Abstract
Background Both the dorsal and the volar portion of the scapholunate interosseous ligament (SLIL)
are major stabilizers of the scapholunate (SL) joint. Most reconstruction methods
to restore SL stability do not address the volar constraints and frequently fail to
reduce the SL gapping. Wrist arthroscopy allows a complete evaluation of the SL interval,
accompanying ligament status, and associated SL advanced collapse (SLAC) wrist changes.
It enables simultaneous reconstruction of the dorsal and palmar SL ligaments anatomically
with the use tendon graft in a boxlike structure.
Materials and Methods From October 2002 to June 2012, the treatment method was applied in 17 patients of
chronic SL instability of average duration of 9.5 months (range 1.5–18 months). There
were three Geissler grade 3 and 14 grade 4 instability cases. The average preoperative
SL interval was 4.9 mm (range 3–9 mm). Dorsal intercalated segment instability (DISI)
deformity was present in 13 patients. Six patients had stage 1 SLAC wrist change radiologically.
Concomitant procedures were performed in four patients.
Description of Technique With the assistance of arthroscopy and intraoperative imaging as a guide, a combined
limited dorsal and volar incision exposed the dorsal and palmar SL interval without
violating the wrist joint capsule. Bone tunnels of 2.4 mm were made on the proximal
scaphoid and lunate. A palmaris longus tendon graft was delivered through the wrist
capsule and the bone tunnels to reduce and connect the two bones in a boxlike fashion.
Once the joint diastasis is reduced and any DISI malrotation corrected, the tendon
graft was knotted and sutured on the dorsal surface of the SL joint extra-capsularly
in a shoe-lacing manner. The scaphocapitate joint was transfixed with Kirschner wires
(K-wires) to protect the reconstruction for 6–8 weeks.
Results The average follow-up was 48.3 months (range 11–132 months). Thirteen returned to
their preinjury job level. Eleven patients had no wrist pain, and six had some pain
on either maximum exertion or at the extreme of motion. The average total pain score
was 1.7/20 compared with the preoperative score of 8.3/20. The postoperative average
total wrist performance score was 37.8/40, with an improvement of 35%. The average
extension range improved for 13%, flexion range 16%, radial deviation 13%, and ulnar
deviation 27%. Mean grip strength was 32.8 kg (120% of the preoperative status, 84%
of the contralateral side). The average SL interval was 2.9 mm (range 1.6–5.5 mm).
Recurrence of a DISI deformity was noted in four patients without symptoms. Ischemic
change of proximal scaphoid was noted in one case without symptoms or progression.
There were no major complications. All patients were satisfied with the procedure
and outcome.
Conclusion Our method of reconstructing both the dorsal and volar SL ligament, in a minimally
invasive way, is a logical and effective technique to improve SL stability. The potential
risk of ischemic necrosis of the carpal bone is minimized by preservation of the scaphoid
blood supply, the small size of the bone tunnels created, and the inclusion of the
capsule at the reconstruction site.
Keywords
wrist arthroscopy - scapholunate ligament - SL dissociation - wrist surgery - tendon
graft
