Arch Hand Microsurg.  2020 Jun;25(2):108-117. 10.12790/ahm.20.0012.

Results of Arthroscopically Assisted Volar and Dorsal Scapholunate Ligament Reconstruction Using Flexor Carpi Radialis: Modified Arthroscopic Corella Technique

• Park YC
• Kim MS
• Lee YK
• Seo CY
• Shin SG

• KMID: 2502706
• DOI: http://doi.org/10.12790/ahm.20.0012

Abstract

Purpose
We evaluated results of arthroscopically assisted volar and dorsal scapholunate(SL) ligament reconstruction using flexor carpi radialis(FCR).
Methods
We reviewed 31 cases who had been operated from August 2015 to June 2018. Two cases were excluded and 4 cases lost contact. Twenty five wrists were included. The average follow-up duration was 25.3months. Diagnostic arthroscopy was performed to evaluate EWAS stage of SL instability and the reparability of SL ligament. The SL reconstruction was performed for the cases which showed EWAS stage IIIC, IV having gap over 3mm and irreparable SL ligament. The interval between the diagnosis and operation was 5.9 days in average. We modified the arthroscopic Corella technique by repairing the graft tendon to FCR.
Results
All SL joints were stabilized to EWAS stage I arthroscopically after reconstruction. DASH score changed from 32.7 to 9.7. Grip power changed from 74.1% to 93.3%. Modified Mayo Wrist score was 83.8. Preoperative SL angle was 53.8。, postoperative 49.6。 and the last was 51.2。. The improvement between preoperative and last follow-up SL angle was statistically significant(p<0.05). The SL angle from operation to last follow-up has increased by 1.67。(39.8%, p<0.01). Twelve cases showed SL gap over 2mm in clenched fist view before operation, but no case at follow-up.
Conclusions
Volar and dorsal SL reconstruction using FCR should provide more stability and strength than only dorsal SL reconstruction. Arthroscopic technique has the merit that it causes minimal damage to extrinsic carpal ligaments and posterior interosseous nerve and can provide rapid recovery.

Keyword

Scapholunate; Reconstruction; Arthroscopic; Corella technique

Figure

• 

  Fig. 1. (A) A half or 1/3 slip of flexor carpi radialis(FCR) is harvested with a thin wire and sutured by whip stitich. (B) The graft tendon is passed to 3-4 portal through the scaphoid tunnel. (C) An 3x8mm interference bio tenodesis screw (Arthrex) is fixated into distal scaphoid. The photo of image intensifier shows the process of screw fixatioin. The photo of image intensifier shows the process of screw fixation. (D) Dorsal lunate is exposed after skin incision is made at lunate under guidance of C-arm. To prevent skin necrosis, subcutaneous tissue dissection should be avoided or transverse skin incision can be used. Image intensifier guided skin incision is helpful. (E) Volar lunate is exposed through volar-central portal [11]. To prevent skin contracture, subcutaneous dissection should be avoided. Image intensifier guided skin incision is recommended.

• 

  Fig. 2. (A) A guidewire is inserted at the center in anteroposterior view to prevent avascular necrosis and fracture. In lateral view, the direction has to be made to correct dorsal intercalated segmental instability deformity and the position should be high enough to avoid the cartilage damage when the bone tunnel is reamed. (B) In left photograph, a suture passer is inserted in the lunate tunnel. In right photograph, the wrist is applied to a traction tower. The suture passer and the graft tendon are shown. (C) Another suture passer is retrieved to the lunate dorsal incision by a tissue grasper. The black arrow is the passer in the lunate. The empty arrow is the passer from 3−4 portal. (D) The graft tendon (asterisk) is passed into the lunate dorsal incision. (E) The graft tendon (asterisk) is passed into the lunate bone tunnel. (F) An interference bio-tenodesis screw is fixated under arthroscope guidance. (G) Midcarpal viewing shows that the scapholunate joint gets stabilized to European Wrist Arthroscopy Society (EWAS) grade 0.

• 

  Fig. 3. (A) The wrist is released from the traction tower. The graft tendon is at the volar-central portal. (B) A hemostat is inserted through intra-capsular route and pulls the graft tendon. (C) The graft tendon is passed to the flexor carpi radialis (FCR) around the scaphoid and tied to the FCR by shoe lace pattern.

• 

  Fig. 4. Arthroscope shows a thin, loose, not-avulsed and irreparable dorsal scapholunate ligament in viewing from midcarpal portal.

• 

  Fig. 5. (A) Scapholunate (SL) gap (arrow) is seen in clenched fist posteroanterior (PA) view. (B) In magnetic resonance imaging (MRI), SL gap and scaphoid subluxation are seen. The left arrow indicates SL gap. The right arrow indicates dorsal subluxation of scaphoid. (C) In the first photo, the cartilage wear of proximal scaphoid is seen. In the second photo, scapholu nate probing in midcarpal viewing shows EWAS stage IV instability. In the last photo, scapholunate probing is improved to European Wrist Arthroscopy Society (EWAS) stage I after reconstruction. (D) Range of motion of flexion and extension. (E) Two years after operation, there is no SL gap in clenched fist PA view. The arrow indicates SL gap improvement. (F) In MRI, there are no SL gap, scaphoid subluxation and subchondral edema except triquetrum fracture after trauma. The left arrow indicates SL gap improvement. The right arrow indicates the reduction of scaphoid.

Reference

1. Stanley JK, Trail IA. Carpal instability. J Bone Joint Surg Br. 1994; 76:691–700.

2. Andersson JK, Garcia-Elias M. Dorsal scapholunate ligament injury: a classification of clinical forms. J Hand Surg Eur Vol. 2013; 38:165–9.

3. Berger RA, Froelich JM. Scapholunate anatomy. In : Shin AY, Day CS, editors. Advances in scapholunate ligament treatment. Chicago: American Society of Surgery of the Hand;2014. p. 14–20.

4. Garcia-Elias M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique. J Hand Surg Am. 2006; 31:125–34.

5. Talwalkar SC, Edwards AT, Hayton MJ, Stilwell JH, Trail IA, Stanley JK. Results of tri-ligament tenodesis: a modified Brunelli procedure in the management of scapholunate instability. J Hand Surg Br. 2006; 31:110–7.

6. Chabas JF, Gay A, Valenti D, Guinard D, Legre R. Results of the modified Brunelli tenodesis for treatment of scapholunate instability: a retrospective study of 19 patients. J Hand Surg Am. 2008; 33:1469–77.

7. Kalb K, Blank S, van Schoonhoven J, Prommersberger KJ. Stabilization of the scaphoid according to Brunelli as modified by Garcia-Elias, Lluch, and Stanley for the treatment of chronic scapholunate dissociation. Oper Orthop Traumatol. 2009; 21:429–41.

8. Nienstedt F. Treatment of static scapholunate instability with modified Brunelli tenodesis: results over 10 years. J Hand Surg Am. 2013; 38:887–92.

9. Sousa M, Aido R, Freitas D, Trigueiros M, Lemos R, Silva C. Scapholunate ligament reconstruction using a flexor carpi radialis tendon graft. J Hand Surg Am. 2014; 39:1512–6.

10. Henry M. Reconstruction of both volar and dorsal limbs of the scapholunate interosseous ligament. J Hand Surg Am. 2013; 38:1625–34.

11. Corella F, Del Cerro M, Ocampos M, Larrainzar-Garijo R. Arthroscopic ligamentoplasty of the dorsal and volar portions of the scapholunate ligament. J Hand Surg Am. 2013; 38:2466–77.

12. Ho PC, Wong CW, Tse WL. Arthroscopic-assisted combined dorsal and volar scapholunate ligament reconstruction with tendon graft for chronic SL instability. J Wrist Surg. 2015; 4:252–63.

13. Berger RA, Imeada T, Berglund L, An KN. Constraint and material properties of the subregions of the scapholunate interosseous ligament. J Hand Surg Am. 1999; 24:953–62.

14. Messina JC, Van Overstraeten L, Luchetti R, Fairplay T, Mathoulin CL. The EWAS classification of scapholunate tears: an anatomical arthroscopic study. J Wrist Surg. 2013; 2:105–9.

15. Wolfe SW. Scapholunate instability. J Hand Surg Am. 2001; 1:45–60.

16. Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996; 78:357–65.

17. Schimmerl-Metz SM, Metz VM, Totterman SM, Mann FA, Gilula LA. Radiologic measurement of the scapholunate joint: implications of biologic variation in scapholunate joint morphology. J Hand Surg Am. 1999; 24:1237–44.

18. Lee YK, Kang HV, Jung YR, Lee JY. Surgical treatment of scapholunate instability. Arch Hand Microsurg. 2018; 23:139–49.

19. O'Meeghan CJ, Stuart W, Mamo V, Stanley JK, Trail IA. The natural history of an untreated isolated scapholunate interosseus ligament injury. J Hand Surg Br. 2003; 28:307–10.

20. Darlis NA, Weiser RW, Sotereanos DG. Partial scapholunate ligament injuries treated with arthroscopic debridement and thermal shrinkage. J Hand Surg Am. 2005; 30:908–14.

21. Darlis NA, Kaufmann RA, Giannoulis F, Sotereanos DG. Arthroscopic debridement and closed pinning for chronic dynamic scapholunate instability. J Hand Surg Am. 2006; 31:418–24.

22. Chee KG, Chin AY, Chew EM, Garcia-Elias M. Antipronation spiral tenodesis: a surgical technique for the treatment of perilunate instability. J Hand Surg Am. 2012; 37:2611–8.

23. Corella F, Del Cerro M, Ocampos M, Simon de Blas C, Larrainzar-Garijo R. Arthroscopic scapholunate ligament reconstruction, volar and dorsal reconstruction. Hand Clin. 2017; 33:687–707.

24. Alonso-Rasgado T, Zhang QH, Jimenez-Cruz D, et al. Evaluation of the performance of three tenodesis techniques for the treatment of scapholunate instability: flexion-extension and radial-ulnar deviation. Med Biol Eng Comput. 2018; 56:1091–105.

25. Andersson JK. Treatment of scapholunate ligament injury: current concepts. EFORT Open Rev. 2017; 2:382–93.

26. Rajan PV, Day CS. Scapholunate ligament insufficiency. J Hand Surg Am. 2015; 40:583–5.

27. Binder AC, Kerfant N, Wahegaonkar AL, Tandara AA, Mathoulin CL. Dorsal wrist capsular tears in association with scapholunate instability: results of an arthroscopic dorsal capsuloplasty. J Wrist Surg. 2013; 2:160–7.