The Treatment of Chronic Scapholunate Dissociation: An, Eviden

The Treatment of Chronic Scapholunate
Dissociation: An, Eviden~ce-BasedAssessment
of the Literature
Heidi Taylor Bloom, MD*
Alan E. Freeland, MD*
Vaughan Bowen, MD, FRCS(C), MB, ChBt
Linda Mrkonjic,
MD, FRCS(C)t
No clear consensus exists on the best
treatment for patients with chronic
symptomaticscapholunate dissociation
uncomplicated by arthritis. Although
most surgeons agree that operative
intervention is indicated, their preferences are divided betweensoft-tissue
and bony procedures. Even within
these treatment categories, opinions
vary. Becauseno definitive guidelines
are available for choosing amongthese
options, discussion about the best
course of managementcontinues.
At the 55th Annual Meeting of the
American Society for Surgery of the
Hand (ASSH) in October 2000,
Perry’s ~ presentation focused on the
variations
in the management of
scapholunate dissociation. In this
study, a questionnaire was sent to all
membersof the ASSH,in which a case
of wrist instability in a 35-year-old
male laborer 9 monthsfollowing a fall
from a ladder was presented. Clinical
examination revealed dorsal swelling,
From the *Department of Orthopedic
Surgery and Rehabilitation,
University of
Mississippi Medical Center, Jackson, Miss; and
the fUniversity of Calgary, Canada.
Drs Bloom, Freeland, Bowen, and Mrkonjic
have not declaredany industry relationships.
Reprint requests: Heidi Taylor Bloom, MD,
Dept of Orthopedic Surgery and Rehabilitation,
University of Mississippi MedicalCenter, 2500N
State St, Jackson, MS39216-4505.
www.orthobluejournal.com
tenderness, and a positive Watsonshift
test. Radiographsdemonstratedscapholunate dissociation. The surgeons were
askedhowthey wouldtreat this patient.
Of the 488 respondents, approximately
all (99%)advocated surgical intervention. Forty-five percent opted for a softtissue procedure, 36%a bony procedure, and 19%preferred to wait before
makinga clinically dependent choice.
This finding, hardly a mandate for a
soft-tissue procedure, mirrors the current state of the literature regarding
treatment.
The current knowledgeon scapholunate dissociation was investigated. The
anatomy and pathomechanics
of
scapholunate dissociation were reviewed and current methodsused for clinical
examination and ima~ging techniques
were investigated. The literature con-
cerning the various treatment modalities
was then analyzed. An evidence-based
assessment
was conducted
to evaluate
the outcomes of different treatment
methods. The quality of published
results was evaluated, and the evidence
for and against a soft-tissue procedure
was comparedwith the evidence for and
against a limited wrist fusion.
The hypothesis for this evidencebased assessment was that soft-tissue
repairs of scapholunate dissociation
producebetter results than limited wrist
fusions.
BACKGROUND
Anatomy
The lunate is located in the center of
the proximal carpal row. The scaphoid
lies to its radial side. Proximally,both
articulate with the distal radius: tlie
195
ORTHOPEDICS
lunate with a spheroidal fossa and the
scaphoid with an elliptical
fossa.
Distally, the lunate articulates with the
capitate, whichlies in the center of the
distal carpal row. The scaphoidbridges
the two carpal rows; its distal pole
articulates with the trapezium and
trapezoid.
The scapholunate ligament complex
is commonly described as having
intrinsic and extrinsic components.
Intrinsic Portion of the Scapholunate Ligament Complex. The scapholunate interosseous ligament connects
the ulnar aspect of the proximalpole of
the scaphoidto the radial aspect of the
lunate. It is a strong ligamentz and has
a key role in preventingcarpal collapse.
The ligament is composedof three distinct components.3 The thick dorsal
region is madeup of short, transversely
oriented collagen fibers, The proximal
region is composedprimarily of fibrocartilage, extending into the cleft
betweenthe scaphoid and lunate and is
analogous to the knee meniscus. The
thin palmarregion consists of obliquely oriented collagen fascicles, just dorsal to the long radiolunate ligament. An
isolated injury to the intrinsic scapholunate portion will not result in diasta4sis.
Kozin5 reported that additional
injury to the extrinsic ligaments--the
volar radioscaphocapitate, long radiolunate, and short radiolunate ligament-is required to demonstrate
radiographic diastasis. Acute injuries
may be severe enough to cause immediate diastasis. Less severe injuries,
which are common,maylead to gradual extrinsic ligamentattrition. Patients
with such injuries do not develop
scapholunate widening and carpal
instability for weeks or even months
after injury.
Extrinsic Portion of the Scapholunate Ligament Complex. The radioscaphocapitate ligament extends from
the radial styloid through a groovein
the waist of the scaphoid to the palmar
aspect of the capitate. It functions as a
fulcrum around which the scaphoid
rotates. The long radiolunate ligament
196
.........
runs parallel to the radioscaphocapitate, extending from the palmar rim of
the distal part of the radius to the radial margin of the palmar horn of the
lunate. Thespaceof Poifier is the interval located between the radioscaphocapitate and long radiolunate ligaments
at the midcarpaljoint. Theshort radiolunate ligament is contiguouswith palmarfibers of the tfiangulofibrocartilage
complex, originating from the palmar
marginof the distal radius and inserting
into the proximal palmarsurface of the
lunate. The radioscapholunate ligament
(ligament of Testut) is a synovially
invested neurovascular pedicle derived
from the anterior interosseous and radial arteries and anterior interosseous
nerve.
Dorsal ligaments also contribute to
wrist stability. The dorsal radiocarpal
ligament Originates from the dorsal
marginof the distal :radius and inserts
at the lunate, lunotriquetral interosseous ligament, and dorsal tubercle
of the triquetrum. ~[’he dorsal intercarpal ligament originates fromthe tfiquetrumand extends radially to insert
into the lunate, the dorsal grooveof the
scaphoid, and the trapezium.
Kinematics
Wrist motion is commonlydescribed
as having two degrees of freedom:flexion and extension in the sagittal plane
and ulnar and radial deviation in the
frontal plane. The wrist motorsprimarily attach distally into the bases of the
metacarpals.
During flexion ar~d extension, the
carpal rows tend to ar~gulate simultaneously. Cineradiograms show that the
proximaland distal rows angulate equally in flexion and extension. 6 During
radial and ulnar deviation, moremotion
occurs betweenthe distal and proximal
rows than at the radiocarpal joint. With
radial deviation to 20°, a concomitant
25° palmar angulation of the proximal
row also is present. With ulnar deviation, 25° of dorsiflexion occurs.
A numberof theories have emerged
explaining the complex intercarpal
movements that occur during wrist
FEBRUARY’2003
VOL26 NO2
motion; the two main theories are the
columnartheory7 8and the ring theory.
Both were devised prior to cineradiology and neither fully explains wrist
kinematics. A combinationof these two
9theories mayprovide the best model.
Because the proximal carpal :row
has no direct tendonattachments, it can
be thought of as an intercalated segment. Landsmeer~° demonstrated that
intercalated segmentsfall into a zigzag
collapse pattern with compressiveloading. Linscheid et al 2 noted that the
lunate tends to dorsiflex relative to the
distal radius and capitate as the
scaphoid is destabilized, thus forminga
dorsiflexed intercalated segmentinstability pattern deformity. A capitolunate
angle >15° is considered abnormal.
The scaphoid flexes to accommodate
the shortenedcarpal length.
Mechanism of Injury
Wrist instabilities involving the
scapholunate joint have been divided
into dynamicand static categories. Two
distinct types of incomplete ligamentous injury may produce a dynamic
scapholunateinstability pattern: 1) limited volar interosseous and radioscaphoid ligament failure, and 2)
scapholunate interosseous and radioscaphoid elongation without ligament
failure. Both injuries result in dynamic
carpal instabilities during wrist motion
without altering the static bony alignmentat rest.
Mayfield et al ~ reported a laboratory study in which cadaveric wrists and
forearms were used to demonstrate
injury to the scapholunate interval.
Frozen cadaveric specimens were used
in simulating a fall on the outstretched
hand causing wrist extension, ulnar
deviation, and intercarpal supination.
Under these loading conditions, the
scapholunatejoint was the first carpal
joint to be injured. Ligamentousinjury
then progressed around the lunate to
produce sequential instability of the
scapholunate, capitolunate, and ~riquetrolunate. Four stages of progressive
perilunar instability weredescribed:
¯ Stage I: Scapholunate dissociation
www.orthobluejournal.com
BLOOM
ET AL
caused by injury to the scapholunate
interosseous and palmarradioscaphocapitate ligaments,
¯ Stage II: Dislocation of the capitolunate joint through the space of
Poirier.
¯ Stage III: Separation of the triquetrum from the lunate with associated injury to the lunotriquetral
and ulnotriquetral ligaments.
¯ Stage IV: Palmar lunate dislocation
due to injury to the dorsal radiocarpal ligament.
Variants mayoccur. Radial styloid~
transscaphoid, transcapitate, and transtriquetral fractures maybe associated
with perilunate injuries. In these fracture dislocationvariants, the injury pattern is still believedto be a progression
from radial to ulnar arc. Onthe ulnar
side of the wrist, the plane of failure
involves the lunotriquetral ligament,
palmar ulnocarpal ligaments, and ulnar
styloid process.
volar scapholunateligament is not primarily loaded. On the other hand, rupture of the dorsal radioulnar ligament
mayhave occurred if the wrist was in a
pronated position. A fall on the dorsiflexed wrist, with localization of
painful symptomsat the thenar eminence, will lead to scapholunate instability.
On physical examination, the exact
area of tenderness must be localized.
Palpation of the wrist includes the
anatomic snuffbox. Tenderness in this
region is a classic sign of scaphoid
fracture. If scapholunate ligament
injury is present, tendemess may be
present in the snuffbox, but tends to be
greatest at the proximal end of the
snuffbox under the extensor carpi
radialis longus tendon. Occasionally,
an associated click or a sensation of
giving waymaybe present if firm pres3sure is applied)
In scapholunatedissociation, a distinct sulcus maysometimesbe palpated
DIAGNOSIS
dorsally between the scaphoid and
Accurate Clinical Evaluation
lunate while slight’Jy flexing and
Wrist injuries with initially normal ~4
extending the wrist. Watson et al
radiographs are frequently designated
described a maneuver to provoke the
as "sprains." The severity of such a
scapholunate instability that occurs
"sprained" wrist maybe underestimatwith wrist loading. This is knownas the
ed and scapholunate ligament injury
"Watsonshift test," in which the wrist
under-diagnosed owing to the normal,
is movedfrom ulnar to radial deviation
initial radiographs. Theseinjuries usu- with pressure applied to the distal pole
ally are protected until they become of the scaphoid.Thetest is positive if a
asymptomatic, but pain persists in
click is produceddorsoradially in the
somepatients. In such patients, further
scapholunatejoint. Pain or laxity durevaluation is necessary to determine
ing this maneuvermay be more subtle
whether partial ligament injuries and indications of scapholunate ligament
instability are present. This conclusion injury.
is documentedby a report of a consecuRadiographic and Other Diagnostic
tive series of 100 cases with a wrist
Studies
injury (excluding fractures) seen in
emergency department, in which 19
Anteroposterior (AP) and lateral
patients demonstratedan increased gap radiographsof the wrist usually are the
radiographically on the clenched fist
first diagnostic study obtained)~ Onthe
12
view. Of these 19 patients, 5 had sigAPwrist radiograph, an interval >3 mm
nificant scapholunateinstability.
suggests a scapholunateligament injury.
A detailed history of the mechanism Onthe lateral view, the normalscaphoof injury is important. For instance, if
lunate angle (angle of Alexander)is °
the patient fell with the wrist in a pal(range: 30°-60°). In scapholunatedissomar-flexedposition, it is less likely that ciation, a dorsal intercalated segment
an injury to the scaphoid or scapholu- instability pattern is seen. This results
nate ligament has occurred because the from disruption of the scapholunatelig-
www.orthobluejournal.com
REVIEW
ament and the extrinsic volar scapholunate ligaments. The vertical lunate
axis extends beyond 15°. The scaphoid
rotates palmarly, and the scapholunate
°angle
.
increases beyond60
In patients with dynamicwrist instability, routine wrist radiographs are
normal. Special radiographic views,
such as the clenchedfist view, in which
compression is transmitted across the
wrist, demonstrate widening at the
scapholunate joint. Scapholunate
widening mayalso be demonstrated by
cineradiography or 6-view motion
studies of the wrist. 2 Wideningof the
scapholunate interval is accentuated
with the wrist in ulnar deviation. As the
wrist movesinto radial deviation, the
scaphoid flexes and becomes perpendicular to the plane of the radius. The
"signet ring sign" is producedwhenthe
distal scaphoid pole is imaged "endon." Beckenbaugh13 noted that if a
scapholunate gap is present in ulnar
deviation, it mayoften close in radial
deviation.
Arthrography can be used to study
the integrity of the carpal ligaments.
Midcarpal, radiocarpal, and distal
radioulnar arthrography, the so-called
triple-phase test, mayreveal interrnption of the intrinsic intercarpal ligaments. Contrast material injected into
the midcarpal joint does not normally
cross into the radiocarpal joint unless
an intrinsic ligament tear is present.
Unfortunately, arthrography is associated with false positive and false negative results, whichmayrender interpretation difficult.
Magnetic resonance imaging (MRI)
can be used to survey the wrist for ligament tears. The images obtained are
detailed, but difficulties in correlating
occult MRIfindings with patient symptoms and arthroscopic and operative
findings have led to less reliance on
this study.
Wrist arthroscopy has the highest
sensitivity and specificity amongthe
special studies group in diagnosing the
carpal ligamentinjuries responsible for
carpal instability. This modality is
more accurate than arthrography or
197
ORTHOPEDICS
MRIfor detecting the site and extent of
ligament injuries. 15 The radiocarpal
and midcarpal joints maybe examined
and the intercarpal joints probed. In
cases of scapholunate dissociation, the
diagnosis is confirmedif the probe or
arthroscope can be passed between the
midcarpaland radiocarpal joints.
Treatment
The management of patients with
acute scapholunate dissociation varies
among surgeons, but the options
include closed reduction and cast
immobilization; cldsed or open reduction and percutaneous Kirschner wire
fixation; open reduction; direct repair
of the scapholunate ligament and support of the repair with K-wires, capsulodesis, or both; and open reduction
and replacement of the scapholunate
ligament with tendon graft, suture
anchors, or some other structural
device. It is importantto re-establish a
normal scapholunate relationship to
prevent abnormal wrist kinematics or
collapse that maylead to articular surface wearand post-traumatic16
arthritis.
The preferred method of treatment
is open reduction of the carpus through
a dorsal approach,placementof at least
two 0.045-inch K-wires to pin the
scaphoidto the lunate and capitate, and
direct repair of the scapholunateligament. Ligament repair is performed
with direct suture for ligaments torn in
their midsubstance or with pullout
sutures or suture anchors for ligaments
avulsed from bone. The reduction
should be protected and supported with
cast immobilization for at least 8
weeks.
The feasibility of secondary ligamentousrepair (>3 weekspost-injury)
dependson identification of a substantial, reparable scapholunate interosseous ligament and reduction of the
palmarly flexed scaphoid without
extensive dissection. The extent to
which the scaphoid becomes fixed in
palmar flexion depends on the magnitude of the initial capsular injury and
the scarfing and capsular contracture,
which increase over time. Closed
198
FEBRUARY
2003 VOL26 NO2
reduction alone or closed reduction and
percutaneous pin fixation are not uniformly successful in maintainingcarpal
alignment and achieving satisfactory
long-term outcomes in wrists with
acute scapholunateinstability.
Late diagnosis is frequent, owingto
the incipient nature .of the symptoms.
Closed treatment has been of little
value except in those patients with
minimal symptoms. Man.y treatments
have been proposed :for reconstruction
of the symptomatic chronic scapholunate injury. Somesurgeons advocate
techniques that prevent scaphoid flexion during wrist motion by joining the
distal and proximal row by fusion to
prevent collapse, while others advocate
soft-tissue reconstruction using intrin~7
sic or extrinsic tissue:. In 1987,Blatt
described a methodof surgical stabilization of the wrist with a dorsal capsulodesis. This techniqueis an indirect
soft-tissue reconstruction in which a
radius-based flap of wrist capsule is
inserted into the distal pole of the
scaphoid, which prevents the scaphoid
from collapsing into excessive flexion.
18
In 1967, Petersen and Lipscomb
recommended arthrodesis
of the
scaphoid, trapezium, and trapezoid as
treatment for rotatory subluxation of
the scaphoid. Watson et aP9 emphasized that the position of the scaphoid
in scaphoid, trapezium, and trapezoid
°arthrodesis must be approximately 45
from the long axis of the forearm when
viewedlaterally. If fused in a morevertical position, or in line with the forearm, wrist motionmaybe significantly
limited, owing to ~Ihe incongruous
alignment of the scaphoid surface in
relation to the elliptical fossa of the
radius. The scaphoid, trapezium, and
trapezoid fusion madintains a neutral
scaphoid position between the proximal and distal carpal rows. Scaphoid,
trapezium, and trapezoid fusion is contraindicated in an arthrfic wrist.
Other intercarpal or limited wrist
fusions have been tried. Scapholunate
fusion has been criticized because it
produces an unacceptable limitation in
wrist motion.2° High bending moments
also cause high nonunionrates. Scaphocapitate fusion locks the scaphoid into
position by the immobile articulation
between the capitate and middle metacarpal; it also creates a load-bearing
columnacross the fusion site that may
accelerate wear and subsequently produce arthritic changes in the radioscaphoidjoint.
MATERIALS AND METHODS
Medline and Science Citation Index
computer searches of the literature
were performed using the terms
"scapholunate dissociation," "carpal
instability," and "scapholunate ligament." All English language citations
between 1965 and 2000 were retrieved
and reviewed. The references from
each article wereused to gain additional citations.
-All studies using scapholunatem~.at
merits with sample sizes of ~>2 were
included. The surgical treatment
groups were divided into soft-tissue
repairs and primary fusions. All softtissue reconstructions (eg, dorsal capsulodesis and tendon weave) were
groupedunder the soft-tissue category,
and all limited intercarpal fusions (eg,
scaphoid, trapezium, and trapezoid and
scapholunate) were grouped in the
fusion category. Dynamicand static
instabilities were included. Studies in
whicha type of intercarpal arthrodesis
was performed for a variety of diagnoses (eg, degenerative joint disease
and Keinbock’sdisease) were reviewed;
and, if possible, onlythose patients with
the diagnosis of scapholunate dissociation were included in the study.
Similarly, patients identified as having
perilunate dislocations were excluded.
Only rarely were bilateral procedures performed in the same patient.
Whenthis occurred, the patient number
was counted as two.
The most useful and most frequently
listed data groups were analyzed:
patient number; duration of symptoms
prior to surgery; length of follow-up;
percentage of postoperative flexionextension arc comparedto the noninvolvedside; percentageof grip strength
www.orthobluejournal.com
BLOOM
ET AL
comparedto the noninvolvedside; presence or absence of painful symptoms;
and complications. Additional data
groups, which were inconsistently
described by investigators, were not
analyzed but included data such as
millimeters of scapholunate diastasis;
range of motion in ulnar and radial
deviation; patient satisfaction; return to
usual, preinjury activities or return to
work status; and radiographic evidence
of reduction, arthrosis, and bonyunion.
Complications were described rather
than reported as a rate. Whenonly
absolute range of motiondata were provided, a 150° flexion-extension arc was
used as the normalvalue for the unint°
volvedside.
RESULTS
The 212 Medline and Scientific
Citation Index references yielded 91
articles pertinent to the treatment of
scapholunatedissociation. Of these, 35
studies includedpatient data. A total of
27 studies between 1978 and 2000 met
criteria for inclusion in the scapholunate dissociation treatment groups. All
investigations were noncontrolled,
nonrandomizedcase series. Seventeen
studies involved soft-tissue scapholunate reconstructions (n=386 patients)
and 10 studies reported limited intercarpal fusions (n=126patients). Tables
1 and 2 detail the studies and collected
data from the soft-tissue reconstruction
and arthrodesis groups, respectively.
DISCUSSION
A recent surge of interest in the wrist
has been noted. Knowledgeabout the
joint, both its normal function and
injury patterns, has increased exponentially. Wrist anatomyis nowwell understood, and current kinematic theories
are believed to be reasonably accurate.
Wrist ligament injures have been a
large focus of research; impressive
quantities of data have accumulated
over the past three decades. Improved
clinical evaluation and imaging techniques havefacilitated diagnosis.
New management techniques have
evolved in response to increased under-
www.orthobluejournal.com
REVIEW
standing of wrist trauma. Operative
repairs are more logical, and most are
designed to merge the new knowledge
on wrist injures with basic orthopedic
principles, Nevertheless, despite a vast
amount of surgical experience and a
numberof reports in the literature, no
consensus exists on the best operation
for a chronic scapholunate dissociation. The surgeon is still faced with
many choices. The purpose of this
study was to try to narrow the choice
and, specifically, to determinewhether
one avenue of management
(soft-tissue
procedures) was superior to the other
(limited wrist fusions) for chronic
scapholunate dissociation.
The managementof patients with
scapholunatedissociation varies according to howsoon the patient presents
after injury. If the dialNosis is madein
the acute injury stage, the options for
treatment include:
¯ closed reduction and cast immobilization,
¯ closed reduction and percutaneous
K-wirefixation,
¯ open reduction with direct repair of
the scapholunate ligament, and
¯ open reduction and repair of the
scapholunate ligan~ent with tendon
graft, anchor sutures, or someother
structural device.
It is importantto correct concurrent
scapholunate deforrnity. Otherwise,
alterations of wrist kinematics and
abnormalarticular stuface loading can
ultimately cause scapholunate advanced
16
collapse and post-traumaticarthritis.
The primary challenge with acute
scapholunate ligament injuries is making an early diagnosis. Most patients
whopresent with chronic radial-sided
wrist pain report a history of mild wrist
injury. In manycases, patients do not
seek medicalattentiort. Other patients,
seen in emergencyrooms or doctors’
offices and diagnosed as having a mild
wrist sprain, are treated with reassurance or short-term splinting and early
movement. The proportion of these
mild wrist sprains progressing to
dynamic scapholunal:e instability is
unknown.Similarly, it is not known
whether dynamic scapholunate instability progresses to static scapholunate
instability with radiographic seParation
of the scapholunatejoint; and eventually, such patients then develop scapholunate advancedcollapse (SLAC)wrist
pattern degenerativearthritis. It is generally thought, that progression
occurs--at least in the more sew~re
cases--but that it takes a long time
(often 15-25 years) for SLAC
wrist pattem degenerative arthritis to become
severe enough to need surgical management. A long interval between the
onset of pain is associated with
scapholunatedissociation and the indications for salvage surgery for posttraumatic SLAC
wrist pattern arthritis.
Limited wrist fusion, total wrist
arthrodesis, and proximal row carpectomy are used in the managementof
SLACwrist arthritis. The results of
these procedures are well established,
reasonablypredictable, and usually satisfactory. Each procedure, however,
leaves the patient with someresidual
wrist impairment, usually in the form
of loss of motion, strength, power, and
endurance. Therefore, the goal is to
identify patients with scapholunate
instability early and offer a reliable
operative procedure, which ideally
would restore function and alleviate
pain.
The most commonly recommended
surgical procedures for scapholunate
dissociation in the absenseof arthritis
are the Blatt capsulodesis, scaphoid
tenodesis, tendon reconstruction of the
scapholunate ligament, and scaphoid,
trapezium, trapezoid fusion. Other procedures, including arthroscopic joint
debridement, autogenous bone-retinaculum-boneligament reconstruction, and
scapholunate or scaphocapitate fusion,
are less commonlyperformed (Tables
and 2).
Reports on the surgical treatment of
scapholunate dissociation have varied
from those that describe the technical
aspects of an operation to others that
report the results of multiple patients
treated using a single method.It is difficult to identify the best method
199
ORTHOPEDICS
,,
FEBRUARY
2003 VOL 26 NO 2
TABLE
1
Treatment of Scapholunate
Study
17
Blatt
Typeof
Reconstruction
Dorsalradioscaphoid
capsulodesis
Palmer
et a121
ECRL/B
tenodesis
through scaphoid
Glickel &
ECRB
or other wrist
22
Millender
extensortenodesis
dorsal & palmar
23
Conyers
Palmarreconstruction
with K-wires
Almquistet a124 ECRB
tenodesisthrough
radius,lunate,capitate,
scaphoid
2s
Lavernia
et al
Dorsalradioscaphoid
capsulodesis
Wintman
et a126 Dorsalradioscaphoid
capsulodesis
Uhlet a127
Dorsalradioscaphoid
capsulodesis,
scapholunate
repair,
suture anchors
VanDenAbbeele FCRtenodesisscaphoid
et a128
to lunate
Weiss29
Bone-retinaculum-bone
3°
Wyricket al
Capsutodesis,
scapholunate
repair
Deshmukh
et a131Dorsal radioscaphoid
capsulodesis
Dissociation
With Soft-Tissue
Repair/Reconstruction
Timeto
Rangeof Grip No. Patients
No. Surgery Follow-Up MotionStrength With Painful
Patients (mos)* (mos)*
(%)*
(%)* Symptoms
12
83.3
80
Complications
30
>1
45.6
72.5
76.4
21
13.2
25.4
72.3
71.1
28
2.4
19.2
76
82
6
36
4
57.6
74.2
73
23
None
21
17
33
75.3
106
2
None
19
17
31
90
87
2
35
24
56
85
Forearm
cellulites (n=l);
EPLsubluxation(n=l)
Pin tract infection(n=2);
wrist sepsis(n=l)
22
9
61
58
5
RSD(n=2)
19
43.2
88.8
38t
3
17
3
30
60
70
All
Neuropraxia
dorsal
sensorybr. radial nerve
(n=5); skin breakdown
(n=l)
Pin tract infection (n=l)
44
58
22
59.5
65.1
23
83%:I:
4%
19
Infection (n=l)
Lac.dorsalsensorybr.
radial nerve(n=l);
R/Oinfection (n=l)
Regionalpain syndrome
(n=3);pin-site infection
(n=2)
Saffaret a132
37
7.2
27
79.2
78
~3
Bickertet al
12
1.3
18
78
81
(6-24)
°
30o-60
65
11.6
75.5
94.6
None
Infection (n=l); RSD
(n=2)
Scapholunate
repair,
tenodesis,capsulodesis
Scapholunate
repair with
mini-anchorsutures
~4
Brunelliet al
FCRtenodesisdistal
scaphoidinto dorsal
radius
3s
Cuenod
Bone-ligament-bone
with capsulodesis
Muermans
et a136 Dorsalradioscaphoid
capsulodesis
Total
13
3
8
2
17
23.8
30
63.4
19.4/30.6§ 4
386
17.6
31..6
71.4
76.7
Avascular
necrosisof
lunate (n=l)
Abbreviations:
ECRB=extensor
carpi radialis brevis,dystrophy.
ECRL=extensor
carpi radialis longus, EPL=extensor
pollicis longus, FCR=flexor
carpi
radialis, R/O=rule
out, andRSD=reflex-sympathetic
*Average.
tlrnproved
in 38%.
~;Decrease.
§Poundspreoperatively~pounds
postoperatively.
because no report describes valid comparative results
between different
methods. In fact, no report documents
the efficacy of surgical management.
This investigation
was undertaken
because we believed that an understanding of the pros and cons of the two
procedures and a detailed knowledge of
200
their outcomes were important but
poorly understood clinical
issues.
Insufficient evidence was available for
proper and satisfactory
evaluation of
the procedures.
Our initial plan was to collect data
from multiple reported studies, pool the
data, and perform a meta-analysis.
Dickerson and Berlin 46 defined metaanalysis as "the statistical analysis of a
large collection of analysis results for
the purpose of integrating the findings." Our study found that the literature on scapholunate dissociation was
not sufficiently homogeneousfor metaanalysis,
thus the evidence-based
www.orthobluejournal.corn
BLOOM
ET AL
REVIEW
TABLE
2
Treatment of Scapholunate Dissociation
Study
Watson
et a119
Hastings
&
3z
Silver
38
Eckenrode
39
Kieinman
Typeof
Arthrodesis
Triscaphe
Scapholunate
Triscaphe
Triscaphe
Arthrodesis
Timeto
Range
of
Grip No. Patients
No. Surgery Follow-Up Motion StrengthWithPainful
Patients(mos)* (mos)*
Complications
(%)*
(%)* Symptoms
30
29
47
79.5
92
0
TransientRSD
(n=3)
3
25.3
57.6
80.7
99
0
None
9
41
4°
Hom& Ruby
Scapholunate
7
Watson&
41
Hempton
Watson
et a142
Kleinman
et a143
Rotman
et a144
4s
Uematsu
Triscaphe
4
Total
With Limited Intercarpal
Triscaphe
I
Triscaphe
12
Scaphocapitolunate16
Scaphoid-lunate3
capitate-triquetrum
126
18
14.7
19
56
62.5
65
74
48.7
71.9
88
6.7
20.25
80
9
17
9.6
10.3
>24
25
22.6
60
60
43.7
38.8
20t
68.1Ibs
30.6kg
17.9
43.2.
65.7
88.5
3
2
4
0
I
6
0
Pyarthrosis,
osteomyelitis
(n--2);avascular
necrosis
of thelunate
(n=l)
Neuropraxia
dorsal
sensory
br. radialnerve
(n=l); neuroma
(n=l)
None
None
Deepinfection(n=2)
Abbreviations:
ECRB=extensor
carpiradialisbrevis,ECRL=extensor
carpin~dialislongus,EPL=extensor
pollicis longus,FCR=flexor
carpi
radialis,andRSD=reflex
symapthetic
dystrophy.
*Average.
~flmproved.
assessment was used. Evidence-based
assessment is an epidemiological
method that has been developed for
analyzing the ~trength of objective
data, subjective results, and other informationobtained from the literature.
Theresults of this study showedthat
the literature on the surgical management of scapholunate dissociation is
not strong from the epidemiological
point of view. Of the 212 reports
obtained from the literature search,
only 27 fulfilled the entry criteria for
this study. All of the other reports concerned different aspects of scapholunate dissociation, such as its diagnosis
or treatments that were described but
no patient data were provided. All 27
reports concernedwith soft-tissue procedures or limited wrist fusion procedures were case-series studies.
It is impossibleto drawhard conclusions from a heterogeneousset of caseseries studies. It is alwayspossiblethat
conclusions are inaccurate because
results may be a matter of chance
alone. At best, an evidence-based
assessment of this type of literature
www.orthobluejournal.com
mayallow the reviewer to see trends.
It was useful to divide the surgical
managementof scapholunate dissociation into two broacl general categories-soft-tissue
procedures and
bony fusions. Soft-tissue reconstructions are attractive because,theoretically, they most accurately restore normal
anatomy:ligament reconstruction for a
ligamentousinjury. The surgeon should
recognize that the viscoelasticity of
tendons is less than that of the ligaments they replace. Skeletal procedures, on the other hand, have are more
predictable and more permanent. For
various reasons, it appears that neither
strategy is ideal. Each has its own
strengths and weakne~;ses.
The literature suggests that surgical
management
tends to !improve patients’
symptoms.This is best illustrated in the
series of Wintman
et ~:1.26 Noneof their
patients reached a satisfactory outcome
with the nonoperative treatment
described. These aut]hors emphasized
that the patients’ subjective pain ratings
and subjective functional outcomes
improved following surgery. In the
majority of patients in this series, pain
frequency was reduced from "pain
throughout the day" preoperatively to
"slightly greater than once a month"at
the time of review. Subjective functional status also was markedlyimproved,
such as brushing teeth, brushing hair,
opening car doors, sweeping, shoveling, throwing, and using a screwdriver.
Interestingly, subjective improvements
were more dramatic than changes in
the objective data, such as range of
motionand~strength.
The literature
also documents a
number of other important points,
which have been gleaned from surgical
experience. In children, wrist ligament
injuries generally are believed to be
less commonthan skeletal injuries.
Zimmermanand Weiland47 noted that
epiphyseal injuries about the wrist are
morefrequently recognized than isolated ligamentous injuries. They recommendsoft-tissue proceduresrather than
intercarpal arthrodesis for the skeletally immaturewrist to minimizethe possiblity of prematuregrowtharrest.
Oneproblemwith soft-tissue recon-
201
ORTHOPEDICS
~
stmctionis its lack of durability. Saffar
et a132 abandoned the use of tendon
grafts for scapholunateligament repair
because they believed the procedure
provided unacceptable results in terms
of motion, grip strength, and radiographic findings. Whenthe scapholunate gap was >4 mmor when the
scaphoid was not reducible, they prefenced limited carpal arthrodesis.
Glickel and Millender22 noted that the
radiographic
appearance of the
scapholunate gap and scapholunate
angle did not appear to improvesignificantly after soft-tissue reconstruction.
He postulated that repairs stretched out
over time, and neither tendon grafts or
ligamentous sutures could withstand
the forces generated across the carpus
in normalactivity.
Proponents of skeletal procedures
have argued that they are more predictable and permanent. Opponentsof
arthrodesis base their argumentsprincipally on the associated long-term alterations in carpal kinematics that they
suspect will occur. It is assumedthat
altered kinematics will produce abnormal loading and lead to post-traumatic
arthritis, however, no objective evidencefor this exists. It is neverthelessa
generally accepted orthopedic principle, and untreated carpal disruptions,
which lead to dorsal intercalated segment instability, have been shownto
deteriorate to a SLACwrist pattem
16
p0st-traumaticarthritis.
Kleinmanand Carroll48 warnthat, in
their experience, patients with subtle
preoperative radiographic degenerative
changeswithin the radiocarpal or intercarpal joints are not candidates for a
limited scaphoid, trapezium, and trapezoid arthodesis.
Augsburger et a149 studied radiocarpal loading characteristics after
scaphoid, trapezium, and trapezoid
fusion in a laboratory setting. They
used pressure sensitive film to measure
radiocarpal contact characteristics after
different surgical simulations in cadaveric wrists. They observed that the
scaphoid, trapezium, and trapezoid
fusion unloads the lunate by creating a
202
FEBRUARY
2003 VOL26 NC)
rigid column from the metacarpals.
Their study also demonstratedthat the
tendon-weave procedure produced
contact pressure similar to that of the
intact wrist. The weakness in their
study was that ligamentous stretching
or the effect of scar formationcould not
be taken into consideration.
The good results of soft-tissue
reconstructions and skeletal procedures must be balanced against the
presence of associated complications.
Complicationsare variably reported in
the literature; no standard definition
exists as to what constitutes a complication. Complication rates vary considerably, indicating great heterogeneity betweenstudies. Described complications include reflex sympatheticdystrophy, skeletal nouunion, various
types of mechanical pain, and infections that were mostly superficial
(involving pin tracts). In somereports,
it was difficult to differentiate complications from "less than satisfactory"
results.
Kleinmanand Cm~:ol148reported a
52%complication rate in 47 consecutive scaphoid, trapezium, and trapezoid
fusions for chronic.’ and dynamic
scapholunateinstability over 10 years.
Theypointed out that it is importantto
pay close attention to technical details.
For instance, failure to close the
scapholunate diastasis or imperfect
scaphoid realignment results in progressive radiocarpal degeneration. They
recommended3 months of immobilization to minimizerisk c,f nonunion.They
also noted that K-wiresused for skeletal fixation should be buried beneaththe
skin. Theybelieved this reducedthe risk
of pin tract infection and the potential
complicationof carpal, osteomyelitis.
Scapholunate fusions have been
associated with nonunionrates as high
as 47%.50 The relatively high nonunion
rate is attributed to the fact that only a
small contact area exists between the
twobones and also to the predicted high
mechanical forces in the region. Hom
and Ruby4° urged, however, that surgeons carefully review the results of
scapholunate fusion. They noted that
failure to achieve radiographic fusion
did not necessarily correlate with poor
outcome. The clinical results in some
patients with failed scapholunatefusion
werestill good, suggestingthat a fibrous
unionmayafford adequatestability.
CONCLUSION
This evidence-based assessment of
the literature on scapholunatedissociation wasused to test the hypothesisthat
soft-tissue repairs of scapholunatedissociation produce better results than
limited wrist fusions. Results demonstrated that the literature is too heterogeneousand individual reports are :not
epidemiologically strong enough to
support or refute the hypothesis. The
literature reflected a great deal of surgical experience and also demonstrated
trends, which can be useful guides to
good managementdecisions.
It is, therefore, still not possible to
objectively recommendone surgical
approach over another. Each described
technique has strengths and weaknesses. Fewdifferences are noted between
the results of soft-tissue reconstructions and skeletal reconstructions, however, no comparisons between the two
exist. Both interventions are logical.
The results obtained from the individual operations were predictable. In
some circumstances, one method rnay
be chosenover another, eg, in children.
Somesurgeons prefer to perform softtissue reconstruction first becausethis
can be convertedto fusion if it is unsatisfactory.
Our basic understanding of wrist
anatomy, kinematics, mechanism of
injury, natural history, and diagnosis of
wrist ligament injuries exceeds our
ability to select the best treatment
choice. Thechoice of operation is still
largely determined by the experience
and bias of the individual surgeon.
Randomized,controlled, multicenter,
clinical trials comparingdifferent management strategies for patients with
scapholunate dissociation are needed.
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www.orthobluejournal.com
REVIEW
BLOOM ET AL
surgical managementof chronic scapholunate
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for Surgery of the Hand; October 5-7, 2000;
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Flatt AE. The scapholunate ligament. J Hand
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5. Kozin SH. The role of arthroscopy in
scapholunateinstability. HandClin. 1999;15:435444.
6. Sarrafian SK, Melamed JL, Goshgadan
GM.Study of wrist motion in flexion and extension. Clin Orthop. 1977; 126:153-159.
7. Navarro A. Anatomyand physiology of
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AR, MackGR. Ulnar midcarpal instability-clinical and laboratory analysis. J HandSurg Am.
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10. LandsmeerJM. Studies in the anatomy of
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I 1. Mayfield JK, Johnson RP, Kilcoyne RK.
Carpal dislocations: pathomechanics and progressive peritunar instability. J HandSurg Am.
1980; 5:226-241.
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Clin North Am. 1984; 15:289-306.
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MV.Examination of the scaphoid. J HandSurg
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15. Schadel-Hopfner M, Iwinska-Zelder J,
Braus T, Bohringer G, Klose KJ, Gotzen L. MRI
versus arthroscopy in the diagnosis of scapholunate ligamentinjui2¢. J HandSurg Br. 2001;26:1721.
16. Watson HK, Ballet FL. The SLACwrist:
scapholunate advancedcollapse pattern of degenerative arthritis. JHandSurgAm.
1984; 9:358-365.
17. Blatt G. Capsulodesis in reconstructive
hand surgery. Dorsal capsulodesis for the unstable
scapboid and volar capsutodesis following excision of the distal ulna. HandClin. 1987; 3:81-102.
wvvw.orthobluejournal.com
18. Peterson HA, Lipscomb PR. Intercarpal
arthrodesis. Arch Surg. 1967; 95:127-134.
19. Watson HK, Ryu J, Akelman E. Limited
triscaphoid intercarpal arthrodesis for rotatory
subluxation of the scaphoid. J Bone Joint Surg
Am. 1986; 68:345-349.
20. Watson HI(, Belniak R, Garcia-Elias M.
Treatment of scapholunate dissociation: preferred treatment--STT fusion vs other methods.
Orthopedics. 1991; 14:365-370.
2l. Palmer AK, Dobyns JI-I, Linscheid RL.
Management
of post-traumatic instability of the
wrist secondaryto ligament rupture. J HandSurg
Am. 1978; 3:507-532.
22. Glickel SZ, Millencler LH. Ligamentous
reconstructionfor chronic intercarpal instability.
J HandSurg Am. 1984; 9:.’;14-527.
23. Conyers DJ. Scapholunate interosseous
reconstruction and imbrication of palmar ligaments. J HandSurg Am. 1990; 15:690-700.
24. Almquist EE, Bach AW,Sack Jr, Fuhs
SE, NewmanDM. Four-bone ligament reconstruction for treatment of chronic complete
scapholunate separation. J HandSurg Am. 1991;
16:322-327.
25. Lavernia C J, Cohen MS, Taleisnik J.
Treatmentof scapholunate dissociation by ligamentous repair and capsulodesis. J HandSurg
Am. 1992; 17:354-359.
26. Wintman BI, Gelberman RH, Katz JN.
Dynamicscapholunate instability: results of
operative treatment with dorsal capsulodesis. J
HandSurg Am. 1995; 20:971-979.
27. Uhl RL, Williamson SC, BowmanMW,
Sotereanos DG, OstermanAL. Dorsal capsutodesis using suture anchors. Am J Orthop. 1997;
26:547-548.
28. Van Den Abbeele I(L, Loh YC, Stanley
JK, Trail IA. Early results of a modifiedBrunelli
procedure for scapholunate instability. J Hand
Surg Br. 1998; 23:258-261.
29. Weiss AP. Scapholunate ligament reconstruction using a bone-re:tinaculum-bone autograft. JHandSurgAm.1998; 23:205-215.
30. Wyrick JD, Stern PJ, Kiefhaber TR.
Motion-preservingprocedures in the treatment of
scapholunate advanced collapse wrist: proximal
row carpectomyversus four-comer atthrodesis. J
HandSurg Am. 1995; 20:9.65-970.
31. DeshmukhSC, Givissis P, Belloso D,
Stanley JK, Trail IA. Blatt’s capsulodesis for
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Br. 1999; 24:215-220.
32. Saffar P, SokolowC,, DuclosL. Soft tissue
stabilization in the management
of chronic scapholunate instability withoutosteoarthritis. A15-year
series. Acta OrthopBelg. 1999; 65:424-433.
33. Bickert B, Sauerbiier M, GermannG.
Scapholunate ligament repair using the Mitek
bone anchor. J HandSurg i~r. 2000; 25:188-192.
34. Brunelli GA, Brunelli GR. A new technique to correct carpal ins~:ability with scaphoid
rotary subluxation: a preliminary report. J Hand
Surg Am. 1995; 20:$82-$85.
35. CuenodP. Osteoligamentoplasty and limited dorsal capsulodesis for chronic scapholunate
dissociation. Ann Chir MainMembSuper. 1999;
18:38-53.
36. MuermansS, De Smet L, Van Ransbeeck
H. Blatt dorsal capsulodesis for scapholunate
instability. Acta OrthopBelg. 1999; 65:434-439.
37. Hastings DE, Silver RL. Intercarpal
arthrodesis in the management
of chronic carpal
instability after trauma. J HandSurg Am. 1984;
9:834-840.
38. Eckenrode JF, Louis DS, Greene TL.
Scaphoid-trapezium-trapezoidfusion in the treatmerit of chronic scapholunateinstability. J Hand
Surg Am. 1986; 11:497-502.
39. Kleinman WB.Long-term study of chronic scapho-lunate instability treated by scaphotrapezio-trapezoid arthrodesis. J HandSurg Am.
1989; 14:429-445.
40. Horn S, Ruby LK. Attempted scapholuhate arthrodesis for chronic seapholunatedissociation. JHand SurgAm. 1991; 16:334-339.
41. Watson HK, HemptonRF. Limited wrist
arthrodeses, I: the triscaphoid joint. J HandSurg
Am. 1980; 5:320-327.
42. Watson HK, GoodmanML, Johnson TR.
Limited wrist arthrodesis, II: intercarpal and
radiocarpal combinations. J Hand Surg Am.
1981; 6:223-233.
43. Kleinman WB, Steichen JB, StdckIand
JW. Managementof chronic rotary subluxation
of the scaphoid by scapho-trapezio-trapezoid
arthrodesis. J HandSurg Am. 1982; 7:125-136.
44. Rotman MB, Manske PR, Pruitt DL,
Szerzinski J. Scaphocapitolunate arthrodesis. J
HandSurg Am. 1993; 18:26-33.
45. UematsuA. Intercarpal fusion for treatmerit of carpal instability: a preliminary report.
Clin Orthop. 1979; 144:159-165.
46. Dickerson K, Berlin JA. Meta-analysis:
state-of-the-science.
Epidemiol Rev. 1992;
14:154-176.
47. Zimmerman NB, Weiland AJ. Scapholunate dissociation in the skeletally immature
carpus. J HandSurg Am. 1990; 15:701-705.
48. Kleinman Vv’B, Carroll C IV. Scaphotmpezio-trapezoid arthrodesis for treatment of
chronic static and dynamicscapho-lunate instability: a 10-year perspective on pitfalls and complications. JHandSurgAm. 1990; 15:408-414.
49. AugsburgerS, Necking L, Horton J, Bach
AW,Tencer AF. A comparison of scaphoidtrapezium-trapezoid fusion and four-bone tendon
weave for scapholunate dissociation. J Hand
Surg Am. 1992; 17:360-369. ~
50. Larsen CF, Jacoby RA, McCabe SJ.
Nonunionrates of limited carpal arthrodesis: a
meta-analysis of the literature. J HandSurg Am.
1997; 22:66-73.
203
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204
FEBRUARY
2003 VOL 26 NO 2
The Treatment of Chronic Scapholunate
Dissociation: An Evidence-Based
Assessmentof the Literature
1. The thickest, strongest portion of the scapholunate interosseousligament is located:
A. Distally.
B. Proximally.
C. Palmarly.
D. Dorsally.
2. A dorsal intercalated segmentinstability pattern seen on wrist radiographs indicates disruption of the scapholunate interosseous ligament
arid the:
A. Lunotriquetral ligament.
B. Extrinsic volar wrist ligaments.
C. Extrinsic dorsal wrist ligaments.
D. Triangular fibrocartilage complex.
3. The wrist ligament about which the scaphoid
flexes is the:
A. Short radiolunate.
B. Long radiolunate.
C. Dorsal intercarpat.
D. Radioscaphocapitate.
4. The range of a normal scapholunateangle is:
A, °.
10°-40
B. °.
200-50
C. °.
300-60
D. °.
40o-70
5. An abnormal scapholunate interval as seen on
an anteroposterior wrist radiographis:
A.
B.
C.
D.
>2 ram.
>3 mm.
>4 ram.
>5 ram.
6. Which of the following most accurately
describesthe Watsonshift test used in the clinical
examination for scapholunatedissociation?
A. A click is perceived as the wrist is passively
flexed and extended.
B. A click is perceived as the wrist is passively
movedfrom radial to ulnar deviation with the
examinerplacing pressure at the proximal pole
of the scaphoid.
C. A click is perceived as the wrist is passively
movedfrom ulnar to radial deviation with the
examinerplacing pressure at the distal pole of
the scaphoid.
D. A click is perceivedwhenthe wrist is passively
brought from a supinated position into a pronated position and the examinerplaces pressure at
the volar aspectof the lunate.
CMEQuiz
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7. Whichmodality has the highest sensitivity and
specificity in diagnosingcarpal injuries that lead
to intercarpal instability?
A
B
C. Triple-phase wrist arthrogram.
D, :Wrist cineradiology.
8. The greatest complication associated with
scapholunatearthrodesis is:
A. Infection.
B. Advanceddegenerative changes.
C. Pain.
D. Nonunion.
9. Transfixing Kirschner wires through the
scapholunatejoint maymost likely cause inadvertent injury to the:
A. Ulnar artery.
B. Median nerve.
C. Dorsal sensory branch radial nerve.
D. Dorsal sensory branch ulnar nerve,
10. In performinga triscaphe arthrodesis, what is
the optimal position of the scaphoidwith respect
to the long axis of the forearm viewedlaterally?
°.
A. 30
°.
B. 45
°.
C. 60
°.
D. 90
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NJ08086
FEBRUARY
2003
THETREATMENT
OFCHRONIC
SCAPHOLUNATE
DISSOCIATION
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B
B
B
B
B
C
C
C
C
C
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D
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D
D
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