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ligament is
the most commonly injured intrinsic wrist
ligament,1 although the diagnosis is frequently missed acutely.2 As a result, many patients
present late with persistent wrist pain and diminished
HE SCAPHOLUNATE (SL) INTEROSSEOUS
grip strength. Several procedures for chronic SL ligament instabilities exist, including arthroscopic
debridement and pinning,3e7 direct repair with capsulodesis,8e10 dorsal capsulodesis alone,11e13 ligamentoplasties,14e19 and bone-retinaculum-bone
reconstruction.20,21 Even if a satisfactory clinical
and functional result is obtained, deterioration of the
radiographic ndings are often noted. Even if the
immediate postoperative reduction is satisfactory, it is
not uncommon to see the loss of reduction with
reference to the SL interval and SL angle at long-term
follow-up.3,9,11,17e20,22e24 In nearly all studies, temporary Kirschner wire xation and splinting were
used postoperatively.5,6,8,9,11,13,19,20,25 As it may take
more than 3 to 4 months for either the repair to heal
2015 ASSH
or the reconstruction to incorporate,26 loss of reduction can be seen even when patients are allowed to
mobilize their wrists as early as 8 weeks following
Kirschner wire removal.19,20
The rationale of using SL screw augmentation is to
provide a more favorable mechanical environment for
soft tissue healing after the repair or reconstruction of
the SL ligament. It allows stable closure of the SL
interval (lag-screw effect), which permits early postoperative cast-free movement. Unlike tenodesis that
only corrects rotatory subluxation, realignment of the
scaphoid and lunate restores normal load transfer
across the scaphoid and lunate fossa. Maintenance of
screw xation for at least 4 months also allows for
durable soft-tissue healing.27,28
The purpose of this article was to evaluate the
outcome of patients with SL instability who had undergone a repair or a reconstruction of SL ligament
together with SL screw augmentation.
MATERIALS AND METHODS
This was a retrospective study of patients surgically
treated with chronic scapholunate instability by the
senior author at the Lindenhof Hospital, Bern,
Switzerland. Patients included in the study had
chronic instability, determined by persistent or
increasing symptoms and signs at least 3 months after
trauma between 1991 and 2012.4,5,10,11,19,29,30 We
excluded those patients with xed SL mal-alignment
or notable arthritic degeneration in either the radioscaphoid or capitolunate joints.
The diagnosis of SL instability was based on
clinical ndings, including tenderness over the scapholunate junction and a positive Watson test, and
conventional radiographs, including standard neutral
posteroanterior view, standard lateral view and
clenched st anteroposterior (AP) view.4 An increase
of the SL angle of greater than 60 ,4,11,13,19,25,31
an increase of the SL interval greater than 3
mm,4e6,8e11,13,19,25,31 an increase of the SL interval
in clenched st view, and the signet ring sign of the
scaphoid were assessed.4,32,33 Magnetic resonance
imaging had been performed prior to the consultation
in 32 cases.
Patients
Thirty-six patients with chronic, reducible scapholunate instability without arthritic changes were reviewed. There were 20 men and 16 women with an
average age of 43 years (range, 21e63 y). Twenty-two
patients had their dominant wrists affected. The
average time from the onset of symptoms to surgery
was 12 months (range, 6e25 mo). All patients recalled
Operative techniques
Wrist arthroscopy was performed for patients with
dynamic instability (ie, SL interval 3 mm, SL angle
of 60 , and the presence of an increased SL interval on clenched st view). In these cases, the
grading of SL instability was based on the Geissler
classication.35 Arthroscopic debridement was performed followed by SL screw augmentation in 11
FIGURE 1: A slip of extensor carpi radialis brevis tendon reconstructs the SL ligament. The tendon slip passes through the
scaphoid and lunate tunnels and is tied over the top with maximal
tension using heavy braided nonabsorbable suture.
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FIGURE 2: A X-rays of a dissociative SL tear with a widening of SL interval and an increase in SL angle. B Primary open repair. C Two
mini-bone anchors are xed in the scaphoid and lunate. D Dorsal capsulodesis uses an ulnarly based strip of the dorsal intercarpal
ligament and attaches to the bone with bone anchors. E X-rays showing the anatomical reduction of SL interval and SL angle. A
Kirschner wire was temporarily used to keep the scaphoid in reduced position. F X-rays of a reduced SL interval and SL angle at 2-year
follow-up. The SL screw was removed 6 months postoperatively.
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FIGURE 3: A X-ray and magnetic resonance images of a dissociative SL tear. No midcarpal or radiocarpal arthritis was noted. B X-ray
showing the reduction of an SL interval and angle after extensor carpi radialis brevis tendon graft reconstruction and SL temporary
screw xation. The reduction was maintained after the removal of screw 4 years postoperatively.
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FIGURE 4: A X-rays of a dissociative SL tear. SL interval and SL angle were reduced by ligament reconstruction and SL temporary
screw xation. B X-rays showing maintenance of the reduction of both the SL interval and SL angle 1 and 8 years postoperatively.
DISCUSSION
The aim of treatment of chronic SL instability is to
restore the anatomy prior to the development of
degenerative arthritis of the radiocarpal and later of the
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