus the Blatt capsulodesis for scapholunate dissociation in a cadaver model. J Hand Surg Am. 2010;35(10):1589e1598. 17. Slater RR Jr, Szabo RM, Bay BK, Laubach J. Dorsal intercarpal ligament capsulodesis for scapholunate dissociation: biomechanical analysis in a cadaver model. J Hand Surg Am. 1999;24(2): 232e239. 18. Larsen CF, Mathiesen FK, Lindequist S. Measurement of carpal bone angles on lateral wrist radiographs. J Hand Surg Am. 1991;16(5): 888e893. 19. Berger RA, Bishop AT, Bettinger PC. New dorsal capsulotomy for the surgical exposure of the wrist. Ann Plast Surg. 1995;35(1): 54e59. 20. Szabo RM, Slater RR Jr, Palumbo CF, Verlach T. Dorsal intercarpal ligament capsulodesis for chronic, static scapholunate dissociation: clinical results. J Hand Surg Am. 2002;27(6):978e984. 21. Pomerance J. Outcome after repair of the scapholunate interosseous ligament and dorsal capsulodesis for dynamic scapholunate instability due to trauma. J Hand Surg Am. 2006;31(8):1380e1386.
REFERENCES 1. Jones WA. Beware the sprained wrist: the incidence and diagnosis of carpal instability. J Bone and Joint Surg Br. 1988;70(2): 293e297. 2. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am. 1984;9(3): 358e365. 3. Almquist EE, Bach AW, Sach JT, Fuhs SE, Newman DM. Four-bone ligament reconstruction for treatment of chronic complete scapholunate separation. J Hand Surg Am. 1991;16(2): 322e327. 4. Blatt G. Capsulodesis in reconstructive hand surgery: dorsal capsulodesis for the unstable scaphoid and volar capsulodesis following excision of the distal ulna. Hand Clin. 1987;3(1):81e102. 5. Bleuler P, Shafighi M, Donati OF, Gurunluoglu R, Constantinescu MA. Dynamic repair of scapholunate dissociation with dorsal extensor carpi radialis longus tenodesis. J Hand Surg Am. 2008;33(2):281e284. 6. Brunelli GA, Brunelli GT. A new technique to correct carpal instability with scaphoid rotary subluxation: a preliminary report. J Hand Surg Am. 1995;20(3):S82eS85.
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25. Nienstedt F. Treatment of static scapholunate instability with modified Brunelli tenodesis: results over 10 years. J Hand Surg Am. 2013;38(5):887e892. 26. Larson TB, Gaston RG, Chadderdon RC. The use of temporary screw augmentation for the treatment of scapholunate injuries. Tech Hand Up Extrem Surg. 2012;16(3):135e140. 27. Cogent JM, Levadoux M, Martinache X. The use of screws in the treatment of scapholunate instability. J Hand Surg Eur Vol. 2011;36(8):690e693. 28. Berger RA, Imeada T, Berglund L, An KN. Constraint and material properties of the subregions of the scapholunate interosseous ligament. J Hand Surg Am. 1999;24(5):953e962.
22. Howlett JP, Pfaeffle HJ, Waitayawinyu T, Trumble TE. Distal tunnel placement improves scaphoid flexion with the Brunelli tenodesis procedure for scapholunate dissociation. J Hand Surg Am. 2008;33(10): 1756e1764. 23. Moran SL, Ford KS, Wulf CA, Cooney WP. Outcomes of dorsal capsulodesis and tenodesis for treatment of scapholunate instability. J Hand Surg Am. 2006;31(9):1438e1446. 24. Chabas JF, Gay A, Valenti D, Guinard D, Legre R. Results of the modified Brunelli tenodesis for treatment of scapholunate instability: a retrospective study of 19 patients. J Hand Surg Am. 2008;33(9): 1469e1477.
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Radiographic Evaluation of the Modified Brunelli Technique Versus a Scapholunotriquetral Transosseous Tenodesis Technique for Scapholunate Dissociation Jennifer W. Hsu, MD, Kathleen M. Kollitz, BS, Mithulan Jegapragasan, MD, Jerry I. Huang, MD
Purpose To compare reduction of the scapholunate articulation using a transosseous tenodesis through the scaphoid, lunate, and triquetrum (SLT) with the modified Brunelli technique (MBT) in a cadaver model, as measured by scapholunate (SL) angle and diastasis on radiographs. Methods Twelve fresh-frozen cadaveric wrists were radiographically examined in a neutral posture, ulnar deviation, and clenched fist position. The SL angle and diastasis were recorded in each position with the SL ligament intact, after sectioning the ligament and secondary restraints, and after reconstruction by either the MBT (6 wrists) or SLT technique (6 wrists). Wrists were cycled through their maximum flexion and extension arc 100 times to simulate wrist motion after ligament sectioning and reconstruction. Results After sectioning and cycling, all wrists demonstrated radiographic evidence of SL diastasis. After ligament reconstruction and cycling, there was no statistically significant difference in diastasis in the MBT reconstructions compared with the SLT reconstructions (3.0 vs 2.4 mm). The SLT group demonstrated better maintenance of the restored SL angle than the MBT reconstructions. Conclusions In this cadaveric model, both MBT and SLT reconstructions restored anatomic parameters in the SL joint, with correction of SL diastasis and SL angle. Future studies to assess the clinical outcomes of SLT tenodesis in patients with chronic SL disruptions are important. Clinical relevance The SLT tenodesis, with a central biologic tether along the SL axis and dorsal reinforcement, may prove clinically useful. (J Hand Surg Am. 2014;-:-e-. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Key words Scapholunate dissociation, reconstruction, tenodesis, Brunelli.
From the Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Seattle, WA. Received for publication December 4, 2013; accepted in revised form March 3, 2014. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Jerry I. Huang, MD, Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, 4245 Roosevelt Way NE, 2nd Floor, Box 354740, Seattle, WA 98105; e-mail: [email protected]. 0363-5023/14/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.03.005
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(SL) DISSOCIATION is the most common carpal instability, frequently causing wrist pain and weakness.1 When left untreated, SL dissociation results in fixed, altered mechanics between the carpals, likely leading to progressive degenerative changes in the radiocarpal and midcarpal joints.2 Surgical treatment is often recommended to alleviate pain, restore function and grip strength, and prevent the development of progressive SL advanced collapse deformity. Various surgical CAPHOLUNATE
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techniques have been described for treatment of chronic SL injuries, including various dorsal capsulodeses, dynamic tenodeses, boneeligamentebone fixations, and screw reductions.3e12 They have the common goal of restoring intercarpal mechanics by restoring the function of the SL interosseous ligament (SLIL) and secondary stabilizers. The surgical technique of Brunelli and Brunelli6 for SL reconstruction routed a slip of the flexor carpi radialis (FCR) through the distal volar portion of the scaphoid and secured it to the dorsal, ulnar portion of the distal radius, thus correcting scaphoid flexion and providing SLIL, as well as dorsal and volar wrist stabilization. The modified Brunelli technique (MBT), as refined by Garcia-Elias et al,7 Talwalker et al,13 and Van Den Abbeele et al,14 attaches the FCR to the dorsal lunate and avoids tenodesis across the radiocarpal joint, which limits wrist motion. Garcia-Elias et al described the triligament tenodesis, which uses the FCR tendon to stabilize an irreparable chronic SL ligament rupture and correct carpal alignment by restoring the function of 3 ligaments: the scaphotrapeziotrapezoidal ligament, the dorsal portion of the SLIL, and the dorsal radiotriquetral ligament. Recently, Ross et al15 described a technique for SL reconstruction in which the FCR tendon is routed through transosseous tunnels in the scaphoid, lunate, and triquetrum. The tendon is then brought dorsally across the triquetrum, lunate, and scaphoid, where it is secured. In addition to the 3-ligament stabilization described by Garcia-Elias et al,7 this scapholunatotriquetral (SLT) tenodesis provides a central biologic tether through the axis of rotation between the scaphoid and lunate and augments the repair with reconstruction of the dorsal SLIL. In their prospective cohort study, Ross and colleagues reported similar subjective and objective short-term outcomes compared with results after MBT. The purpose of this biomechanical study was to compare the degree of stabilization obtained with the more commonly performed MBT with the SLT tenodesis technique in a cadaver model of complete SL dissociation. We hypothesized that the SLT tenodesis reconstruction would be comparable to the MBT in resisting SL diastasis in our biomechanical study.
or wrist injury, instability, or degenerative changes. The limbs were disarticulated at the elbow and prepared in a manner similar to that described by Pollock et al.16 Midline dorsal and volar forearm incisions were made, and skin flaps were elevated to expose the extensor carpi radialis brevis, extensor carpi radialis longus, and extensor carpi ulnaris tendons and the FCR, flexor carpi ulnaris, flexor digitorum superficialis, and flexor digitorum profundus tendons volarly. We placed number 2 TiCron sutures (Covidien, Inc, Mansfield, MA) into the extensor carpi ulnaris and flexor carpi ulnaris tendons with an interlocking, grasping suture technique. The extensor carpi radialis longus, extensor carpi radialis brevis, 4 flexor digitorum superficialis, and 4 flexor digitorum profundus tendons were sutured side to side into respective bundles. The FCR tendon was split in half longitudinally. Half of the tendon was woven with TiCron suture, which left the remaining half to be used for ligamentous reconstruction. The forearms were then mounted onto a stand consisting of a wooden floor with a vertical wooden support arm. Longitudinal threaded Steinmann pins were placed from the floor of the stand into the medullary canal of the proximal ulna and radius to support the forearm vertically, followed by placement of transverse pins into the distal radius and ulna. Metal S-hooks were used to suspend weights from the prepared tendons to simulate different wrist positions, as described by Slater et al.17 Wrist position was created using 2.3-kg weights on each set of tendons. Wrist flexion was created with the FCR and flexor carpi ulnaris tendons. Extension was created with the extensor carpi ulnaris and combined extensor carpi radialis brevis/extensor carpi radialis longus tendons. Ulnar deviation was created with the extensor carpi ulnaris and flexor carpi ulnaris tendons. Clenched fist stress view was created with 4.6-kg weights attached to the flexor digitorum superficialis and flexor digitorum profundus tendons. With the weights applied, each wrist was allowed to reach its maximum excursion, as dictated by each wrist’s soft tissues, except in the case of the clenched fist position. To ensure that load transferred across the wrist axially rather than causing wrist flexion during application of weights in the clenched fist position, the wrist was manually held in a neutral position. We used fluoroscopy to obtain standard radiographic views of all wrists. Posteroanterior (PA) views were obtained for wrists in neutral, ulnar deviation, and clenched fist positions. Lateral views were obtained for wrists in neutral, flexed, extended, ulnar deviated, and clenched fist positions. For this
MATERIALS AND METHODS Twelve cadaveric upper extremities were evaluated and were found to have no physical examination findings or radiographic evidence of previous forearm J Hand Surg Am.
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initial set of data, the SL ligament remained intact. The limbs were then removed from the frame, and SL dissociation was created in all 12 wrists through a dorsal ligamentesparing capsulotomy. The SLIL was sharply transected with a scalpel blade. Secondary stabilizers were also released with incision through the volar approach with sectioning of the scaphotrapeziotrapezoid joint capsule and the volar radioscaphocapitate ligament. A set of PA and lateral radiographs were obtained for all wrists at this time and referred to as cut. While mounted to the frame, the wrists were cycled 100 times through maximal wrist flexion and extension to simulate repetitive loading of the wrist. Another set of radiographs was obtained for the wrists and referred to as cut-cycled.
ligament-sparing capsulotomy.19 Care was taken to preserve the dorsal radiotriquetral ligament. A 3.2-mm drill hole entering at the insertion of the dorsal SL ligament and aiming toward the tuberosity was made with a cannulated drill. A counter curvilinear incision was made over the scaphoid tubercle. We routed a distally based 10-cm strip of FCR tendon that was the radial 3-mm portion through the scaphoid tunnel using a suture passer. We then passed the FCR slip through a slit in the dorsal radiotriquetral ligament, which acts as a pulley to tension the ligamentous reconstruction (Fig. 1). A 2.2-mm corkscrew suture anchor (Arthrex, Naples, FL) was placed in the lunate and the tendon was secured. The tendon was also sutured to itself over the scaphoid tunnel to reinforce the repair.
Surgical reconstruction Six wrists underwent SLIL reconstruction with the MBT, as described by Garcia-Elias et al.7 The remaining 6 wrists underwent SLT tenodesis as described by Ross et al,15 except for a modification described subsequently. After the reconstruction, each wrist was remounted on the frame, and a set of PA and lateral radiographs was obtained in each wrist position. This data set was referred to as reconstructed. Each wrist was cycled through 100 repetitions of its maximal flexion and extension arc, followed by repeat imaging. This data set was referred to as reconstructedcycled. The digital radiographs were viewed on OsiriX (Pixmeo, Geneva, Switzerland), a Digital Imaging and Communications in Medicine viewer, for measurement of SL intervals on PA views of the wrists. The SL interval was calculated as the distance between the midpoint of the scaphoid and the lunate. To accurately calibrate measurements, a radiopaque metal coin 21 mm in diameter was mounted to the wood frame on all PA views. Pixelstick (Plum Amazing, Princeville, HI) software was used to determine SL angle on lateral views of the wrists. The angle was measured using a line drawn between the most volar point of the scaphoid tubercle distally and the proximal pole and a line perpendicular to the axis between the 2 distal poles of the lunate.18 Means were compared using paired t tests to examine differences in measurements performed within repair groups, and unpaired t tests to examine differences between repair groups.
Scapholunatotriquetral tenodesis: A dorsal ligament-sparing capsulotomy was modified to create a more ulnar flap to allow better access to the triquetrum.15 The volar aspect of the scaphoid exposure and the FCR split were, similar to an MBT reconstruction. A transscaphoid tunnel was drilled dorsally from proximal to distal, from the scaphoid’s lunate articular facet to the volar aspect of the scaphoid tubercle. The dorsal proximal entry point was placed just dorsal to the center point of the scaphoid’s lunate facet and not at the dorsal insertion of the SL ligament, as in the MBT (Fig. 2). A lunotriquetral tunnel was drilled from the ulnar side of the triquetrum and across the lunotriquetral joint to exit the lunate just volar to the midpoint of the lunates’ scaphoid facet. By placing the lunate exit volarly and the scaphoid exit dorsally, tensioning of the obliquely oriented graft allowed for correction of dorsal intercalated segmental instability deformity (DISI). We passed the FCR graft through the scaphoid from volar to dorsal and then through the tunnels in the lunate and triquetrum (Fig. 2). We tensioned the tendon as it exited the triquetrum, which reduced dorsal subluxation of the scaphoid and closed the SL interval. In contrast to the technique of Ross et al,15 an interference screw was not used to secure the tendon graft to the triquetrum in these cadaver wrists owing to concern regarding potential iatrogenic triquetral fracture in the osteopenic cadaveric specimens. The graft was then brought dorsally across the proximal carpal row and secured in the scaphoid waist with a suture anchor to recreate the dorsal SLIL (Fig. 2). When graft length was sufficient, the graft was taken through the base of the capsular graft and sutured in place (Fig. 2). The SLT tenodesis created a tendon tether along the central axis of the scapholunate joint as well as the dorsal
Surgical technique Modified Brunelli technique: We made a longitudinal incision over the dorsal aspect of the wrist and then a
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FIGURE 1: A In the MBT reconstruction, the scaphoid bone tunnel exits dorsally at the insertion of the SL ligament. The FCR graft is brought volar to dorsal through the bone tunnel, across a trough in the dorsal lunate, and through a slit in the dorsal radiotriquetral ligament. The ligament acts as a pulley for the graft B, which is tensioned and sutured over the lunate with a suture anchor C. D Excess graft can be sutured over itself on the scaphoid to reinforce the reconstruction.
then cycled, with the SL interval in the clenched fist position measuring 3.0 mm in the MBT group and 2.4 mm in the SLT group (P ¼ .29). The overall final reductions in scapholunate diastasis (comparing sectioned and cycled specimen with final SL intervals after reconstruction and cycling) were 2.6 mm in the SLT specimens, compared with 1.2 mm in the MBT specimens.
SLIL (Fig. 3). In addition, passing the FCR tendon through the scaphoid tunnel, similar to the MBT, reconstructed the scaphotrapeziotrapezoid ligament, which is an important secondary stabilizer that prevents scaphoid flexion. RESULTS Scapholunate interval In the intact state, the mean SL interval distance was 2.6 mm in the MBT group and 1.8 mm in the SLT group (P ¼ .03). After ligament sectioning and cycling, all wrists demonstrated significant SL diastasis on the clenched fist view compared with the intact intervals, with average distance of 4.3 mm in the MBT and 5.0 mm in the SLT groups (P ¼ .05 and P ¼ .02, respectively) (Fig. 4). The MBT and SLT wrists were not significantly different after cycling (mean, 4.3 and 5.0 mm, respectively; P ¼ .50). After reconstruction, the mean SL interval in the clenched fist position was greater in the MBT group at 2.3 mm, compared to the SLT group at 1.8 mm, although not statistically significant (P ¼ .34) (Fig. 5). Wrists were J Hand Surg Am.
Scapholunate angle The average SL angle was 47 across groups before sectioning, with MBT wrists at an average of 45 and SLT wrists at an average of 49 (P ¼ .41). After ligament sectioning and cycling, the SL angle increased from an average of 47 to 61 in the clenched fist position (P < .001) (Fig. 6). After reconstruction, the SL angle was restored to 47 in the MBT group and 52 in the SLT group (P ¼ .18). Cycling the wrists increased the SL angle in the MBT group by 6 to an average of 53 after cycling (P ¼ .05). The SL angle in the SLT group increased by 2 after cycling to 54 , but this was not statistically significant (P ¼ .41). After SL reconstruction and r
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FIGURE 2: A In the SLT tenodesis, the FCR strip is brought volar to dorsal through a scaphoid bone tunnel, exiting just dorsal to the center point of the lunate facet of the scaphoid. B A bone tunnel is made starting ulnarly through the triquetrum to the lunate, and C the FCR graft is brought through the lunotriquetral tunnel from radial to ulnar. D The graft is tensioned and brought dorsally across the proximal row. E A suture anchor placed into the dorsal portion of the scaphoid secures the graft in position, recreating the dorsal SLIL. F Looking from dorsally onto a flexed wrist after SLT tenodesis, the scaphoid and lunate are in their anatomically restored positions.
identified. The Blatt capsulodesis and modifications such as the Szabo dorsal capsulodesis involve advancement of the dorsal joint capsule and dorsal intercarpal ligament into the scaphoid for static SL instability to prevent scaphoid flexion and progressive DISI.4,20 Moran et al11 presented a series of 31
cycling, the SL angle was similar in the MBT and SLT reconstructions (53 vs 54 ). DISCUSSION Despite numerous surgical options for chronic SL dissociation, a reference standard has not yet been J Hand Surg Am.
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wrist motion to stress the reconstruction. Greatest differences in SL interval and SL angle were noted in the clenched fist position. The MBT reconstructed wrists had better restoration of the SL interval, reduction of the diastasis, and correction of the SL angle compared with the Blatt capsulodesis. The current literature yields conflicting data regarding the long-term efficacy of the MBT in maintaining carpal anatomy and mechanics. In a retrospective analysis of 15 patients after MBT reconstruction at an average follow-up of 36 months, Moran et al23 noted significant improvement in SL angle but not SL intervals with persistent diastasis in patients with static instability. In contrast, Chabas et al24 performed a retrospective analysis of 19 patients with a mean follow-up of 37 months and found improvement of SL interval from 2.8 mm preoperatively to 2.4 mm postoperatively, a correction that was maintained on final follow-up. Recently, Nienstedt25 reported on 12-year follow-up after MBT. Preoperatively, the SL gap was 5.1 mm, which corrected to 2.4 mm after surgery. At final follow-up, this increased to 2.8 mm. The average SL angle improved from 72 to 46 postoperatively and increased again to 63 at final follow-up. Because of concerns regarding progressive SL gapping, several authors recommended screw augmentation in treating chronic SL ligament injuries.12,26 Compared with the K-wire cohort, Larson et al26 demonstrated better improvement in the SL diastasis, correction of the SL angle, and maintenance of the reduction with use of a temporary SL screw. However, iatrogenic fractures of the scaphoid and lunate have been reported.27 One concern with MBT reconstruction is that excessive tightening of the SL joint dorsally may cause a hinge effect with gapping volarly. Berger et al28 demonstrated the importance of the palmar region in its contribution to rotational constraint of the SL joint. Comparatively, the SLT technique offers the advantage of positioning bone tunnels near the center of the axis of rotation between the scaphoid and lunate. This allows even tensioning between the 2 bones and apposition of the facets. Furthermore, passage of the tendon across the lunotriquetral interval provides additional stabilization in settings of perilunate injury. Passage of the tendon dorsally across the proximal row into the scaphoid reinforces the dorsal intercarpal ligament, another important secondary stabilizer of the SL articulation. Ross et al15 reported the average 14-month outcomes of 11 patients after SLT reconstruction and found a reduction in SL interval from an average of 4.2 mm preoperatively to 1.6 mm postoperatively. The
FIGURE 3: Position of the bony tunnels through the scaphoid, lunate, and triquetrum.
patients treated with Blatt or Mayo dorsal capsulodesis. On final follow-up at a mean of 54 months, there was radiographic deterioration with an SL gap increase from 2.7 to 3.9 mm. In a series of direct repair and dorsal capsulodesis, Pomerance21 reported deterioration of clinical and radiographic results in high-demand patients with strenuous jobs. At longterm follow-up after a mean of 66 months, the SL gap was 4 mm, increasing to 6 mm with stress, in the strenuous patient cohort compared with 2 mm, increasing to 3 mm with stress, in the nonstrenuous cohort. The MBT is a popular method that reconstructs the disrupted dorsal SLIL with a strip of the FCR tendon. Garcia-Elias et al7 described the 3-ligament tenodesis as a modification of the Brunelli technique, which further augments the secondary stabilizers. In a cadaveric biomechanical study, Howlett et al22 demonstrated the advantages of distal tunnel placement for more anatomic reconstruction to correct DISI deformity. Pollock et al16 performed a cadaveric study to compare MBT reconstruction with Blatt capsulodesis. Wrists were loaded with weights, and measurements were obtained in different positions after simulated J Hand Surg Am.
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FIGURE 4: Average SL diastasis after SL ligament reconstruction by the A MBT or B the SLT technique, as measured in neutral deviation, ulnar deviation, and clenched fist positions.
FIGURE 5: Anteroposterior fluoroscopic images demonstrating SL diastasis after sectioning of the SL and secondary ligaments and wrist cycling, compared with images taken after reconstruction and cycling. A, B Wrist before and after MBT reconstruction and cycling. C, D Wrist before and after SLT reconstruction and cycling. After MBT reconstruction and cycling, cadaveric wrists on average displayed increased diastasis B, compared with SLT reconstruction D.
SL angle was also reduced from 81 preoperatively to 57 postoperatively. Improvements in Quick Disabilities of the Arm, Shoulder, and Hand scores (mean, 50e21) and Patient-Rated Wrist Evaluation scores J Hand Surg Am.
(mean, 43e19) were found, as were improvements in grip strength. Although follow-up was short, these preliminary clinical and radiographic results are encouraging. r
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FIGURE 6: Average SL angle after ligament reconstruction by A the MBT or B the SLT technique, as measured in neutral deviation, ulnar deviation, and clenched fist positions.
Limitations in our study include those inherent in cadaver-based studies. Cadaver specimens do not allow tissue healing to assess reconstruction durability accurately. Radiographic measurements such as SL interval and SL angle do not comprehensively describe dynamic intercarpal mechanics, and their relationship to long-term clinical outcomes and degenerative changes is unknown. Our technique did not include securing the FCR tendon graft to the triquetrum with a tenodesis screw as described in the original publication of Ross et al.15 Use of a tenodesis screw would have strengthened the construct and possibly further reduced the SL diastasis. Preliminary clinical results and our biomechanical ones of SLT tenodesis suggest that this technique is an effective reconstruction that may lead to restoration and maintenance of intercarpal relationships and mechanics similar to those obtained with the MBT.
7. Garcias-Elias M, Lluch A, Stanley JK. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique. J Hand Surg Am. 2006;31(1):125e134. 8. Harvey EJ, Hanel D, Knight JB, Tencer AF. Autograft replacements for the scapholunate ligament: a biomechanical comparison of hand-based autografts. J Hand Surg Am. 1999;24(5): 963e967. 9. Harvey EJ, Berger RA, Osterman AL, Fernandez DL, Weiss AP. Bone-tissue-bone repairs for scapholunate dissociation. J Hand Surg Am. 2007;32(2):256e264. 10. Szabo RM. Scapholunate ligament repair with capsulodesis reinforcement. J Hand Surg Am. 2008;33(9):1645e1654. 11. Moran SL, Cooney WP, Berger RA, Strickland J. Capsulodesis for the treatment of chronic scapholunate instability. J Hand Surg Am. 2005;30(1):16e23. 12. Rossenwasser M, Miyasajsa KG, Strauch RJ. The RASL procedure: reduction and association of the scaphoid and lunate using the Herbert screw. Tech Hand Up Extrem Surg. 1997;1(4):263e272. 13. Talwalkar SC, Edwards AT, Hayton MJ, Stilwell JH, Trail IA, Stanley JK. Results of tri-ligament tenodesis: a modified Brunelli procedure in the management of scapholunate instability. J Hand Surg Br. 2006;31(1):110e117. 14. Van Den Abbeele KLS, Loh YC, Stanley JH, Trail IA. Early results of a modified Brunelli procedure for scapholunate instability. J Hand Surg Br. 1998;23(2):258e261. 15. Ross M, Loveridge J, Cutbush K, Couzens G. Scapholunate ligament reconstruction. J Wrist Surg. 2013;2(2):110e115. 16. Pollock PJ, Sieg RN, Baechler MF, Scher D, Zimmerman NB, Dubin NH. Radiographic evaluation of the modified Brunelli technique versus the Blatt capsulodesis for scapholunate dissociation in a cadaver model. J Hand Surg Am. 2010;35(10):1589e1598. 17. Slater RR Jr, Szabo RM, Bay BK, Laubach J. Dorsal intercarpal ligament capsulodesis for scapholunate dissociation: biomechanical analysis in a cadaver model. J Hand Surg Am. 1999;24(2): 232e239. 18. Larsen CF, Mathiesen FK, Lindequist S. Measurement of carpal bone angles on lateral wrist radiographs. J Hand Surg Am. 1991;16(5): 888e893. 19. Berger RA, Bishop AT, Bettinger PC. New dorsal capsulotomy for the surgical exposure of the wrist. Ann Plast Surg. 1995;35(1): 54e59. 20. Szabo RM, Slater RR Jr, Palumbo CF, Verlach T. Dorsal intercarpal ligament capsulodesis for chronic, static scapholunate dissociation: clinical results. J Hand Surg Am. 2002;27(6):978e984. 21. Pomerance J. Outcome after repair of the scapholunate interosseous ligament and dorsal capsulodesis for dynamic scapholunate instability due to trauma. J Hand Surg Am. 2006;31(8):1380e1386.
REFERENCES 1. Jones WA. Beware the sprained wrist: the incidence and diagnosis of carpal instability. J Bone and Joint Surg Br. 1988;70(2): 293e297. 2. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am. 1984;9(3): 358e365. 3. Almquist EE, Bach AW, Sach JT, Fuhs SE, Newman DM. Four-bone ligament reconstruction for treatment of chronic complete scapholunate separation. J Hand Surg Am. 1991;16(2): 322e327. 4. Blatt G. Capsulodesis in reconstructive hand surgery: dorsal capsulodesis for the unstable scaphoid and volar capsulodesis following excision of the distal ulna. Hand Clin. 1987;3(1):81e102. 5. Bleuler P, Shafighi M, Donati OF, Gurunluoglu R, Constantinescu MA. Dynamic repair of scapholunate dissociation with dorsal extensor carpi radialis longus tenodesis. J Hand Surg Am. 2008;33(2):281e284. 6. Brunelli GA, Brunelli GT. A new technique to correct carpal instability with scaphoid rotary subluxation: a preliminary report. J Hand Surg Am. 1995;20(3):S82eS85.
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25. Nienstedt F. Treatment of static scapholunate instability with modified Brunelli tenodesis: results over 10 years. J Hand Surg Am. 2013;38(5):887e892. 26. Larson TB, Gaston RG, Chadderdon RC. The use of temporary screw augmentation for the treatment of scapholunate injuries. Tech Hand Up Extrem Surg. 2012;16(3):135e140. 27. Cogent JM, Levadoux M, Martinache X. The use of screws in the treatment of scapholunate instability. J Hand Surg Eur Vol. 2011;36(8):690e693. 28. Berger RA, Imeada T, Berglund L, An KN. Constraint and material properties of the subregions of the scapholunate interosseous ligament. J Hand Surg Am. 1999;24(5):953e962.
22. Howlett JP, Pfaeffle HJ, Waitayawinyu T, Trumble TE. Distal tunnel placement improves scaphoid flexion with the Brunelli tenodesis procedure for scapholunate dissociation. J Hand Surg Am. 2008;33(10): 1756e1764. 23. Moran SL, Ford KS, Wulf CA, Cooney WP. Outcomes of dorsal capsulodesis and tenodesis for treatment of scapholunate instability. J Hand Surg Am. 2006;31(9):1438e1446. 24. Chabas JF, Gay A, Valenti D, Guinard D, Legre R. Results of the modified Brunelli tenodesis for treatment of scapholunate instability: a retrospective study of 19 patients. J Hand Surg Am. 2008;33(9): 1469e1477.
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