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Anatomical front and back (ANAFAB) reconstruction addresses the critical volar and dorsal ligaments associated with scapholunate dissociation. We hypothesized that patients with symptomatic, chronic, late-stage scapholunate dissociation would demonstrate improvements in all radiographic parameters and patient-reported outcomes (PROMs) after ANAFAB reconstruction. From 2018 to 2021, 21 ANAFAB reconstructions performed by a single surgeon were followed prospectively, with 20 patients having a minimum follow-up of 12 months. In total, 17 men and four women were included, with an average age of 49 years. Three patients had modified Garcia-Elias stage 3 disease, eight stage 4, seven stage 5, and three stage 7. ANAFAB reconstruction of intrinsic and extrinsic ligament stabilizers was performed using a hybrid synthetic tape/tendon graft in a transosseous reconstruction. Pre- and postoperative radiographic parameters, grip, pinch strength, the Patient-Rated Wrist Evaluation, PROMIS Upper Extremity Function, and PROMIS Pain Interference outcome measures were compared. Mean follow-up was 17.9 months (range: 12–38). Radiographic parameters were improved at follow-up, including the following: scapholunate angle (mean 75.3° preoperatively to 69.2°), scapholunate gap (5.9–4.2 mm), dorsal scaphoid translation (1.2–0.2 mm), and radiolunate angle (13.5° to 1.8°). Mean Patient-Rated Wrist Evaluation scores for pain and function decreased from 40.6 before surgery to 10.4. We were unable to detect a significant difference in grip or pinch strength or radioscaphoid angle with the numbers tested. There were two minor complications, and two complications required re-operations, one patient who was converted to a proximal row carpectomy for failure of fixation, and one who required tenolysis/arthrolysis for arthrofibrosis. At 17.9-month average follow-up, radiographic and patient-reported outcome parameters improved after reconstruction of the critical dorsal and volar ligament stabilizers of the proximal carpal row with the ANAFAB technique. Therapeutic IV. [ABSTRACT FROM AUTHOR]

Intervention for scapholunate instability is aimed at halting the degenerative process by restoring ligament integrity and normalizing carpal kinematics. Part 1 of this Current Concepts article reviewed the anatomy, kinematics, and biomechanical properties of the scapholunate ligament as well as its critical stabilizers. In this section, we provide a foundation for understanding the spectrum of scapholunate ligament instability and incorporate meaningful new anatomical insights that influence treatment considerations. These updates clarify the importance of the critical stabilizers of the scapholunate interval, ligament-specific considerations in scapholunate ligament reconstruction, and the risks of ligament disinsertion when surgically exposing the dorsal wrist. We propose a ligament-based treatment algorithm based on the stage of injury, degree and nature of ligament damage, and presence of arthritic changes. [ABSTRACT FROM AUTHOR]

Injuries to the scapholunate joint are the most frequent cause of carpal instability. The sequelae of these injuries account for considerable morbidity, and if left untreated, may lead to scapholunate advanced collapse and progressive deterioration of the carpus. Rupture of the scapholunate interosseous ligament and its critical stabilizers causes dyssynchronous motion between the scaphoid and lunate. Additional ligament injury or attenuation leads to rotary subluxation of the scaphoid and increased scapholunate gap. Intervention for scapholunate instability is aimed at halting the degenerative process by restoring ligament integrity and normalizing carpal kinematics. In the first section of this review, we discuss the anatomy, kinematics, and biomechanical properties of the scapholunate ligament as well as its critical ligament stabilizers. We provide a foundation for understanding the spectrum of scapholunate ligament instability and incorporate meaningful new anatomical insights that influence treatment considerations. The purpose is to provide an update regarding the anatomy of the scapholunate ligament complex, importance of the critical ligament stabilizers of the proximal carpal row, introduction of safe technique to surgically expose the scaphoid and lunate, as well as pathoanatomy as it pertains to the treatment of scapholunate dissociation. In the second section of this review, we propose a novel ligament-based treatment algorithm based on the stage of injury, degree and nature of ligament damage, and presence of arthritic changes. [ABSTRACT FROM AUTHOR]

If early active motion after 3-ligament tenodesis is safe, it may yield more patient comfort and an early return to activities. Therefore, the aim of this study was to investigate whether early active motion is noninferior to late active motion after 3-ligament tenodesis for scapholunate interosseous ligament injuries. This prospective, multicenter cohort study, using a noninferiority design with propensity score matching, compared a late active motion protocol (immobilization for 10–16 days, wrist therapy in weeks 5–6) with an early active motion protocol (immobilization for 3–5 days, wrist therapy during week 2). Patients who were older than 18 years, had complete baseline information on demographics, and underwent 3-ligament tenodesis were included. The outcome measures were postoperative Patient-Reported Wrist/Hand Evaluation scores, pain, complications, return to work, range of motion, grip strength, and satisfaction with treatment results at 3 months of follow-up. After propensity matching, a total of 108 patients were included. Patient-Reported Wrist/Hand Evaluation and pain scores during physical load following an early active motion protocol were noninferior compared with scores following a late active motion protocol. Furthermore, early active motion did not lead to an increase of complications, differences in range of motion or grip strength, or less satisfaction with the treatment result. An earlier return to work was not observed. Early active motion leads to noninferior results without more complications as compared with late active motion. Based on these findings, early active motion can be considered safe, and might be recommended due to its potential benefits compared with late active motion after 3-ligament tenodesis. Therapeutic III. [ABSTRACT FROM AUTHOR]

This study compared the interobserver agreement of arthroscopic classification of suspected scapholunate interosseous ligament (SLIL) pathology with and without midcarpal arthroscopy to help inform diagnostic strategies. It also measured the association of midcarpal arthroscopy with recommendations for reconstructive surgery. The association of midcarpal arthroscopy with the type of surgery recommended was also studied. Fourteen consecutive videos of diagnostic radiocarpal and midcarpal wrist arthroscopy for suspected SLIL pathology were selected. An international survey-based experiment was conducted among upper extremity surgeons of the Science of Variation Group. Participants were randomized to view either radiocarpal arthroscopic videos or radiocarpal and midcarpal videos. Surgeons rated SLIL pathology according to the Geissler classification and recommended surgical or nonsurgical treatment. If surgical treatment was recommended, they indicated the type of procedure. The interobserver agreement for the Geissler classification was slight/fair for observers who reviewed midcarpal and radiocarpal videos and for those who viewed radiocarpal videos only. Viewing midcarpal videos was associated with higher pathology grades, the recommendation for reconstructive surgery, and a preference for tenodesis over scapholunate ligament repair. Diagnostic wrist arthroscopy for a wrist with normal radiological alignment has poor interobserver agreement. The pursuit of a pathology that accounts for wrist symptoms in a nonspecific interview and examination and normal radiographs is understandable; however, the low reliability of the scapholunate pathology of diagnostic arthroscopy might be associated with more potential harm than benefit. [ABSTRACT FROM AUTHOR]

Conventional X-ray imaging is usually the first diagnostic assessment after clinical examination in case of suspected scapholunate interosseous ligament (SLIL) injury. Nevertheless, there is no consensus on the norms of the scapholunate distance (SLD) or carpal angles. Therefore, we aimed to determine the utility of static and dynamic radiographs in the diagnostic of an SLIL injury in comparison with the reference standard arthroscopy. We retrospectively analyzed the preoperative X-ray series and surgical records of arthroscopies of 414 patients. Radiological assessment included conventional static X-rays in the posteroanterior (PA) projection, clenched fist views in ulnar and radial deviations, in which the SLD at the midportion of the scapholunate (SL) joint was measured. The scapholunate angle (SLA) and radiolunate angle (RLA) were measured on lateral wrist radiographs. Receiver operating characteristic (ROC) curves were created to determine possible cut-off points of the radiological indices for the diagnosis of SLIL injury. Further, a logistic regression with the parameters having the highest area under the curve (AUC) was calculated. We found that SLD in ulnar inclination (AUC= 0.774), SLD in PA projection (AUC = 0.748), and SLA (AUC = 0.737) had the highest diagnostic value. The AUC of the combination of these three parameters was 0.822 for all patients with any SLIL lesion and 0.850 for patients with SLIL lesions of 3–4 Geissler grade. Further investigation of SLIL pathology would be appropriate in the case of SLD in ulnar inclination of 2.7 mm, SLD in PA projection of 1.9 mm and SLA of 63° [ABSTRACT FROM AUTHOR]

Carpal injuries tend to occur due to significant trauma. If unrecognized they can result in significant morbidity. Prompt diagnosis and appropriate treatment of these injuries acutely is required to prevent long term functional disablement. [ABSTRACT FROM AUTHOR]

To compare the kinematic effects of the dorsal fiber-splitting approach for scapholunate ligament repair to a dorsal "window" approach that spares all ligaments. We randomized 24 fresh-frozen paired cadaveric forearms to either the dorsal fiber-splitting capsulotomy approach (FSC) or the dorsal window approach (window) following scapholunate interosseous ligament (SLIL) division. Loaded fluoroscopic radiographs were obtained after each of the 4 testing conditions following cyclic loading (200 cycles; 71 N): (1) intact SLIL, (2) SLIL-division, (3) surgical approach, and (4) closure. FSC specimens were randomly allocated to 2 subgroups for closure with either a suture anchor (n = 6) or a simple running suture closure (n = 6). Radiographic parameter measurements included the scapholunate gap, radiolunate angle, scapholunate angle, and dorsal scaphoid translation. Following the FSC, there were significant alterations in all radiographic parameters when compared with the intact and SLIL-division conditions. The window approach did not result in significant changes in any radiographic parameter. When compared to the window approach, all radiographic parameters of the FSC approach were significantly altered. Following closure with suture anchors in the FSC group, radiographic parameters improved, whereas with standard closure they failed to do so. Despite anchor closure, dorsal scaphoid translation, radiolunate angle, and scapholunate angle all remained elevated compared with scapholunate-divided wrists. The FSC produced significant changes in carpal posture under load, including scapholunate diastasis, dorsal intercalated segment instability, and dorsal scaphoid translation in SLIL-deficient wrists. The window approach preserved the critical dorsal ligament stabilizers and did not produce changes in carpal posture. The FSC may create iatrogenic changes in carpal posture that cannot be fully corrected with standard or anchor closure. The window approach does not alter carpal posture and should be considered when performing surgical procedures on the scaphoid or lunate. [ABSTRACT FROM AUTHOR]

Carpal instability is a complex subject and the theories behind the pathoanatomy and management continue to evolve in the literature. The consequences of carpal instability for the patient can be significant and lead to functional impairment and long-term pain. We outline the normal anatomy of the carpus and relate the complex interactions between the ligamentous and bony structures to the patterns of injury both acute and chronic. We then go on to review current opinion on the classification, assessment and management of patients with carpal instability. [ABSTRACT FROM AUTHOR]

Case control. This study aimed to investigate the alterations seen in the activation patterns of the forearm muscles and to demonstrate the associated functional outcomes, in patients with scapholunate interosseous ligament (SLIL) injury. The study involved 15 patients with SLIL injury (instability group) and 11 healthy participants (control group). Both groups were evaluated with regard to their pain, grip strength, and upper extremity functional level (disabilities of the arm, shoulder and hand and patient-rated wrist evaluation questionnaires), and they also underwent a dynamic electromyography analysis of their forearm muscle activity. The activation patterns of the extensor carpi ulnaris (ECU), extensor carpi radialis (ECR), flexor carpi ulnaris, and flexor carpi radialis muscles during wrist extension and flexion were recorded by means of surface electromyography. In the instability group, the pain severity was higher and the functional level was worse than in the control group (P <.05). Furthermore, during wrist extension, the ECR activity was lower and the ECU activity was higher in the instability group than in the control group (P <.05). Dynamic stabilization of the wrist, flexor carpi ulnaris, and flexor carpi radialis muscles have been shown to play an active role with ECU and ECR. Increased ECU and decreased ECR activation may pose a potential risk in terms of enhancing the scapholunate gap. We, therefore, propose that appropriate preventive neuromuscular exercise strategies implemented as part of a physiotherapy program for patients with SLIL lesions might increase the contribution of the dynamic stability effect of the relevant muscles. • The extensor carpi ulnaris activation was increased in the instability group during the concentric, eccentric, and resting phases of wrist extension than for the control group. • Extensor carpi radialis muscle was decreased during the concentric, isometric, and eccentric phases in the instability group. • The flexor carpi radialis and flexor carpi ulnaris muscle activations were higher during the resting phase in the instability group. • Pain scores were obtained for the instability group than for the control group. • The disabilities of the arm, shoulder, and hand and patient-rated wrist evaluation scores were worse in the instability group than in the control group. [ABSTRACT FROM AUTHOR]

To assess the validity and reliability of the posterior radioscaphoid angle (PRSA), an indicator of dorsal displacement of the scaphoid, in distinguishing wrists with and without chronic scapholunate instability (SLI). We prospectively evaluated 40 patients (22 men and 18 women; mean age, 46 ± 13 years) with suspected SLI with radiographs and computed tomography arthrography. Based on these data, 3 groups were defined: positive SLI (n = 16), negative SLI (n = 19), and questionable SLI (n = 5). An independent reader measured the PRSA on sagittal computed tomography images using the same procedure. The PRSA median values were significantly lower in the negative SLI group (98°) compared with the positive SLI (110°) and questionable SLI (111°) groups. The difference between the positive SLI and questionable SLI groups was not significant. The best differentiation between patients with and without SLI was obtained with a PRSA threshold value of 103° (specificity of 86% and sensitivity of 79%). In this preliminary study, PRSA analysis offers a quantitative tool for the evaluation of dorsal scaphoid displacement in cases of SLI, including for patients presenting with questionable initial radiography findings. Diagnostic II. [ABSTRACT FROM AUTHOR]

Scapholunate (SL) ligament tears in the acute setting can be treated by primary repair through various techniques. The purpose of this study was to compare repair of the SL ligament with suture anchors alone versus repair of the SL ligament augmented with suture tape. Twelve fresh-frozen cadavers (6 matched pairs) underwent a dorsal approach to the wrist and the SL ligament was sharply dissected off of its scaphoid attachment. Six cadavers underwent direct repair of the SL ligament using 2 suture anchors. The other 6 underwent repair of the SL ligament, which was then augmented with suture tape. All specimens then underwent load to failure testing using tensile distraction forces applied by a universal testing system. Maximum load to failure and mode of failure were recorded. Maximum load to failure (135 N; SD, 44.94 N) for specimens that were repaired and augmented with the internal brace was higher than that for specimens in the repair-only group (68 N; SD, 14.69 N). Biomechanical testing demonstrated a higher maximum load to failure in SL ligament repairs augmented with suture tape compared with a repair-only technique in this cadaveric model. Acute SL ligament injuries may benefit from suture tape augmentation by increasing the stability of the primary repair. This may prove to be beneficial in higher-demand patients. [ABSTRACT FROM AUTHOR]

Scapholunate ligament is the most commonly injured ligament in the wrist and requires accurate diagnosis and treatment. It presents with pain, stiffness and can lead to carpal instability as well as degenerative arthritis if left untreated, with subsequent loss of function and disability. There are several management options currently available but there is no consensus on how best to manage a wrist with chronic sequelae of scapholunate ligament injury. This review explores available evidence in the literature on optimal treatment options including non-operative and operative procedures, relevant surgical techniques and their associated outcomes. A summary of the current concepts in the management of Chronic Scapholunate ligament injury is presented. [ABSTRACT FROM AUTHOR]

The treatment of athletes with carpal ligament injuries provides many challenges. Our initial goals remain to make a timely and accurate diagnosis, provide treatment options, and create an environment for shared decision making. To optimize outcomes and facilitate return to play, early surgical intervention may be warranted. This article reviews common carpal ligament injury patterns in the athlete with a focus on both classic and newer surgical techniques. [ABSTRACT FROM AUTHOR]

Current biomechanical data suggest that static scapholunate (SL) ligament dissociation occurs only when there is loss of competence of the extrinsic ligaments either acutely or with attenuation over time. We aimed to identify whether patients with an SL gap greater than 2 mm demonstrated concomitant dorsal radiocarpal ligament (DRC) and dorsal intercarpal ligament (DIC) ligament changes on magnetic resonance imaging (MRI) scans that were identified as having an SL ligament tear. We included 90 patients who had a posttraumatic MRI scan of the wrist diagnosed with an SL injury. We recorded basic demographics; 2 attending fellowship-trained musculoskeletal radiologists evaluated the integrity of the SL, DRC, and DIC ligaments and graded these as normal, low-grade injury (sprain or partial tear) or full-thickness tear. The association between the integrity of the DRC and DIC ligaments and the presence of a scapholunate gap of 2 mm or greater was analyzed. A total of 48 patients (53%) had an SL distance of 2 mm or greater on MRI. Of these patients, 28 (58%) had a partial or total tear of the DIC and/or DRC ligament. Compared with patients with an SL interval less than 2 mm, patients with an SL interval 2 mm or greater more often demonstrated DIC signal change (31% vs 12%), DRC signal change (52% vs 14%), or combined or isolated DIC and/or DRC signal change (52% vs 14%). Dorsal extrinsic ligaments demonstrate MRI signal change suggestive of acute or chronic injury in patients with an SL interval 2 mm or greater more often than in patients with an SL interval less than 2 mm. These results reinforce that MRI findings of SL ligament tear need to be interpreted in a larger context, perhaps with additional attention to the DIC and DRC appearance upon MRI. In addition, MRI evaluation of dorsal extrinsic ligaments may aid in clinical decision-making for patients with SL injury. Diagnostic IV. [ABSTRACT FROM AUTHOR]

The article focuses on the management of injuries to the hands and wrist of athletes, and includes complications of treatment of sports injuries of the hand and wrist; list of sports injuries such as fractures, dislocations, and ligamentous; and impact of improper cast application on the same.

Purpose To evaluate the diagnostic utility of scaphoid dorsal subluxation on magnetic resonance imaging (MRI) as a predictor of scapholunate interosseous ligament (SLIL) tears and compare this with radiographic findings. Methods Thirty-six MRIs were retrospectively reviewed: 18 with known operative findings of complete Geissler IV SLIL tears that were surgically repaired, and 18 MRIs performed for ulnar-sided wrist pain but no SLIL tear. Dorsal subluxation of the scaphoid was measured on the sagittal MRI cut, which demonstrated the maximum subluxation. Independent samples t tests were used to compare radiographic measurements of scapholunate (SL) gap, SL angle, and capitolunate/third metacarpal-lunate angles between the SLIL tear and the control groups and to compare radiographic measurements between wrists that had dorsal subluxation of the scaphoid and wrists that did not have dorsal subluxation. Interrater reliability of subluxation measurements on lateral radiographs and on MRI were calculated using kappa coefficients. Results Thirteen of 18 wrists with complete SLIL tears had greater than 10% dorsal subluxation of the scaphoid relative to the scaphoid facet. Average subluxation in this group was 34%. Four of 18 wrists with known SLIL tears had no subluxation. No wrists without SLIL tears (control group) had dorsal subluxation. The SL angle, capitolunate/third metacarpal-lunate angle and SL gap were greater in wrists that had dorsal subluxation of the scaphoid on MRI. Interrater reliability of measurements of dorsal subluxation of the scaphoid was superior on MRI than on lateral x-ray. Conclusions An MRI demonstration of dorsal subluxation of the scaphoid, of as little as 10%, as a predictor of SLIL tear had a sensitivity of 72% and a specificity of 100%. The high positive predictive value indicates that the presence of dorsal subluxation accurately predicts SLIL tear. Type of study/level of evidence Diagnostic II. [ABSTRACT FROM AUTHOR]

This case describes an early controlled mobilization (ECM) approach that uses dart-throwing motion (DTM) with a twist orthoses as an alternative to immobilization for conservative management of a minimally displaced and intra-articular distal radius styloid fracture with an associated scapholunate ligament injury in a 47-year-old female health care administrator (JP). Pain-free active DTM began at day 10 (5 times/d) with a dynamic DTM with a twist orthosis worn during the day from weeks 3 to 6. At 6 weeks, JP had pain-free functional mobility and strength with minimal limitation in household and occupational activities, returning to her normal sporting activities by 3 months. ECM led to rapid return of normal functioning in the short term with no apparent impact on intermediate outcomes at 8 months. This case allows hand therapists to consider a similar ECM approach for the management of similar injuries in their patients. Level of evidence: Level 5 and case report. [ABSTRACT FROM AUTHOR]

Purpose To evaluate the biomechanical properties of 3 scapholunate repair techniques. Methods In 51 cadavers, the scapholunate ligament was exposed through a dorsal approach, incised at its scaphoid insertion, and repaired using 1 of 3 techniques: 2 single-loaded suture anchors, 2 double-loaded suture anchors, or 2 transosseous sutures. Twenty-four repaired specimens underwent load to failure (LTF) testing using tensile distraction on a servo-hydraulic machine. Twenty-seven specimens underwent cyclical testing to measure gap formation at the scapholunate joint. Results The mode of failure was suture pullout through the substance of the ligament in 22 specimens, failure at the bone suture interface in 1, and anchor pullout in 1. Double-loaded anchor repairs demonstrated a significantly higher mean ultimate LTF compared with single-loaded anchor (91 N vs 35 N) and transosseous (91 N vs 60 N) repairs. Transosseous repairs demonstrated a higher mean ultimate LTF compared with single-loaded suture repairs (60 N vs 35 N). After 300 cycles, the average gap for the transosseous repair group was double that for the single- and double-loaded repairs, although not statistically significant. Conclusions Primary scapholunate ligament repairs using double-loaded suture anchors demonstrated significantly higher strength compared with single-loaded anchors and transosseous repairs. On cyclic loading, transosseous repairs demonstrated the greatest gap formation with no measurable difference between single- and double-loaded repairs. Clinical relevance In a cadaveric model for primary repairs, double-loaded suture anchors demonstrated the highest LTF and offer a similar but unproven performance in vivo . [ABSTRACT FROM AUTHOR]

Purpose To assess midterm outcomes of our bone-ligament-bone (BLB) grafts for chronic scapholunate (SL) instability and better define criteria for their use. Methods We conducted a retrospective review of 26 patients treated with BLB grafts and dorsal capsulodesis between 1997 and 2009. Twenty-four patients were reviewed. Mean follow-up was 8.2 years. Two patients had dynamic lesions, 7 had SL dissociation, 14 had a dorsal intercalated segment instability lesion, and 1 had SL advanced collapse stage 1. Mean age at surgery was 46 years. All patients presented with pain and 14 had lack of strength. Results were reviewed clinically and radiologically. Images were assessed by 4 surgeons and 1 radiologist for radial styloid, radioscaphoid, radiolunate, midcarpal, and scaphotrapeziotrapezoid degenerative changes. Results Five patients needed subsequent 4-corner arthrodesis. Of the remaining 19 patients at follow-up, both extension and flexion decreased to 73% of the contralateral side. Postoperative grip strength improved from 78% to 90% of the nonsurgical wrist. Quick Disabilities of the Arm, Shoulder, and Hand score was 10 of 100 and the Patient-Rated Wrist Evaluation score was 10 of 100. Radiologically, the SL gap was improved and maintained at follow-up. The SL angle (mean before surgery, 79°) was initially corrected to 69° but returned to preoperative values at follow-up. Eleven of the 19 cases had signs of midcarpal arthritis. Conclusions Bone-ligament-bone grafts with SL dorsal capsulodesis were able to restore and maintain an improved SL interval in all patients. The technique achieved good clinical results and high patient satisfaction, but it did not stop the progression of arthritis, particularly at the midcarpal level. This technique is an option for isolated unrepairable lesion of the dorsal SL ligament with an easily correctable lunate and especially when restoration of grip strength is important. Type of study/level of evidence Therapeutic IV. [ABSTRACT FROM AUTHOR]

Purpose To evaluate the natural history of untreated complete or partial scapholunate (SL) ligament tears associated with displaced distal radius fractures. Methods Between 1995 and 1997, 51 consecutive patients aged < 60 years with displaced distal radius fractures were examined arthroscopically to assess for concomitant soft tissue injuries. Thirty-two of 51 patients had an SL ligament tear, 10 had a complete tear (Lindau grade 3), and 22 had a partial tear (Lindau grades 1 and 2). Thirty-two patients had AO type-C fractures, 3 had type-B fractures, and 16 had type-A fractures. In 2010, 47 of the 51 patients were still alive, and they were invited for an interview, clinical examination, and radiography. Results Thirty-eight of the 51 original patients participated in the long-term follow-up. Mean grip strength was 83% relative to the contralateral hand in patients with a complete tear, as compared with 92% in patients with partial or no SL tears (nonsignificant). Median Disabilities of the Arm, Shoulder, and Hand questionnaire score was 2 (range, 0‒55) for complete SL tears, compared with 9 (range, 0‒70) for the others (nonsignificant). No differences were found regarding visual analog scale pain or wrist motion/forearm rotation. None of the patients developed a static SL dissociation or a SL advanced collapse wrist. Conclusions No major differences were found in the subjective, objective, or radiographic outcome after a complete (grade 3) or partial (grade 1 or 2) SL untreated tear associated with displaced distal radius fracture. It should be noted that none of the patients had a grade 4 SL tear, which may have a different outcome. Type of study/level of evidence Prognostic II. [ABSTRACT FROM AUTHOR]

Objective The aim of this study is to assess the diagnostic value of direct MR arthrography compared to conventional MR imaging in the diagnosis of different pathologic entities affecting the internal ligaments of the wrist mainly the scapholunate and lunotriquetral ligaments. Subjects and methods This study included 51 patients complaining of chronic wrist pain. Conventional MRI and MR arthrography (MRA) were done in all cases. Results A comparison of the sensitivity of conventional MRI versus MRA was done by correlating the final diagnosis of each modality with the results of arthroscopy. Regarding complete SLL tears, MRI revealed a SEN, SPE and ACC of 61.54%, 96.77%, and 86.36%, while MRA showed a SEN, SPE and ACC of 92.31%, 100%, and 97.73% respectively, partial SLL tears, un-enhanced MRI revealed SEN, SPE and ACC of 10%, 94.12%, and 75%, while MRA showed 66.67%, 85.71%, and 81.82% respectively, complete LTL tears un-enhanced MRI revealed a SEN, SPE, and ACC of 25%, 100%, and 79.5% respectively, while MRA showed 91.67%, 100%, and 97.73% respectively. Conclusion MR arthrography is a potent additional tool facilitating the diagnosis of different pathologic entities affecting the major internal ligaments of the wrist joint and helps to reduce arthroscopic interventions. [ABSTRACT FROM AUTHOR]

Classical arthroscopic techniques for scapholunate instability consist of debridement, thermal shrinkage, and percutaneous pinning. Good results are obtained in acute lesions or in chronic partial tears, but they are less predictable when the lesion is complete, because of the poor healing capacity of the scapholunate ligament and because it is not possible to perform an anatomic ligamentous reconstruction with these techniques. Open techniques are thus required for reconstruction, but they damage the soft tissues. We recently published a description and cadaver study of an arthroscopic ligamentoplasty, trying to combine the advantages of arthroscopic techniques (minimally invasive surgery) and open techniques (reconstruction of the ligament). With this approach, it is possible to reconstruct the dorsal scapholunate ligament and the secondary stabilizers while causing minimal damage to the soft tissues and avoiding injury to the posterior interosseous nerve and detachment of the dorsal intercarpal ligament. The current report describes an additional step to this technique with which it is possible to reconstruct the volar portion of the scapholunate ligament. We also describe an early mobilization postoperative protocol that we believe is equally important. [Copyright &y& Elsevier]

Injuries to the scapholunate joint are the most frequent cause of carpal instability and account for a considerable degree of wrist dysfunction, lost time from work, and interference with activities. Although it is insufficient to cause abnormal carpal posture or collapse on static radiographs, an isolated injury to the scapholunate interosseous ligament may be the harbinger of a relentless progression to abnormal joint mechanics, cartilage wear, and degenerative changes. Intervention for scapholunate instability is aimed at arresting the degenerative process by restoring ligament continuity and normalizing carpal kinematics. In this review, we discuss the anatomy, kinematics, and biomechanical properties of the scapholunate articulation and provide a foundation for understanding the spectrum of scapholunate ligament instability. We propose an algorithm for treatment based on the stage of injury and the degree of secondary ligamentous damage and arthritic change. [ABSTRACT FROM AUTHOR]

Purpose: Numerous surgical techniques have been described for the treatment of chronic scapholunate ligament instability. We hypothesized that scapholunate ligament reconstruction using an acellular dermal matrix was biomechanically comparable to previously described surgical reconstructions. Methods: The scaphoid and lunate with the entire scapholunate ligament were harvested from 15 cadaveric specimens. The scapholunate ligament was transected and reconstructed using an acellular dermal matrix (Arthroflex; LifeNet Health, Virginia Beach, VA) and 4 micro suture anchors in 10 specimens. Five specimens were kept with the native scapholunate ligament intact. Five other specimens were reconstructed using a 1.0-mm-thick dermal matrix, and a second cohort of 5 specimens was reconstructed using a 1.5-mm-thick matrix. Tensile testing of all specimens was performed using a servohydraulic material testing system and data acquisition software. The tensile test apparatus applied a distractive load of 10 mm/min (0.17 mm/s) until the specimens reached ultimate failure. Failure force, failure displacement, stiffness, and energy to failure were calculated. Results: All 5 specimens in the intact group failed at the scapholunate ligament midsubstance. The mean ultimate failure force was 172 N, with mean stiffness of 74 N/mm. In the reconstruction group with 1.0-mm dermal matrices, the mode of failure was at the suture–matrix interface in all specimens, whereas the 1.5-mm dermal matrix reconstruction cohort all failed at the bone–suture anchor interface. In the 1.0-mm reconstruction group, the mean ultimate failure force was 77 N, with mean stiffness of 24 N/mm. In the 1.5-mm dermal matrix reconstruction cohort, the mean ultimate failure force was 111 N, with mean stiffness of 30 N/mm. Conclusions: Scapholunate ligament reconstruction using acellular dermal matrix and suture anchors demonstrated similar biomechanical properties to previously described reconstruction techniques. Clinical relevance: Scapholunate ligament reconstruction using acellular dermal matrix warrants clinical investigation as a potential treatment alternative for chronic scapholunate instability. [Copyright &y& Elsevier]

Purpose: In patients with chronic scapholunate (SL) dissociation or dynamic instability, ligament repair is often not possible, and surgical reconstruction is indicated. The ideal graft ligament would recreate both anatomical and biomechanical properties of the dorsal scapholunate ligament (dorsal SLIL). The finger proximal interphalangeal joint (PIP joint) collateral ligament could possibly be a substitute ligament. Methods: We harvested human PIP joint collateral ligaments and SL ligaments from 15 cadaveric limbs. We recorded ligament length, width, and thickness, and measured the biomechanical properties (ultimate load, stiffness, and displacement to failure) of native dorsal SLIL, untreated collateral ligaments, decellularized collateral ligaments, and SL repairs with bone–collateral ligament–bone composite collateral ligament grafts. As proof of concept, we then reseeded decellularized bone–collateral ligament–bone composite grafts with green fluorescent protein-labeled adipo-derived mesenchymal stem cells and evaluated them histologically. Results: There was no difference in ultimate load, stiffness, and displacement to failure among native dorsal SLIL, untreated and decellularized collateral ligaments, and SL repairs with tissue-engineered collateral ligament grafts. With pair-matched untreated and decellularized scaffolds, there was no difference in ultimate load or stiffness. However, decellularized ligaments revealed lower displacement to failure compared with untreated ligaments. There was no difference in displacement between decellularized ligaments and native dorsal SLIL. We successfully decellularized grafts with recently described techniques, and they could be similarly reseeded. Conclusions: Proximal interphalangeal joint collateral ligament–based bone–collateral ligament–bone composite allografts had biomechanical properties similar to those of native dorsal SLIL. Decellularization did not adversely affect material properties. Clinical relevance: These tissue-engineered grafts may offer surgeons another option for reconstruction of chronic SL instability. [Copyright &y& Elsevier]

Purpose: Scapholunate dissociation (SLD) is thought to be a common cause of both acute and chronic wrist pain. Classically, this condition is attributed to a traumatic event and is thought to inevitably lead to the development of degenerative arthritis. Bilateral findings should thus be infrequent. The purpose of the present study was to determine the incidence of bilateral radiographic SLD and associated arthritic changes. Methods: Demographic, radiographic, and clinical data were obtained from 124 patients with abnormal x-ray findings in at least 1 wrist. Radiographs reviewed included posteroanterior, lateral, and Moneim views of both symptomatic and asymptomatic wrists. Pathology was defined as a scapholunate gap ≥ 5 mm and/or a scapholunate angle ≥ 60°. Arthritic changes were assessed. Results: A majority of the 124 patients (51%) were unable to recall any specific injury to their wrist. On the symptomatic side, 101 (81%) patients had a pathologic measurement for their scapholunate gap, and 109 (88%) had an abnormal angle measurement. On the asymptomatic side, 64 (52%) of the gap measurements and 87 (70%) of the angle measurements were pathologic. Ninety-nine patients (80%) had abnormal radiographic findings bilaterally for at least 1 variable on each side. Only 13 patients (11%) had a clinical instability pattern typical of SLD. Half the patients had radiographic degenerative changes at presentation. Conclusions: Bilateral radiographic SLD is much more common than previously assumed, is often asymptomatic, and does not inevitably lead to degenerative arthritis. These findings should call into question the assumption of a uniquely traumatic etiology. Further, most patients presented with pathologies unrelated to the scapholunate articulation. Surgical intervention chosen on the basis of radiologic findings, in the absence of clinical instability, might not be the best course of action, unless criteria are established to determine which patients eventually develop arthritic changes or become symptomatic. Type of study/level of evidence: Therapeutic III. [Copyright &y& Elsevier]

Polyglycolic acid and poly-L-lactic acid have become popular choices for bioabsorbable anchor fixation in the hand and wrist. We report a case of osteolysis, synovitis, and chondral erosion secondary to a poly-L-lactic acid suture anchor in the wrist. [Copyright &y& Elsevier]

Purpose: Many different stress views for the diagnosis of scapholunate (SL) instability have been described in the literature. The purpose of this study is to compare these stress views and determine which view has the greatest utility for demonstrating SL gap radiographically. Methods: We performed a literature search for articles describing SL radiographic stress views. We created SL instability in 9 cadaveric wrists by ligamentous sectioning and imaged each specimen using all radiographic views found in the literature. These included the “clenched pencil” view, clenched fist views in varying positions, and traction views. Scapholunate gaps were measured using digital calipers. Results: We found 8 different SL radiographic stress views specifically described in the literature. In order to further characterize the best stress views, we studied additional parameters, including varied ulnar deviation and degree of obliquity. The clenched pencil view resulted in the most consistent views with the widest SL gaps. With clenched fist views, SL gap trended to a peak at 30° of ulnar deviation. Conclusions: The clenched pencil view was the best stress view to demonstrate dynamic SL instability. It also allows for a contralateral comparison on 1 radiograph. We recommend this view when evaluating for SL pathology. Clinical relevance: This assessment of relative diagnostic utility might assist clinicians in the creation and use of protocols for the diagnosis of dynamic SL instability. [ABSTRACT FROM AUTHOR]

An unusual complication after tenodesis for scapholunate instability (Brunelli''s technique) is described. More than 1 year after the procedure, a fracture of the scaphoid with collapse was observed. Further examination concluded there was avascular necrosis of the scaphoid. The patient was treated with a proximal row carpectomy. [Copyright &y& Elsevier]

Purpose: We have recently treated several patients with gout of the wrist and scapholunate ligament pathology. The purpose of this investigation was to report the arthroscopic findings of 7 such patients. Methods: We searched our medical records for patients with a diagnosis of gout and nontraumatic wrist pathology. We retrospectively reviewed the clinical, arthroscopic, radiographic, and pathologic findings in 7 patients who failed nonsurgical management and were treated with wrist arthroscopy. Results: All 7 wrists had diffuse synovitis and crystalline deposits throughout the radiocarpal joint. There were focal crystalline precipitates on the scapholunate and lunotriquetral ligaments but not on the triangular fibrocartilage complex. Scapholunate or lunotriquetral ligament disruption was noted in 6 and 5 wrists, respectively. An early scapholunate advanced collapse pattern of arthritis was present in 5 patients. Conclusions: Gout affecting the wrist may be associated with crystal deposition on the scapholunate and lunotriquetral ligaments. Ligament incompetence and a scapholunate advanced collapse pattern of wrist arthritis was noted in 6 of our 7 patients. [Copyright &y& Elsevier]

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

Purpose: To present the early results of arthroscopic debridement and thermal shrinkage using radiofrequency probes for partial (Geissler grades I and II) scapholunate (SL) interosseous ligament injuries of the wrist. Methods: Sixteen patients with a mean age of 34 years (range, 18–54 y) presenting with chronic dorsoradial wrist pain unresponsive to initial conservative treatment for a mean period of 12 weeks were included in this study. No patient showed radiologic signs of static dissociation (SL interval, <3.5 mm; mean SL angle, 49°) before surgery. Diagnostic arthroscopy showed a partial SL tear in 14 patients and redundancy of the ligament in 2. Partial SL tears involved the membranous (proximal) and volar part of the ligament. All lesions were debrided and treated with thermal shrinkage using a bipolar radiofrequency probe. Results: The mean follow-up period was 19 months (range, 9–34 mo). Fourteen patients experienced substantial pain relief whereas in 2 the pain remained unchanged. Eight patients were completely pain free. The mean flexion-extension arc was 142° and the mean grip strength was 78% that of the unaffected side. No patient showed radiologic signs of arthritis or static or dynamic instability after surgery (SL interval remained <3.5 mm; mean SL angle, 53°). Based on the modified Mayo wrist score there were 8 excellent, 6 good, 1 fair, and 1 poor result. Conclusions: Partial SL ligament tears can be a source of radial-sided wrist pain. Scapholunate ligament debridement and thermal shrinkage effectively provided pain relief for most of the patients treated. Stability was maintained radiographically. No complications were noted from the use of radiofrequency probes. These reasonably favorable short-term results should be viewed cautiously. A longer follow-up study is necessary to determine the ultimate efficacy of this procedure. [Copyright &y& Elsevier]

Purpose: To evaluate the intraobserver and interobserver variability in diagnosing scapholunate dissociation (SLD) by wrist cineradiography. Methods: A musculoskeletal radiologist, hand surgeon, and trauma surgeon assessed the records of 50 consecutive wrist cineradiographies performed in 25 patients. Fluoroscopy was performed on the unaffected and affected wrist and consisted of radiographer-controlled passive flexion-extension and passive radial-ulnar deviation in both posteroanterior and lateral projections. To determine the intraobserver variability, the 3 reviewers reassessed all wrist cineradiographies 6 months after their first assessment. The kappa coefficient for interobserver agreement was calculated using the jackknife method. The Cohen kappa was used to assess intraobserver variability. Results: The interobserver variability for diagnosing SLD by cineradiography was excellent (κ = 0.84). The intraobserver variability for the hand surgeon was excellent (κ = 0.80), and was good for the radiologist (κ = 0.72) and the trauma surgeon (κ = 0.76). Conclusions: Cineradiography is a promising and helpful, noninvasive tool for diagnosing SLD. It is widely available and has relatively low costs. Conventional radiographs remain essential in the primary workup for suspected SLD. However, we recommend cineradiography when an SLD is clinically suspected. Type of study/level of evidence: Diagnostic III. [Copyright &y& Elsevier]

A 33-year-old male injured his left wrist while sumo wrestling. Plain radiographs revealed a palmar lunate dislocation. Initial attempts at closed reduction were unsuccessful. An open reduction was performed through a palmar approach using axillary block. The lunate was palmarly dislocated through a rent in the capsule, without ligamentous attachments to the radius. Once the lunate was reduced, the torn palmar intracapsular ligaments were repaired. Percutaneous Kirschner wire (K-wire) fixations of the SL joint and the LT joint were performed with two K-wires. The wrist was immobilized in a short arm cast for 6 weeks. The K-wires were then removed, and the range of motion and strengthening exercises were initiated. Twelve weeks after the operation the patient returned to sumo wrestling. One year after the original injury, he noted wrist pain, only when engaged in sumo wrestling. The range of motion of the left wrist was 65 degrees of extension, 60 degrees of flexion, radial deviation of 20 degrees, and ulnar deviation of 50 degrees. He had normal pronation and supination of the forearm. Grip strength, as measured with a Jamar dynamometer, was 65 kilograms on the right side compared with 65 kilograms. Radiographs showed a scapholunate gap of 1.5mm with a scapholunate angle of 55 degrees. [ABSTRACT FROM AUTHOR]