SCIENTIFIC ARTICLE
Scapholunate Ligament Reconstruction Using a Flexor Carpi Radialis Tendon Graft Marco Sousa, MD, Ricardo Aido, MD, Daniel Freitas, MD, Miguel Trigueiros, MD, Rui Lemos, PhD, César Silva, MD Purpose To review the results of scapholunate ligament reconstruction using a flexor carpi radialis tendon graft. Methods We performed a retrospective review of 22 patients with post-traumatic scapholunate instability who were treated with a modification of the Brunelli, a flexor carpi radialis tendon graft. Results The mean follow-up was 61 months. The average age was 40 years. The average loss of flexion was 23 and of extension was 22 compared with the contralateral side. Grip strength averaged 67% of the nonoperated side. All patients except 2 returned to work. Degenerative changes were seen in 3 patients at the time of revision. Complications occurred in 2 patients and included avascular necrosis of the scaphoid. Conclusions Perfect biomechanical reconstruction might not be possible for scapholunate dissociation. Our results show, however, that ligament reconstruction led to satisfactory results from the patient’s point of view. (J Hand Surg Am. 2014;-:-e-. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Scapholunate dissociation, wrist instability, dynamic, stability, tenodesis.
S
is the most common type of carpal instability.1 The procedures currently available to treat symptomatic SL instability vary from capsulodesis to bone-ligament-bone transfers and from partial fusions to proximal row carpectomies.2e7 However, none of these procedures have shown success in all stages, and there is no agreement on when each procedure is appropriate. The choice depends on several factors including individual needs, lesion characteristics, and time of dysfunction.8 Radioscapholunate, radiocapitolunate, and especially the scapholunate interosseous ligament (SLIL) CAPHOLUNATE (SL) INSTABILITY
From the Orthopaedic and Traumatology Department, Centro Hospitalar do Porto, Porto, Portugal. Received for publication August 30, 2013; accepted in revised form April 15, 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: Marco André Guedes de Sousa, MD, Av. Dr. Manuel Teixeira Ruela n.72 C302, 4460-362, Senhora da Hora, Porto, Portugal; e-mail: [email protected]. 0363-5023/14/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.04.031
ensure linkage between the scaphoid and the lunate.9 Despite the importance of all of these structures, until the SLIL is injured, there is relatively little change in motion pattern.10e12 Short et al11,12 demonstrated that carpal biomechanical change leads to degenerative changes. Scapholunate advanced collapse (SLAC) describes a pattern of progressive arthritis secondary to SL ligament instability.13 Chronic scaphoid flexion and lunate extension lead to arthritis and finally to SLAC. Thus, treatment of SL instability should have as its objective the restoration of normal carpal kinematics.14 The choice of an adequate therapeutic option must be based on the patient’s instability stage. However, there is no consensus in classification. Watson et al15 defined these lesions as predynamic, dynamic, static, degenerative, and secondary. Wolfe9 organized them into occult, dynamic, SL dissociation, dorsal intercalated segmental instability, and SLAC. The algorithm proposed by Garcia-Elias et al16 allows staging the injury and relates it to treatment options.
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
MODIFIED BRUNELLI PROCEDURE
Despite all difficulties, almost all surgeons consider surgical procedures to treat both the acute and the chronic SL instability.17 In 1975, Dobyns et al18 described the tendon reconstruction for SL instability. In 1995, Brunelli and Brunelli2 used the flexor carpi radialis (FCR) tendon to reconstruct SL linkage. This procedure was further modified, first by Van den Abbeele et al,3 who suggested not crossing the radiocarpal joint. Garcia-Elias et al16 also described a reconstruction based on the FCR, the 3 ligament tenodesis, which reproduces the action of the 3 ligaments (scaphotrapezioptrapezoid, dorsal SL, and dorsal radiotriquetral). The modified Brunelli ligamentoplasty does not cross the radioulnar joint and thereby avoids the potential negative effect on wrist mobility. The aim of this retrospective study was to evaluate our experience with this procedure in 22 patients diagnosed with chronic SL instability and who had no sign of osteoarthritis.
8 weeks after surgery. Contact sports are not advised until 6 months after surgery. RESULTS The mean follow up time was 61 months (range, 17e98 mo). Persistent pain was measured using visual analog scale (VAS) grading scale (10 ¼ severe pain, 0 ¼ no pain). After surgery, 7 patients had no pain, 8 had mild pain, and 7 had moderate or severe pain). The average DASH score was 16 at follow-up, and average VAS score for pain was 2. These results are detailed in Table 1. Ranges of motion at follow-up were compared with the contralateral side and on average were 23 less flexion, 22 less extension, 6 less radial deviation, and 3 less ulnar deviation. The average grip strength was 67% of the nonoperated side. All patients except 2 returned to work; however, only 13 returned to their work/sport activities at levels equal to those preinjury. Radiographic evaluation revealed arthritic changes in 3 patients. The correction obtained by the surgery allowed SL diastasis correction to an average of 1.9 mm. With time, SL diastasis increased to an average of 3.1 mm. These results are detailed in Table 1. Complications occurred in 2 patients. One patient experienced complex regional pain syndrome and another developed avascular necrosis of the scaphoid 6 months after surgery. A total wrist arthroplasty was performed, yet pain persisted after 1 year, and wrist arthrodesis was necessary.
MATERIALS AND METHODS Our study was a retrospective single-center study of 22 patients with chronic post-traumatic SL instability who underwent the modified Brunelli procedure between 1999 and 2009. All patients were operated by 1 of the 2 senior authors (C.S. and M.T.). There were 18 men and 4 women with an average age of 40 years (range, 20e55 y) (Table 1) at the time of surgery. The causes of the lesion were domestic accident in 2, sports-related in 5, and occupational in 15. All patients had dissociation with nonrepairable SL ligaments and without arthritic changes (stages 3 and 4 according to the Garcia-Elias et al classification16). The average follow-up time was 61 months (range, 17e98 mo). The patients were assessed after surgery for pain, range of motion, grip strength, radiological evaluation, and Disabilities of the Arm, Shoulder, and Hand (DASH) score. The study was approved by our institutional review board, and informed consent was obtained from all patients.
DISCUSSION Of the 3 components of the SLIL, the dorsal component is the strongest and most important for SL stability. However, secondary stabilizers are also important for the maintenance of normal SL kinematics.19,20 There is general consensus that acute SLIL lesions should be repaired to prevent carpal instability and SLAC. Chronic lesions should also be treated for the same reason. The transition between acute and chronic is arbitrarily set at 6 weeks after injury.21 Surgery must allow alignment restoration, must improve load distribution, and slow or arrest degenerative changes. Tendon grafts are the most popular reconstructive procedures. After Dobyns el al18 described a ligament reconstruction technique in 1975, procedures have considerably evolved. Brunelli and Brunelli,2 Van den Abbeele et al,3 and Garcia-Elias et al16 described reconstructions with small variations. According to the Garcia-Elias et al16 algorithm based on 6 stages of disease, the best patients for
Surgical technique We followed the Brunelli technique2 together with Van den Abbeele et al’s described modification3 of suturing the tendon on itself and attaching it to the lunate or to the radiolunotriquetral ligament without crossing the radiocarpal articulation. A palmar plaster cast, which includes the thumb, is applied. Six weeks after surgery, gentle range of motion exercises are started. The K-wires that fix the scaphoid to the lunate and the scaphoid to the capitate are removed J Hand Surg Am.
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Vol. -, - 2014
TABLE 1.
Patient Demographics and Results* Loss to Contralateral Side ( )
Patient
Early Return to Postoperative Latest SL Work Postoperative SL Pain Arthritic (Preoperative SL Diastasis Diastasis Postoperative Age Follow-Up Radial Ulnar (mm) DASH Angle ( ) (mm) Level) (VAS) (y) (mo) Gender Flexion Extension Deviation Deviation Changes 28
98
M
5
25
30
5
5
Yes
No
3
4
22
79
2*
41
96
F
6
50
35
10
5
No
No
3
4
31
78
3
52
95
M
7
45
50
5
5
Yes
No
3
4
34
59
4
39
88
M
1
15
10
5
0
No
Yes
1
2
13
63
5
35
83
M
1
30
25
10
15
No
Yes
3
4
20
55
6
27
83
M
1
10
25
0
0
No
Yes
1
3
8
43
7
55
82
M
0
15
10
5
0
No
Yes
2
3
20
47
8
39
81
M
1
30
25
5
0
No
No
1
3
16
52
r
Vol. -, - 2014
9
47
72
M
0
25
20
5
5
No
No
2
3
11
43
10
51
64
M
0
20
20
5
0
No
Yes
1
3
13
75
11*
38
62
F
7
70
35
15
15
Yes
No
3
–
61
–
12
50
54
M
1
15
15
0
0
No
Yes
2
4
3
68
13
37
52
M
2
25
15
5
0
No
Yes
2
3
11
46
14
24
45
F
2
15
20
5
5
No
No
2
4
14
57
15
41
44
F
2
20
20
5
0
No
Yes
2
4
9
62
16
45
42
M
0
15
20
10
5
No
No
2
3
8
52
17
49
41
M
1
20
30
5
5
No
Yes
2
3
20
43
18
41
38
M
1
25
30
5
5
No
Yes
1
2
21
65
19
47
37
M
1
5
10
0
0
No
Yes
1
3
1
48
20
38
32
M
0
5
5
0
0
No
Yes
1
3
2
50
21
39
26
M
0
0
0
5
0
No
Yes
1
2
2
62
22
20
17
M
0
20
25
10
5
No
No
2
2
4
57
Mean
40
61
2
23
22
6
3
2
3
16
57
Maximum
55
70
50
15
15
61
Minimum
20
0
0
0
0
1
Median
40
20
20
5
3
MODIFIED BRUNELLI PROCEDURE
J Hand Surg Am.
1
*Flexion, extension, radial deviation, and ulnar deviation are related to the contralateral side. SL diastasis is measured in postoperative images. SL distasis and SL angle are measured in the latest image. Return to work: yes means return to previous level. Patient 2 developed chronic regional pain syndrome, and patient 11 developed avascular necrosis of the scaphoid.
3
4
MODIFIED BRUNELLI PROCEDURE
ligamentoplasty are those in stages 4 and 5. Reducibility is an important issue. If the scaphoid and lunate are brought together with minimal force, the dissociation is reducible. Despite our high rate of occupational accidents, results were similar to those in the previous studies regarding ligamentoplasties. When we examined our results and the published series, we noticed that major pain relief was one of the main advantages of this technique. In the previous series, ligamentoplasties lost an average of 30% of flexion-extension. Our patients had grip strength averaging about 67% of the uninjured side, which was less than Van den Abbeele et al’s (80%),3 but similar to Garcia-Elias et al’s (65%)16 results. There is a considerable loss of motion, but from a functional point of view, it does not seem to be an major issue. Assessment of the impact on routine activities reveals an average DASH score of 16, with a maximum of 60 in the patient with avascular necrosis of the scaphoid. Apart from that, most patients’ DASH scores were representative of the second positive aspect of this technique, which is a greatly acceptable functional level. However, all the patients had some disability. Even the patient who did not have mobility deficits had diminished capacity to handle heavy objects. Unfortunately, we were unable to record the evolution of the SL angle. Measurements of this parameter seemed to show incomplete corrections in some cases or loss of correction with time (Table 1). We must consider that the measurement of the intercarpal angles depends on the examiner, but confirmation of loss of correction is apparently possible with assessment of the SL diastasis, increasing from an average of 2 mm to an average of 3 mm. There was no apparent relation between these radiographic parameters and the patients’ pain and functionality. The majority of our patients returned to work, although only 13 did so at preoperative levels. We noticed that those who did not return to their previous functional level have an average VAS of 3.1 and an average DASH of 22, which were higher averages than those of the patients who returned to their previous functional level (average VAS, 0.9; average DASH, 11). Some patients who did not return to work had better VAS and DASH scores than patients who did. As a nonrelated observation, the proportion of patients eligible to financial compensation in this series was high. A recent prospective study questioned the results of tendon reconstruction owing to the resulting loss of wrist mobility and the onset of degenerative changes.22 Three of our patients developed radiographic evidence of degenerative arthritis. This was J Hand Surg Am.
better than other studies, even with similar follow-up time. Nevertheless, we believe that, over time, the prevalence of these changes should increase. The degenerative alterations were assessed by radiography; however, an arthroscopic evaluation would probably detect a greater number of degenerative alterations. While Van den Abbeele et al3 did not report degenerative changes in their 9-month followup study, Garcia-Elias et al16 reported such changes in a study with a 46-month average follow-up. We think tendon reconstruction has a role in SL dissociation. We only use this procedure for patients without degenerative changes and when it is possible to reduce the SL dissociation at surgery. Unfortunately, ligament reconstruction seems to have no predictable outcome. Our results demonstrate an important loss of mobility. We cannot reproduce the good results of Van den Abbeele et al3 with a loss of only 9 of flexion. Our results are more similar to those of Garcia-Elias et al.16 Not to cross the radiocarpal joint seems to improve mobility, but probably it is not the only factor related to loss of mobility associated with this technique. The reconstruction probably does not simulate the the strong dorsal portion and the weak volar portion of the native SLIL. However, it is unlikely that other reconstructive techniques do either. Mobility reduction is a matter of concern regardless of reconstructive technique. Current procedures cannot restore normal carpal kinematics. It has been suggested that intercarpal arthrodesis also results in loss of wrist motion and can alter wrist kinematics, which can lead to premature arthritis.23e27 Scaphotrapeziotrapezoid or scaphocapitate arthrodeses lead to an abnormal transmission of load and to a 50% mobility reduction, representing a greater mobility loss than by the ligamentoplasty obtained in our series and in other published studies. Moran et al28 compared results of the modified Brunelli procedure and dorsal capsulodesis. They found good results and no statistical differences between the groups. Dorsal capsulodesis seems technically easy; however, wrist flexion is also reduced, and the scaphoid remains unstable until it reaches the limits of flexion set by the capsulodesis. The reduction and association of the scaphoid and lunate procedure also failed to restore normal SL kinematics.29 In our study, avascular necrosis of the scaphoid was a complication we encountered. Similar cases were reported by De Smet et al30 and by Berschback et al31 after a Blatt capsulodesis. The direction and diameter of a bone tunnel are also probably important. Our patient r
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MODIFIED BRUNELLI PROCEDURE
who developed scaphoid necrosis had SL fixation for 6 weeks following capsulodesis. In many patients, 1 or even 2 objectives of reconstruction were not achieved. More studies using this technique are necessary along with innovations to improve biomechanical and radiological results.
14. Gelberman RH, Cooney WP, Szabo RM. Carpal instability. Instr Course Lect. 2001;50:123e124. 15. Watson HK, Weinzweig J, Zeppieri J. The natural progression of scaphoid instability. Hand Clin. 1997;13:39e49. 16. Garcia-Elias M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique. J Hand Surg Am. 2006;31(1):125e134. 17. Zarkadas PC, Gropper PT, Neil J, Percy BH. A survey of the surgical management of acute and chronic scapholunate instability. J Hand Surg Am. 2004;29(5):848e857. 18. Dobyns JH, Linscheid RL, Chao EYS, et al. Traumatic instability of the wrist. Instr Course Lect. 1975;24:189e199. 19. Viegas SF. The dorsal ligaments of the wrist. Hand Clin. 2001;17(1): 65e75, vi. 20. Kuo CE, Wolfe SW. Scapholunate instability: current concepts in diagnosis and management. J Hand Surg Am. 2008;33(6):998e1013. 21. Blatt G, Tobias B, Lichtman D. Scapholunate injuries. In: Lichtman DM, Herbert AA, eds. The Wrist and Its Disorders. Philadelphia: WB Saunders; 1998:268e306. 22. Pauchard N, Dederichs A, Segret J, Barbary S, Dap F, Dautel G. The role of three-ligament tenodesis in the treatment of chronic scapholunate instability. J Hand Surg Eur Vol. 2013;38(7):758e766. 23. Garcia-Elias M, Cooney WP, An KN, Lindscheid RL, Chao EY. Wrist Kinematics after limited intercarpal arthrodesis. J Hand Surg Am. 1989;14(5):791e799. 24. Pisano SM, Peimer CA, Wheeler DR, Sherwin F. Scaphocapitate intercarpal arthrodesis. J Hand Surg Am. 1991;16(2):328e333. 25. Watson HK, Belniak R, Garcial Elias M. Treatment of scapholunate dissociation: preferred treatment—STT fusion versus other methods. Orthopedics. 1991;14(3):365e368. 26. Watson HK, Hempton RF. Limited wrist arthrodeses. I. The triscaphoid joint. J Hand Surg Am. 1980;5(3):320e327. 27. Kleinman WB, Carroll C. Scapho-trapezio-trapezoid arthrodesis for a treatment of chronic static and dynamic scapho-lunate instability: a 10-year perspective on pitfalls and complications. J Hand Surg Am. 1990;15(3):408e414. 28. 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. 29. 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(4):263e272. 30. De Smet L, Sciot R, Degreef I. Avascular necrosis of the scaphoid after three-ligament tenodesis for scapholunate dissociation: case report. J Hand Surg Am. 2011;36(4):587e590. 31. Berschaback K, Kalainov D, Bednar H. Osteonecrosis of the scaphoid after scapholunate interosseous ligament repair and dorsal capsulodesis. A case report. J Hand Surg Am. 2010;35(5):732e735.
REFERENCES 1. Taleisnik J. Current concepts review: carpal instability. J Bone Joint Surg am. 1988;70(8):1262e1268. 2. Brunelli GA, Brunelli GR. A new surgical technique for carpal instability with scapho-lunate dissociation (eleven cases) [in French]. Ann Chir Main Memb Super. 1995;14(4e5):207e213. 3. Van den Abbeele KLS, Loh YC, Stanley JK, Traley IA. Early results of a modified brunelli procedure for scapholunate instability. J Hand Surg Br. 1998;23(2):258e261. 4. Almquist EE, Bach AW, Sack JT, Fuhs SE, Newman DM. Four bone ligament reconstruction for treatment of chronic complete scapholunate separation. J Hand Surg Am. 1991;16(2):322e326. 5. 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. 6. Brunelli GA, Brunelli GR. A new technique to correct carpal instability with scaphoid rotary subluxation: a preliminary report. J Hand Surg Am. 1995;20(3 Pt 2):S82eS85. 7. Lindscheid RL, Dobyns JH. Treatment of scapholunate dissociation. Rotatory subluxation of the scapbhoid. Hand Clin. 1992;8(4): 645e652. 8. Walsh JJ, Berger RA, Cooney WP. Current status of scapholunate interosseous ligament injuries. J Am Acad Orthop Surg. 2002;10(1): 32e42. 9. Wolfe SW. Scapholunate instability. J Am Soc Surg Hand. 2001;1(1): 45e60. 10. Ruby LK, An KN, Lindscheid RL, Cooney WP III, Chao EY. The effect of scapholunate ligament section on scapholunate motion. J Hand Surg Am. 1987;12(5 Pt 1):767e771. 11. Short WH, Werner FW, Green JK, Masaoka S. Biomechanical evaluation of the ligamentous stabilizers of the scaphoid and lunate: part II. J Hand Surg Am. 2005;30(1):24e34. 12. Short WH, Werner FW, Green JK, Sutton LG, Brutus JP. Biomechanical evaluation of the ligamentous stabilizers of the scaphoid and lunate: part III. J Hand Surg Am. 2007;32(3):297e309. 13. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am. 1984;9(3): 358e365.
J Hand Surg Am.
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Scapholunate Ligament Reconstruction Using a Flexor Carpi Radialis Tendon Graft Marco Sousa, MD, Ricardo Aido, MD, Daniel Freitas, MD, Miguel Trigueiros, MD, Rui Lemos, PhD, César Silva, MD Purpose To review the results of scapholunate ligament reconstruction using a flexor carpi radialis tendon graft. Methods We performed a retrospective review of 22 patients with post-traumatic scapholunate instability who were treated with a modification of the Brunelli, a flexor carpi radialis tendon graft. Results The mean follow-up was 61 months. The average age was 40 years. The average loss of flexion was 23 and of extension was 22 compared with the contralateral side. Grip strength averaged 67% of the nonoperated side. All patients except 2 returned to work. Degenerative changes were seen in 3 patients at the time of revision. Complications occurred in 2 patients and included avascular necrosis of the scaphoid. Conclusions Perfect biomechanical reconstruction might not be possible for scapholunate dissociation. Our results show, however, that ligament reconstruction led to satisfactory results from the patient’s point of view. (J Hand Surg Am. 2014;-:-e-. Copyright Ó 2014 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Scapholunate dissociation, wrist instability, dynamic, stability, tenodesis.
S
is the most common type of carpal instability.1 The procedures currently available to treat symptomatic SL instability vary from capsulodesis to bone-ligament-bone transfers and from partial fusions to proximal row carpectomies.2e7 However, none of these procedures have shown success in all stages, and there is no agreement on when each procedure is appropriate. The choice depends on several factors including individual needs, lesion characteristics, and time of dysfunction.8 Radioscapholunate, radiocapitolunate, and especially the scapholunate interosseous ligament (SLIL) CAPHOLUNATE (SL) INSTABILITY
From the Orthopaedic and Traumatology Department, Centro Hospitalar do Porto, Porto, Portugal. Received for publication August 30, 2013; accepted in revised form April 15, 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: Marco André Guedes de Sousa, MD, Av. Dr. Manuel Teixeira Ruela n.72 C302, 4460-362, Senhora da Hora, Porto, Portugal; e-mail: [email protected]. 0363-5023/14/---0001$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2014.04.031
ensure linkage between the scaphoid and the lunate.9 Despite the importance of all of these structures, until the SLIL is injured, there is relatively little change in motion pattern.10e12 Short et al11,12 demonstrated that carpal biomechanical change leads to degenerative changes. Scapholunate advanced collapse (SLAC) describes a pattern of progressive arthritis secondary to SL ligament instability.13 Chronic scaphoid flexion and lunate extension lead to arthritis and finally to SLAC. Thus, treatment of SL instability should have as its objective the restoration of normal carpal kinematics.14 The choice of an adequate therapeutic option must be based on the patient’s instability stage. However, there is no consensus in classification. Watson et al15 defined these lesions as predynamic, dynamic, static, degenerative, and secondary. Wolfe9 organized them into occult, dynamic, SL dissociation, dorsal intercalated segmental instability, and SLAC. The algorithm proposed by Garcia-Elias et al16 allows staging the injury and relates it to treatment options.
Ó 2014 ASSH
r
Published by Elsevier, Inc. All rights reserved.
r
1
2
MODIFIED BRUNELLI PROCEDURE
Despite all difficulties, almost all surgeons consider surgical procedures to treat both the acute and the chronic SL instability.17 In 1975, Dobyns et al18 described the tendon reconstruction for SL instability. In 1995, Brunelli and Brunelli2 used the flexor carpi radialis (FCR) tendon to reconstruct SL linkage. This procedure was further modified, first by Van den Abbeele et al,3 who suggested not crossing the radiocarpal joint. Garcia-Elias et al16 also described a reconstruction based on the FCR, the 3 ligament tenodesis, which reproduces the action of the 3 ligaments (scaphotrapezioptrapezoid, dorsal SL, and dorsal radiotriquetral). The modified Brunelli ligamentoplasty does not cross the radioulnar joint and thereby avoids the potential negative effect on wrist mobility. The aim of this retrospective study was to evaluate our experience with this procedure in 22 patients diagnosed with chronic SL instability and who had no sign of osteoarthritis.
8 weeks after surgery. Contact sports are not advised until 6 months after surgery. RESULTS The mean follow up time was 61 months (range, 17e98 mo). Persistent pain was measured using visual analog scale (VAS) grading scale (10 ¼ severe pain, 0 ¼ no pain). After surgery, 7 patients had no pain, 8 had mild pain, and 7 had moderate or severe pain). The average DASH score was 16 at follow-up, and average VAS score for pain was 2. These results are detailed in Table 1. Ranges of motion at follow-up were compared with the contralateral side and on average were 23 less flexion, 22 less extension, 6 less radial deviation, and 3 less ulnar deviation. The average grip strength was 67% of the nonoperated side. All patients except 2 returned to work; however, only 13 returned to their work/sport activities at levels equal to those preinjury. Radiographic evaluation revealed arthritic changes in 3 patients. The correction obtained by the surgery allowed SL diastasis correction to an average of 1.9 mm. With time, SL diastasis increased to an average of 3.1 mm. These results are detailed in Table 1. Complications occurred in 2 patients. One patient experienced complex regional pain syndrome and another developed avascular necrosis of the scaphoid 6 months after surgery. A total wrist arthroplasty was performed, yet pain persisted after 1 year, and wrist arthrodesis was necessary.
MATERIALS AND METHODS Our study was a retrospective single-center study of 22 patients with chronic post-traumatic SL instability who underwent the modified Brunelli procedure between 1999 and 2009. All patients were operated by 1 of the 2 senior authors (C.S. and M.T.). There were 18 men and 4 women with an average age of 40 years (range, 20e55 y) (Table 1) at the time of surgery. The causes of the lesion were domestic accident in 2, sports-related in 5, and occupational in 15. All patients had dissociation with nonrepairable SL ligaments and without arthritic changes (stages 3 and 4 according to the Garcia-Elias et al classification16). The average follow-up time was 61 months (range, 17e98 mo). The patients were assessed after surgery for pain, range of motion, grip strength, radiological evaluation, and Disabilities of the Arm, Shoulder, and Hand (DASH) score. The study was approved by our institutional review board, and informed consent was obtained from all patients.
DISCUSSION Of the 3 components of the SLIL, the dorsal component is the strongest and most important for SL stability. However, secondary stabilizers are also important for the maintenance of normal SL kinematics.19,20 There is general consensus that acute SLIL lesions should be repaired to prevent carpal instability and SLAC. Chronic lesions should also be treated for the same reason. The transition between acute and chronic is arbitrarily set at 6 weeks after injury.21 Surgery must allow alignment restoration, must improve load distribution, and slow or arrest degenerative changes. Tendon grafts are the most popular reconstructive procedures. After Dobyns el al18 described a ligament reconstruction technique in 1975, procedures have considerably evolved. Brunelli and Brunelli,2 Van den Abbeele et al,3 and Garcia-Elias et al16 described reconstructions with small variations. According to the Garcia-Elias et al16 algorithm based on 6 stages of disease, the best patients for
Surgical technique We followed the Brunelli technique2 together with Van den Abbeele et al’s described modification3 of suturing the tendon on itself and attaching it to the lunate or to the radiolunotriquetral ligament without crossing the radiocarpal articulation. A palmar plaster cast, which includes the thumb, is applied. Six weeks after surgery, gentle range of motion exercises are started. The K-wires that fix the scaphoid to the lunate and the scaphoid to the capitate are removed J Hand Surg Am.
r
Vol. -, - 2014
TABLE 1.
Patient Demographics and Results* Loss to Contralateral Side ( )
Patient
Early Return to Postoperative Latest SL Work Postoperative SL Pain Arthritic (Preoperative SL Diastasis Diastasis Postoperative Age Follow-Up Radial Ulnar (mm) DASH Angle ( ) (mm) Level) (VAS) (y) (mo) Gender Flexion Extension Deviation Deviation Changes 28
98
M
5
25
30
5
5
Yes
No
3
4
22
79
2*
41
96
F
6
50
35
10
5
No
No
3
4
31
78
3
52
95
M
7
45
50
5
5
Yes
No
3
4
34
59
4
39
88
M
1
15
10
5
0
No
Yes
1
2
13
63
5
35
83
M
1
30
25
10
15
No
Yes
3
4
20
55
6
27
83
M
1
10
25
0
0
No
Yes
1
3
8
43
7
55
82
M
0
15
10
5
0
No
Yes
2
3
20
47
8
39
81
M
1
30
25
5
0
No
No
1
3
16
52
r
Vol. -, - 2014
9
47
72
M
0
25
20
5
5
No
No
2
3
11
43
10
51
64
M
0
20
20
5
0
No
Yes
1
3
13
75
11*
38
62
F
7
70
35
15
15
Yes
No
3
–
61
–
12
50
54
M
1
15
15
0
0
No
Yes
2
4
3
68
13
37
52
M
2
25
15
5
0
No
Yes
2
3
11
46
14
24
45
F
2
15
20
5
5
No
No
2
4
14
57
15
41
44
F
2
20
20
5
0
No
Yes
2
4
9
62
16
45
42
M
0
15
20
10
5
No
No
2
3
8
52
17
49
41
M
1
20
30
5
5
No
Yes
2
3
20
43
18
41
38
M
1
25
30
5
5
No
Yes
1
2
21
65
19
47
37
M
1
5
10
0
0
No
Yes
1
3
1
48
20
38
32
M
0
5
5
0
0
No
Yes
1
3
2
50
21
39
26
M
0
0
0
5
0
No
Yes
1
2
2
62
22
20
17
M
0
20
25
10
5
No
No
2
2
4
57
Mean
40
61
2
23
22
6
3
2
3
16
57
Maximum
55
70
50
15
15
61
Minimum
20
0
0
0
0
1
Median
40
20
20
5
3
MODIFIED BRUNELLI PROCEDURE
J Hand Surg Am.
1
*Flexion, extension, radial deviation, and ulnar deviation are related to the contralateral side. SL diastasis is measured in postoperative images. SL distasis and SL angle are measured in the latest image. Return to work: yes means return to previous level. Patient 2 developed chronic regional pain syndrome, and patient 11 developed avascular necrosis of the scaphoid.
3
4
MODIFIED BRUNELLI PROCEDURE
ligamentoplasty are those in stages 4 and 5. Reducibility is an important issue. If the scaphoid and lunate are brought together with minimal force, the dissociation is reducible. Despite our high rate of occupational accidents, results were similar to those in the previous studies regarding ligamentoplasties. When we examined our results and the published series, we noticed that major pain relief was one of the main advantages of this technique. In the previous series, ligamentoplasties lost an average of 30% of flexion-extension. Our patients had grip strength averaging about 67% of the uninjured side, which was less than Van den Abbeele et al’s (80%),3 but similar to Garcia-Elias et al’s (65%)16 results. There is a considerable loss of motion, but from a functional point of view, it does not seem to be an major issue. Assessment of the impact on routine activities reveals an average DASH score of 16, with a maximum of 60 in the patient with avascular necrosis of the scaphoid. Apart from that, most patients’ DASH scores were representative of the second positive aspect of this technique, which is a greatly acceptable functional level. However, all the patients had some disability. Even the patient who did not have mobility deficits had diminished capacity to handle heavy objects. Unfortunately, we were unable to record the evolution of the SL angle. Measurements of this parameter seemed to show incomplete corrections in some cases or loss of correction with time (Table 1). We must consider that the measurement of the intercarpal angles depends on the examiner, but confirmation of loss of correction is apparently possible with assessment of the SL diastasis, increasing from an average of 2 mm to an average of 3 mm. There was no apparent relation between these radiographic parameters and the patients’ pain and functionality. The majority of our patients returned to work, although only 13 did so at preoperative levels. We noticed that those who did not return to their previous functional level have an average VAS of 3.1 and an average DASH of 22, which were higher averages than those of the patients who returned to their previous functional level (average VAS, 0.9; average DASH, 11). Some patients who did not return to work had better VAS and DASH scores than patients who did. As a nonrelated observation, the proportion of patients eligible to financial compensation in this series was high. A recent prospective study questioned the results of tendon reconstruction owing to the resulting loss of wrist mobility and the onset of degenerative changes.22 Three of our patients developed radiographic evidence of degenerative arthritis. This was J Hand Surg Am.
better than other studies, even with similar follow-up time. Nevertheless, we believe that, over time, the prevalence of these changes should increase. The degenerative alterations were assessed by radiography; however, an arthroscopic evaluation would probably detect a greater number of degenerative alterations. While Van den Abbeele et al3 did not report degenerative changes in their 9-month followup study, Garcia-Elias et al16 reported such changes in a study with a 46-month average follow-up. We think tendon reconstruction has a role in SL dissociation. We only use this procedure for patients without degenerative changes and when it is possible to reduce the SL dissociation at surgery. Unfortunately, ligament reconstruction seems to have no predictable outcome. Our results demonstrate an important loss of mobility. We cannot reproduce the good results of Van den Abbeele et al3 with a loss of only 9 of flexion. Our results are more similar to those of Garcia-Elias et al.16 Not to cross the radiocarpal joint seems to improve mobility, but probably it is not the only factor related to loss of mobility associated with this technique. The reconstruction probably does not simulate the the strong dorsal portion and the weak volar portion of the native SLIL. However, it is unlikely that other reconstructive techniques do either. Mobility reduction is a matter of concern regardless of reconstructive technique. Current procedures cannot restore normal carpal kinematics. It has been suggested that intercarpal arthrodesis also results in loss of wrist motion and can alter wrist kinematics, which can lead to premature arthritis.23e27 Scaphotrapeziotrapezoid or scaphocapitate arthrodeses lead to an abnormal transmission of load and to a 50% mobility reduction, representing a greater mobility loss than by the ligamentoplasty obtained in our series and in other published studies. Moran et al28 compared results of the modified Brunelli procedure and dorsal capsulodesis. They found good results and no statistical differences between the groups. Dorsal capsulodesis seems technically easy; however, wrist flexion is also reduced, and the scaphoid remains unstable until it reaches the limits of flexion set by the capsulodesis. The reduction and association of the scaphoid and lunate procedure also failed to restore normal SL kinematics.29 In our study, avascular necrosis of the scaphoid was a complication we encountered. Similar cases were reported by De Smet et al30 and by Berschback et al31 after a Blatt capsulodesis. The direction and diameter of a bone tunnel are also probably important. Our patient r
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MODIFIED BRUNELLI PROCEDURE
who developed scaphoid necrosis had SL fixation for 6 weeks following capsulodesis. In many patients, 1 or even 2 objectives of reconstruction were not achieved. More studies using this technique are necessary along with innovations to improve biomechanical and radiological results.
14. Gelberman RH, Cooney WP, Szabo RM. Carpal instability. Instr Course Lect. 2001;50:123e124. 15. Watson HK, Weinzweig J, Zeppieri J. The natural progression of scaphoid instability. Hand Clin. 1997;13:39e49. 16. Garcia-Elias M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique. J Hand Surg Am. 2006;31(1):125e134. 17. Zarkadas PC, Gropper PT, Neil J, Percy BH. A survey of the surgical management of acute and chronic scapholunate instability. J Hand Surg Am. 2004;29(5):848e857. 18. Dobyns JH, Linscheid RL, Chao EYS, et al. Traumatic instability of the wrist. Instr Course Lect. 1975;24:189e199. 19. Viegas SF. The dorsal ligaments of the wrist. Hand Clin. 2001;17(1): 65e75, vi. 20. Kuo CE, Wolfe SW. Scapholunate instability: current concepts in diagnosis and management. J Hand Surg Am. 2008;33(6):998e1013. 21. Blatt G, Tobias B, Lichtman D. Scapholunate injuries. In: Lichtman DM, Herbert AA, eds. The Wrist and Its Disorders. Philadelphia: WB Saunders; 1998:268e306. 22. Pauchard N, Dederichs A, Segret J, Barbary S, Dap F, Dautel G. The role of three-ligament tenodesis in the treatment of chronic scapholunate instability. J Hand Surg Eur Vol. 2013;38(7):758e766. 23. Garcia-Elias M, Cooney WP, An KN, Lindscheid RL, Chao EY. Wrist Kinematics after limited intercarpal arthrodesis. J Hand Surg Am. 1989;14(5):791e799. 24. Pisano SM, Peimer CA, Wheeler DR, Sherwin F. Scaphocapitate intercarpal arthrodesis. J Hand Surg Am. 1991;16(2):328e333. 25. Watson HK, Belniak R, Garcial Elias M. Treatment of scapholunate dissociation: preferred treatment—STT fusion versus other methods. Orthopedics. 1991;14(3):365e368. 26. Watson HK, Hempton RF. Limited wrist arthrodeses. I. The triscaphoid joint. J Hand Surg Am. 1980;5(3):320e327. 27. Kleinman WB, Carroll C. Scapho-trapezio-trapezoid arthrodesis for a treatment of chronic static and dynamic scapho-lunate instability: a 10-year perspective on pitfalls and complications. J Hand Surg Am. 1990;15(3):408e414. 28. 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. 29. 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(4):263e272. 30. De Smet L, Sciot R, Degreef I. Avascular necrosis of the scaphoid after three-ligament tenodesis for scapholunate dissociation: case report. J Hand Surg Am. 2011;36(4):587e590. 31. Berschaback K, Kalainov D, Bednar H. Osteonecrosis of the scaphoid after scapholunate interosseous ligament repair and dorsal capsulodesis. A case report. J Hand Surg Am. 2010;35(5):732e735.
REFERENCES 1. Taleisnik J. Current concepts review: carpal instability. J Bone Joint Surg am. 1988;70(8):1262e1268. 2. Brunelli GA, Brunelli GR. A new surgical technique for carpal instability with scapho-lunate dissociation (eleven cases) [in French]. Ann Chir Main Memb Super. 1995;14(4e5):207e213. 3. Van den Abbeele KLS, Loh YC, Stanley JK, Traley IA. Early results of a modified brunelli procedure for scapholunate instability. J Hand Surg Br. 1998;23(2):258e261. 4. Almquist EE, Bach AW, Sack JT, Fuhs SE, Newman DM. Four bone ligament reconstruction for treatment of chronic complete scapholunate separation. J Hand Surg Am. 1991;16(2):322e326. 5. 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. 6. Brunelli GA, Brunelli GR. A new technique to correct carpal instability with scaphoid rotary subluxation: a preliminary report. J Hand Surg Am. 1995;20(3 Pt 2):S82eS85. 7. Lindscheid RL, Dobyns JH. Treatment of scapholunate dissociation. Rotatory subluxation of the scapbhoid. Hand Clin. 1992;8(4): 645e652. 8. Walsh JJ, Berger RA, Cooney WP. Current status of scapholunate interosseous ligament injuries. J Am Acad Orthop Surg. 2002;10(1): 32e42. 9. Wolfe SW. Scapholunate instability. J Am Soc Surg Hand. 2001;1(1): 45e60. 10. Ruby LK, An KN, Lindscheid RL, Cooney WP III, Chao EY. The effect of scapholunate ligament section on scapholunate motion. J Hand Surg Am. 1987;12(5 Pt 1):767e771. 11. Short WH, Werner FW, Green JK, Masaoka S. Biomechanical evaluation of the ligamentous stabilizers of the scaphoid and lunate: part II. J Hand Surg Am. 2005;30(1):24e34. 12. Short WH, Werner FW, Green JK, Sutton LG, Brutus JP. Biomechanical evaluation of the ligamentous stabilizers of the scaphoid and lunate: part III. J Hand Surg Am. 2007;32(3):297e309. 13. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am. 1984;9(3): 358e365.
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