Treatment of Chronic Scapholunate Dissociation with FCR Tenodesis: A Systematic Review of the Results of MBT and 3LT Technique

Abstract

A systematic literature review was performed to assess the results of modified Brunelli tenodesis modified Brunelli technique (MBT) and three-ligament tenodesis (3LT) in the treatment of chronic scapholunate (SL) ligament injuries reported between 1998 and 2001. This review describes the surgical techniques, clinical outcomes, radiological evaluations, and complication rates among 600 patients. Following adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 15 studies were included (289 MBT and 311 3LT procedures). A heterogeneity in surgical technique was noted. An average pain reduction of 3 points on the visual analog score and a flexion–extension arch compatible with most daily activities were found. Radiographic follow-up showed medium-term improvements, but loss of reduction was observed in the long term. Secondary degeneration was seen in 15% of cases. Radiographic decay did not correlate with clinical outcomes. The overall complication rate was 9%. This review underscores the satisfactory clinical outcome of both procedures. Nonetheless, both interventions pose risks of complications and/or degeneration in the long term.

 

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Keywords

scapholunate instability - wrist - ligament injury - carpal instability

The scapholunate interosseus ligament (SLIL) stands out as the most frequently injured carpal ligament in young individuals. In 1980, Mayfield delineated SLIL injuries as part of a broader injury spectrum.[1] The initial stage, characterized by isolated SLIL involvement, represents the predominant cause of dissociative carpal instability.[2] Without intervention, a progressive cascade may ensue, beginning with the attenuation of secondary stabilizers of the scapholunate (SL) interval, leading to altered load distribution, scapholunate advanced collapse (SLAC), and ultimately wrist osteoarthritis.[3] In chronic cases, primary ligament healing is often not feasible[4] and reconstructive measures become necessary. The primary treatment goal is to enhance clinical outcomes, with a secondary emphasis on averting osteoarthritis development.

In 1995, Brunelli and Brunelli[5] introduced a technique using a flexor carpi radialis (FCR) tendon graft for the reconstruction of both the primary and secondary stabilizers of the SL interval. This technique introduced controlling the distal palmar scaphoid instability as well as the proximal SL joint instability. Subsequently, in 1998, Van Den Abbeele et al[6] modified this technique by suturing the FCR tendon strip back onto the carpus rather than on the distal radius (modified Brunelli technique [MBT]). This modification prevents bridging of the radiocarpal joint, thereby preserving greater wrist flexion. In both techniques (Brunelli and MBT), the bone tunnel is oriented anteroposteriorly through the distal pole of the scaphoid. This way, the bone tunnel uses a well-vascularized portion of the scaphoid, enhancing tendon incorporation in the bone. MBT was further altered in 2006 by Garcia-Elias et al,[7] who introduced a more longitudinal orientated scaphoid tunnel. This alteration allows for a tunnel exit over the scaphoid insertion of the dorsal SL ligament and a fixation of the graft to the lunate using a suture anchor. Similar to MBT, the graft is then passed through the dorsal radiotriquetral ligament and sutured to itself.[7] With this technique, (1) the palmar distal stability of the scaphoid is reconstructed, (2) the dorsal SL ligament is reconstructed, and (3) the ulnar translocation of the lunate is reduced. This procedure, known as three-ligament tenodesis (3LT), reconstructs the SLIL, scapho-trapezio-trapezoid complex and lunotriquetral ligaments. The two techniques are illustrated in [Fig. 1].

Fig. 1 (A) Illustration of the modified Brunelli technique (adapted from Van Den Abbeele et al[6]) and (B) three-ligament tenodesis technique (Garcia-Elias et al.[7]) for reconstruction of the scapholunate complex. FCR, flexor carpi radialis; RLT, radiolunotriquetral ligament.

Multiple studies have examined the outcomes of these surgical approaches. This systematic review aims to provide a comprehensive overview of the clinical, functional, and radiological outcomes of both MBT and 3LT procedures, including an analysis of complication rates. Both short- and long-term results are incorporated in this review.

Materials and Methods

Data Sources and Searches

An online systematic literature search was conducted using both the PICO and SPIDER methods ([Table 1]).[8]

Table 1 PICO and SPIDER search strategy for MBT versus 3LT

PICO (patient/population, intervention, comparison, and outcomes)
P: Patients with scapholunate ligament injury
I: 3-ligament tenodesis technique
C: Modified Brunelli technique
O: Clinical, functional, and radiographic outcomes
SPIDER (sample, phenomenon of interest, design, evaluation, research type)
S: Patients with scapholunate ligament injury
P/I: 3-ligament tenodesis technique and modified Brunelli technique
D: Case study, case-control study
E: Clinical, functional, and radiographic outcomes
R: Quantitative research

Studies written in English between 1998 and 2021 were identified by searching the PubMed, Scopus, and Cochrane databases. No restrictions were placed on journal type or level of evidence. Duplicate entries or articles reporting data from the same database were removed. The bibliographies of the relevant articles were examined to identify any additional studies missed in the initial search. Case series or case-control studies involving patients with SLIL injuries treated using MBT or 3LT were included, while single case reports, letters to the editor, book chapters, technical reports, virtual surgery models, biomechanical studies, and anatomical cadaver studies were excluded. This review adhered to the PRISMA guidelines.

 

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Outcome

The primary outcome of interest was pain. To standardize the diverse range of pain assessments used, all pain scores were grouped into four categories: no pain, mild pain, moderate pain, and severe pain. A visual analog scale (VAS) score of 0 was considered equivalent to no pain, while a VAS score of 1 to 3 was classified as mild pain, 4 to 6 as moderate pain, and 7 to 10 as severe pain. Secondary outcomes included patient-reported outcomes, range of motion (ROM), grip strength, return to work status, radiographic findings, and any complications encountered.

 

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Quality Assessment

The risk of bias was assessed by three independent reviewers using the Newcastle–Ottawa Scale (NOS) for case-control series ([Supplementary Table S1], available in the online version only) and the National Heart, Lung, and Blood Institute (NIH) quality assessment tool for case series ([Supplementary Table S2], available in the online version only). Points of doubt were discussed between the three independent researchers until a consensus was reached.

Table 2 Overview of number of cases, length of follow-up, patient demographics, diagnostic modalities, and indication in all included articles describing MBT or 3LT procedure

Article	Technique	No. of cases	Mean FU (range), mo	Male/female	Mean age (y)	Diagnostic tool	Indication
Garcia-Elias et al[7]	3LT	38	46 (7–98)	24/14	31	Open exploration	21 GE stage 3 8 GE stage 4 9 GE stage 5
Pauchard et al[24]		20	25 (12–46)	15/5	43	Computed tomography (CT) arthrography + wrist arthroscopy	12 static 8 dynamic
Blackburn et al[14]		203	12	110/93	47	Unknown	Chronic
Goeminne et al [25]		50	111 (18–175)	34/14	40	Radiographs + CT arthrography (4) + MRI (8) + arthroscopy (11)	Chronic, static
Van Den Abbeele et al[6]	MBT	22	9 (6–16)	11/11	30	Wrist arthroscopy	15 predynamic 4 dynamic 3 static
Moran et al[10]		15	36 (24–84)	n.a.	39	Wrist arthroscopy	Chronic 9 dynamic 6 static
Talwalkar et al[15]		117	47 (11–101)	50/67	38	Radiographs + wrist arthroscopy	72 dynamic 45 static, reducible
De Smet and Van Hoonacker[12]		10	29 (12–62)	7/3	40	Radiographs + MRI + arthroscopy	Chronic, static
Chabas et al[26]		19	37 (12–60)	16/3	43	Radiographs + arthrography	12 dynamic 7 static, reducible
Links et al[9] [27]		21	29 (24–36)	15/6	30	Arthro-MRI	Static
Nienstedt[27]		8	166 (144–180)	7/1	40	Radiograph	Static
Ellanti et al[13]		13	12	9/4	35	Wrist arthroscopy	10 dynamic 3 static, reducible
Rohman et al[11]		22	n.a.	n.a.	n.a.	Open exploration + wrist arthroscopy	1 acute 17 chronic 4 complex chronic
Sousa et al[28]		22	61 (17–98)	18/4	40	Radiograph + wrist arthroscopy	Chronic, GE stage 3–4
Elgammal and Lukas[16]		20	24 (6–53)	19/1	43	Radiograph + wrist arthroscopy	Geissler grade 4

Abbreviations: FU, follow-up; 3LT, three-ligament tenodesis; MBT, modified Brunelli tenodesis; MRI, magnetic resonance imaging; n.a., not available; GE; Garcia-Elias stage.

 

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Statistical Analysis

A descriptive analysis was performed using weighted means. Other quantitative evaluation was not possible due to heterogeneity between studies and lack of direct comparative results.

 

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Results

Our search originally identified a total of 90 articles. After screening, 15 reports, including 12 case series and 3 case-control series, were deemed suitable for final review. The selection process adhered to the PRISMA guidelines and is depicted in [Fig. 2].

Fig. 2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart for article inclusion.

Study Characteristics

The three case-control series underwent assessment using the NOS ([Supplementary Table S1], available in the online version only). Two reports, by Links et al[9] and Moran et al,[10] lacked description of outcome assessment or loss to follow-up. The lowest score, a 6, was attributed to Rohman et al[11] due to inadequate demographic description and an inability to test subject comparability.

The evaluation of the 12 case series was conducted using the NIH quality assessment tool ([Supplementary Table S2], available in the online version only). In three articles, the indication was poorly described, making subject comparisons challenging.[6] [12] [13] One article, Blackburn et al,[14] introduced bias by altering the rehabilitation protocol during the study, while another article, Ellanti et al,[13] lacked detailed technical procedure descriptions. Consequently, eight studies received a good score, while four studies received a fair score.

 

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Patient Characteristics, Diagnosis, and Indication

From these 15 reports, data of 600 patients were analyzed, comprising 289 MBT cases and 311 3LT cases. This patient cohort had a mean age of 40.8 years and consisted of 57% men ([Table 2]).

The indications for SLIL reconstruction varied across the studies, with each study presenting different criteria. A diverse range of diagnostic methods was employed, including plain radiographs, arthrographic computed tomography (arthro-CT), arthrographic magnetic resonance imaging (arthro-MRI), open exploration, and wrist arthroscopy. Wrist arthroscopy as the sole diagnostic tool was used in four studies.[6] [13] [15] [16] Two studies did not employ wrist arthroscopy but relied on open exploration[7] or arthro-MRI.[9] In the remaining articles, arthroscopy was used as a secondary confirmation when other diagnostic modalities were inconclusive.

Lesions were classified using the classification suggested by Garcia-Elias et al, differentiation between dynamic or a static SLIL injury or consideration on the timing of the injury (chronic vs. acute injuries). This categorization is depicted in [Table 2].

 

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Surgical Technique and Postoperative Treatment

The majority of MBT and 3LT studies described the use of a distally based strip of FCR, except for a single patient in Rohman et al's series where a palmaris longus tendon graft technique was employed.[11] In the series of Elgammal and Lukas, a slight alteration in tunnel direction from the volar tubercle to the mid-waist dorsum was described.[16] Variations in technique execution were observed, including discrepancies in graft fixation methods (suture, anchor, interference screw), passage beneath the ulnocarpal ligaments, and utilization of K-wire stabilization.

Postoperative treatment predominantly involved immobilization for 6 to 8 weeks using a short arm cast, with or without thumb inclusion for both techniques. K-wire removal was consistent across studies, typically occurring 6 to 8 weeks postoperatively, with one exception of using a temporary screw fixation, which was removed between 3 and 6 months[9] ([Table 3]). Limited immobilization protocols were noted in two series.[11] [14] Strength exercises typically commenced between 6 and 12 weeks postoperatively, and return to sports was typically delayed until 3 to 6 months after surgery.

Table 3 Overview of immobilization type and duration, removal of hardware, and rehabilitation program

Article	Technique	Immobilization time	Immobilization type	K-wire removal	Rehabilitation
Garcia-Elias et al[7]	3LT	6 wk + relative immobilization 6 wk	Short arm thumb spica cast 6 wk + removable splint 6 wk	8 wk	6 mo: start contact sports
Pauchard et al[24]		8 wk	Short arm volar resin cast	8 wk	/
Blackburn et al[14]		<2 wk	Cast	/	Strength exercises: 6 wk
Goeminne et al[25]		6 wk	Short arm thumb spica cast	6 wk	Active motion: 6 wk Wrist loading activities: 12 wk
Van Den Abbeele et al[6]	MBT	6 wk + relative immobilization 6 wk	Scaphoid cast 6 wk + brace 6 wk	/	Strength exercises: 12 wk
Talwalkar et al[15]		6 wk	Above-elbow cast	/	6 wk: gentle range of motion 12 wk: start grip strengthening exercises
De Smet and Van Hoonacker[12]		6 wk	/	/	Mobilization at 8 wk Strength exercises: 12 wk
Chabas et al[26]		6 wk	Short arm thumb cast	6 wk	Mobilization at 6 wk
Links et al[9]		8 wk	Thumb spica cast 2 wk + thumb circular cast 6 wk	3–6 mo (screw)	8 wk: gentle movement 12 wk: strengthening exercises
Nienstedt[27]		6 wk	Short arm thumb cast	6 wk	6 wk: active assisted motion 12 wk: return to sports activities and heavy work
Ellanti et al[13]		/	/	/	/
Rohman et al[11]		4 wk	Average cast or brace	/	/
Sousa et al[28]		6 wk	Palmar short arm thumb cast	8 wk	6 mo: start contact sports
Elgammal and Lukas[16]		8 wk	Thumb cast	8 wk	/

Abbreviations: 3LT, three-ligament tenodesis; MBT, modified Brunelli tenodesis.

 

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Functional and Clinical Results

[Table 4] presents the analysis of functional outcomes, encompassing pain scores (VAS), return to work rates, and postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) scores. A notable reduction in overall pain levels was observed, with VAS scores decreasing from 6 preoperatively to 3 postoperatively, a trend consistent across both 3LT and MBT procedures. The overall return to work rate was 65%, with 51% of patients returning to their previous occupations and 15% transitioning to different work roles. However, for 7% of patients, postoperative employment was no longer feasible. Upon closer examination of the MBT group, 45% of patients returned to work, compared with 70% in the 3LT group. The overall postoperative DASH score was calculated to be 25.

Table 4 Functional outcomes (% continued and changed work, VAS, DASH) described in four articles with 3LT (gray colored) and 10 articles with MBT (white colored)

Study	Technique	No. of patients	% continued work	% changed work	% quit work	VAS pre-op (avg)	VAS post-op (avg)	DASH post-op (avg)
Garcia-Elias et al[7]	3LT	38	76	18	5	n.a.	n.a.	n.a.
Pauchard et al[24]		20	50	25	25	4.8	3.3	31.3
Blackburn et al[14]		203	n.a.	n.a.	n.a.	5.3	2.5	n.a.
Goeminne et al[25]		16	81	6	12	5.3	2.5	n.a.
Van Den Abbeele et al[6]	MBT	22	64	n.a.	36	7.1	3	n.a.
Talwalkar et al[15]		117	18	20	n.a.	n.a.	3.7	n.a.
De Smet and Van Hoonacker[12]		10	90	n.a.	n.a.	n.a.	n.a.	12
Chabas et al[26]		19	63	21	16	7.5	3	30
Links et al[9]		21	n.a.	n.a.	n.a.	n.a.	n.a.	36
Nienstedt[27]		8	87	0	13	n.a.	n.a.	9
Ellanti et al[13]		13	100	0	0	9	1.5	34.9
Rohman et al[11]		22	n.a.	n.a.	n.a.	n.a.	n.a.	36
Sousa et al[28]		22	59	32	9	n.a.	2	16
Elgammal and Lukas[16]		20	75	n.a.	n.a.	6	3	20
WA total			58	20	16	6	3	28
WA 3LT			70	17	12	5	3	31
WA MBT			45	22	20	7	3	24

Abbreviations: Avg, average; DASH, Disabilities of the Arm, Shoulder, and Hand; 3LT, three-ligament tenodesis; MBT, modified Brunelli tenodesis; n.a., not available; VAS, visual analog scale; WA, weighted average.

Note: Weighted averages (WA) are calculated. Missing data are indicated as n.a. (not available).

[Table 5] presents the analysis of clinical outcomes, focusing on ROM and grip strength. Overall ROM analysis showed 44-degree wrist flexion, 52-degree extension, 18-degree radial deviation (RD), and 28-degree ulnar deviation (UD) at the final follow-up. A comparison between the two procedures showed that the flexion–extension arch was 9 degrees larger after 3LT. Additionally, an average grip strength equivalent to 74% of the contralateral side was observed.

Table 5 Clinical parameters (flexion, extension, radial deviation, ulnar deviation, and grip strength) described in four articles with 3LT (dark colored) and 11 articles with MBT (white colored)

Study	Technique	No. of patients	Flexion (degrees)	Extension (degrees)	Radial deviation (degrees)	Ulnar deviation (degrees)	Grip relative contralateral (%)
Garcia-Elias et al[7]	3LT	38	51	52	15	28	65
Pauchard et al[24]		20	39	43	14	24	76
Blackburn et al[14]		203	48	60	18	28	n.a.
Goeminne et al[25]		16	57	55	20	37	73
Van Den Abbeele et al[6]	MBT	22	42	49	19	30	57
Talwalkar et al[15]		15	40	43	16	26	87
De Smet and Van Hoonacker[12]		117	45	55	18	29	80
Chabas et al[26]		10	49	48	17	34	77
Links et al[9]		19	41	50	24	29	78
Nienstedt[27]		21	45	55	13	21	98
Ellanti et al[13]		8	37	63	21	32	85
Rohman et al[11]		13	38	56	20	20	75
Sousa et al[28]		22	38	43	n.a.	n.a.	n.a.
Elgammal and Lukas[16]		22	n.a.	n.a.	n.a.	n.a.	67
Garcia-Elias et al[7]		20	41	54	19	31	81
WA total			46	55	19	28	74
WA 3LT			48	57	17	28	70
WA MBT			43	53	18	28	79

Abbreviations: 3LT, three-ligament tenodesis; MBT, modified Brunelli tenodesis; n.a., not available; WA, weighted average.

Note: Weighted averages are calculated.

 

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Radiological Results

Radiological findings were assessed for 184 patients and categorized based on the length of follow-up, as outlined in [Table 6]. After a maximum follow-up of 3 years, four authors reported on the radiological results of 75 patients, with an average SL angle of 60 degrees before and after surgery and an average SL distance evolution from 4 to 3.2 mm. For patients with a follow-up period ranging from 3 to 5 years, data from 55 MBT patients indicated an average SL angle evolution from 62 degrees before surgery to 54 degrees afterward, with an SL distance decreasing from 3.6 to 2.5 mm. Long-term radiological data (follow-up period >5 years) was available for 54 patients revealing an average SL angle from 72 to 76 degrees and an average SL distance of 3.8 to 3.2 mm.

Table 6 Radiographic parameters divided into short, medium, and long follow-up: ≤3 years (MBT = 55 patients; 3LT = 20 patients), 3 to 5 years (MBT = 55 patients), and ≥5 years (MBT = 30 patients; 3LT = 24 patients)

Follow-up	No. of patients	Technique	SL angle (degrees), pre-op	SL angle (degrees), post-op	SL gap (mm), pre-op	SL gap (mm), post-op
≤3 y
Van Den Abbeele et al[6]	22	MBT	50	50	n.a.	n.a.
Ellanti et al[13]	13		61	63	2.8	2.8
Elgammal and Lukas[16]	20		82	77	4	3
Pauchard et al[24]	20	3LT	72	75	3.9	3.7
Weighted average
3–5 y
Moran et al[10]	15	MBT	63	54	4	3
Chabas et al[26]	19		61	62	2.8	2.4
Links et al[9]	21		61	46	3.9	2.2
Weighted average		MBT	62	54	3.6	2.5
≥5 y
Nienstedt[27]	8	MBT	72	63	5.1	2.8
Sousa et al[28]	22	MBT	n.a.	n.a.	n.a.	3.1
Goeminne et al[25]	24	3LT	72	80	3.4	3.5
Weighted average

Abbreviations: n.a., not available; 3LT, three-ligament tenodesis; MBT, modified Brunelli tenodesis; SL, scapholunate.

 

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Complications

Complications, reported by 13 authors, are categorized based on their postoperative timing, and ranked by frequency in [Table 7]. The predominant complication, scar tenderness, was primarily managed through surgical exploration and excision of neurinomas. An overall complication rate of 9% was noted.

Table 7 Overview of postoperative complications

Complication	Total	3LT	MBT
Short term
Scar tenderness	15	0	15
complex regional pain syndrome (CRPS)	9	2	7
Tendinitis	5	5	0
Infection	4	3	1
Tendon adhesions	2	1	1
Synovitis	1	0	1
Hypertrophic scarring	1	0	1
Long term
Scaphoid necrosis	3	2	1
scapho-trapezio-trapezoid (STT) arthritis	2	2	0
Loosening of fixation	1	1	0
Impingement	1	1	0
Varia
Denervation	2	0	2
Ulnar side wrist pain	2	0	2
Total number of patients	538	311	227
Total number of complications	49	17	32

 

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Secondary Degeneration

Radiographic progression toward secondary degeneration, such as SLAC wrist, was documented by nine authors. The findings were classified based on timing and are presented in [Table 8]. Overall, degeneration occurred in 15% of cases, with 70% of these instances necessitating secondary surgery.

 

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Discussion

Despite the wealth of published literature, no universally accepted gold standard has emerged in the treatment of chronic SLIL injuries. Furthermore, reports featuring long-term follow-up of current treatment options are scarce. This systematic review describes the outcomes of patients treated with MBT or 3LT for SL instability. When interpreting, we have to acknowledge that these results are derived from a heterogeneous set of case series and case-control studies.

Table 8 Overview of secondary osteoarthritis and cases that needed salvage surgery in the 3LT and MBT groups

Study	Technique	No. of patients	Secondary osteoarthritis	Salvage surgery
Follow-up of 1–3 y
Pauchard et al[24]	3LT	20	2	2 1 4CF 1 STT fusion
Elgammal and Lukas[16]	MBT	20	3	2 1 4CF 1 PRC
Follow-up of 3–5 y
Garcia-Elias et al[7]	3LT	38	9	0
Moran et al[10]	MBT	15	2	1 wrist fusion
Talwalkar et al[15]	MBT	55	–	4 2 SC fusion 2 wrist fusion
Chabas et al[26]	MBT	19	1	–
Follow-up of >5 y
Goeminne et al[25]	3LT	50	15 needed surgery +15/24 without the need for surgery	15 11 PRC 2 4CF 2 wrist fusion
Nienstedt[27]	MBT	8	1	–
Sousa et al[28]	MBT	22	3	1 total wrist fusion

Abbreviations: 4CF, four-corner fusion; 3LT, three-ligament tenodesis; MBT, modified Brunelli tenodesis; PRC, proximal row carpectomy; SC, scaphocapitate.

Functional and Clinical Results

Among the included literature, seven studies compared pre- and postoperative pain, with an average improvement of 3 points on the VAS. When looking at ROM, a larger flexion–extension arch was observed with the 3LT procedure compared with the MBT. Yet, this variance may lack clinical relevance, since the ROM achieved through both methods aligns with the demands of daily activities. Previous research has shown a combined flexion–extension arch of approximately 40 degrees, together with a combined radioulnar deviation of also 40 degrees, is adequate for most daily tasks.[17]

The findings from this review should be viewed in the context of other surgical techniques to enable meaningful comparisons. Montgomery et al[18] performed a systematic review involving 805 wrists with chronic SLIL injury and comparing 4 different surgical techniques (capsulodesis, tenodesis, bone tissue bone reconstruction, and intentional fibrous nonunion procedure), with MBT included as one of the tenodesis techniques. The combined postoperative outcome across these categories demonstrated a higher mean grip strength than both our MBT and 3LT results (83 vs. 79 and 70%) but a similar ROM (postoperative flexion of 46 degrees and extension of 53 degrees).

In a comparative study of ligament tenodesis and capsulodesis, Daly et al[19] found a significant improvement in the VAS pain score, DASH, and grip strength for the ligament tenodesis technique compared with capsulodesis. They described a 3.4-point improvement on the VAS scale in their ligament tenodesis group, which is consistent with our findings.

We found a higher percentage of patients returning to work in the 3LT group, although the MBT group exhibited better grip strength. These findings suggest that grip strength may not be the sole determining factor in return to work. Previous studies have highlighted that factors such as duration of absence from work and gender may play a more significant role in return-to-work rates than grip force.[20] Armijo-Olivo et al[21] proposed that the DASH score could serve as a predictive indicator for return to work, a notion supported by Daly et al,[19] who reported a postoperative DASH score of 20.2 and a return-to-work rate of 87%. However, due to insufficient data in the reports included in this review, we cannot further elaborate on this finding.

 

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Radiological Results

Radiographic follow-up in the medium term can be contextualized by comparing it to findings from other studies. The systematic review conducted by Montgomery et al[18] described a mean SL gap of 2.7 mm and an SL angle of 57.9 degrees after an average follow-up of 4 years. Interestingly, no differences between the four treatment categories (capsulodesis, tenodesis, bone tissue bone reconstruction, and intentional fibrous nonunion procedure) were found. These results are comparable to our MBT results, which demonstrated an improvement from 62 to 54 degrees for SL angle and 3.6 to 2.5 mm for SL gap. Moreover, these radiographic parameters also align with those reported by Daly et al in their meta-analysis comparing tenodesis and capsulodesis groups, where they found an SL gap of 2.9 mm and an SL angle of 61 degrees, with significant improvement noted for both procedures.[19]

Secondary degeneration was reported in 15% of cases, as noted by nine authors in our review. However, Montgomery et al[18] observed progression to SLAC wrist in only 8.4% of the patient cases over a broad follow-up period from 36 up to 89 months. Interestingly, the ligament tenodesis group in their series exhibited the lowest degeneration rate, with only 3.1% observed at the final follow-up. It is important to note that this group included additional techniques such as dynodesis (dynamic extension assist and volar tenodesis), scapholunotriquetral tenodesis, and tenodesis with fiber wire augmentation,[18] and it is not specified how many studies mentioned any progression to SLAC.

In our review, 70% of degenerative cases required salvage surgery, illustrating that all instances of SLAC are symptomatic.[22] To date, no predictive parameters for the development of postoperative SLAC wrist have been found when looking at preoperative radiographic data.[6] However, successful cases have shown a correlation between immediate postoperative reduction of the SL gap and the correction of the radiolunate and SL angle at final follow-up.[23] Nonetheless, due to limited reported long-term radiological outcomes, the question of whether these tenodesis techniques can truly influence the natural progression of the lesion remains unanswered.

 

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Complications

Our results revealed a spectrum of complications ranging from benign lesions (e.g., tendinitis) to devastating complications necessitating salvage surgery (e.g., scaphoid necrosis). Looking at the results of Montgomery et al,[18] a comparable requirement for salvage surgery was observed in the tenodesis and capsulodesis groups (4 and 5%, respectively), whereas a higher rate was noted for bone–tissue–bone and intentional fibrous nonunion procedures (12% for both). Similarly, Daly et al[19] reported a need for secondary surgery in 6% of tenodesis cases and in 4% of capsulodesis cases, with an average follow-up of 3.2 years. When comparing these findings to our series, a similar need for salvage surgery of 5.6% at the medium-term follow-up was observed.

 

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Strengths and Limitations

We acknowledge several limitations to this review. First, a wide heterogeneity in the surgical techniques was observed, encompassing variations such as the use of K-wires, the method of ligament fixation, and the postoperative rehabilitation protocol. Additionally, the reports included in this systematic review primarily consisted of case studies with limited outcomes. Consequently, the postoperative clinical and functional outcomes exhibited significant heterogeneity, rendering direct comparisons challenging and statistical analysis impossible.

 

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Conclusion

This systematic review presents the outcomes of MBT and 3LT in the treatment of chronic SL ligament injuries. The included reports demonstrated a heterogeneity in technical implementation. Despite the possible variations in technique, MBT and 3LT exhibited comparable reductions in pain and improvements in ROM postsurgery. However, a noteworthy complication rate and instances of secondary osteoarthritis evolution were observed in many cases. Combining these findings, these procedures appear to offer acceptable clinical benefits alongside non-negligible risks of complications.

Yet, the question of whether these procedures genuinely influence the natural progression of the lesion remains unanswered ([Table 9]). The findings in this review reflect current results and are based on the analysis of heterogenous data. Moving forward, high-quality, multicenter trials with standardized follow-up protocols are warranted to accurately assess the true outcomes of these procedures.

Table 9 summary of (dis)advantages of both techniques

	Pros	Cons
MBT	Higher postoperative grip strength	Greater likelihood of complications such as scarring, scar tenderness, and CRPS
	Good postoperative SL angle (53.7–63 degrees) and gap (2.5–3 mm)	More at risk of complications from K-wires or screws, which are more often used in MBT
	Improved postoperative pain and DASH score
3LT	Higher return-to-work percentage	More complex procedure compared with MBT
	Slightly larger flexion–extension arc	High postoperative SL angle (75–80 degrees) and SL gap (3.5–3.7 mm)
	Improved postoperative pain and DASH score	Increased incidence of secondary osteoarthritis (OA)

Abbreviations: DASH, Disabilities of the Arm, Shoulder, and Hand; 3LT, three-ligament tenodesis; MBT, modified Brunelli tenodesis; SL, scapholunate.

 

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Conflict of Interest

None declared.

Authors' Contributions

This literature review and data collection were conducted by E.S., under the guidance of S.G., and N.v.B.S.G. is the first author of the manuscript.

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Publication History

Received: 15 May 2024

Accepted: 09 October 2024

Article published online:
08 November 2024