the treatment of chronic scapholunate dissociation: an

The Treatment of Chronic ScapholunateDissociation: An, Eviden~ce-Based Assessmentof the LiteratureHeidi 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 besttreatment for patients with chronicsymptomatic scapholunate dissociationuncomplicated by arthritis. Althoughmost surgeons agree that operativeintervention is indicated, their prefer-ences are divided between soft-tissueand bony procedures. Even withinthese treatment categories, opinionsvary. Because no definitive guidelinesare available for choosing among theseoptions, discussion about the bestcourse of management continues.

At the 55th Annual Meeting of theAmerican Society for Surgery of theHand (ASSH) in October 2000,Perry’s~ presentation focused on thevariations in the management ofscapholunate dissociation. In thisstudy, a questionnaire was sent to allmembers of the ASSH, in which a caseof wrist instability in a 35-year-oldmale laborer 9 months following a fallfrom a ladder was presented. Clinicalexamination revealed dorsal swelling,

From the *Department of OrthopedicSurgery and Rehabilitation, University ofMississippi Medical Center, Jackson, Miss; andthe fUniversity of Calgary, Canada.

Drs Bloom, Freeland, Bowen, and Mrkonjichave not declared any industry relationships.

Reprint requests: Heidi Taylor Bloom, MD,Dept of Orthopedic Surgery and Rehabilitation,University of Mississippi Medical Center, 2500 NState St, Jackson, MS 39216-4505.

tenderness, and a positive Watson shifttest. Radiographs demonstrated scapho-lunate dissociation. The surgeons wereasked how they would treat this patient.Of the 488 respondents, approximatelyall (99%) advocated surgical interven-tion. Forty-five percent opted for a soft-tissue procedure, 36% a bony proce-dure, and 19% preferred to wait beforemaking a clinically dependent choice.This finding, hardly a mandate for asoft-tissue procedure, mirrors the cur-rent state of the literature regardingtreatment.

The current knowledge on scapholu-nate dissociation was investigated. Theanatomy and pathomechanics ofscapholunate dissociation were review-ed and current methods used for clinicalexamination and ima~ging techniqueswere investigated. The literature con-

cerning the various treatment modalitieswas then analyzed. An evidence-basedassessment was conducted to evaluate

the outcomes of different treatmentmethods. The quality of publishedresults was evaluated, and the evidencefor and against a soft-tissue procedurewas compared with the evidence for andagainst a limited wrist fusion.

The hypothesis for this evidence-based assessment was that soft-tissuerepairs of scapholunate dissociationproduce better results than limited wristfusions.

BACKGROUNDAnatomy

The lunate is located in the center ofthe proximal carpal row. The scaphoidlies to its radial side. Proximally, botharticulate with the distal radius: tlie

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ORTHOPEDICS ......... FEBRUARY’2003 VOL 26 NO2

lunate with a spheroidal fossa and thescaphoid with an elliptical fossa.Distally, the lunate articulates with thecapitate, which lies in the center of thedistal carpal row. The scaphoid bridgesthe two carpal rows; its distal polearticulates with the trapezium andtrapezoid.

The scapholunate ligament complexis commonly described as havingintrinsic and extrinsic components.

Intrinsic Portion of the Scapho-lunate Ligament Complex. The scapho-lunate interosseous ligament connectsthe ulnar aspect of the proximal pole ofthe scaphoid to the radial aspect of thelunate. It is a strong ligamentz and hasa key role in preventing carpal collapse.The ligament is composed of three dis-tinct components.3 The thick dorsalregion is made up of short, transverselyoriented collagen fibers, The proximalregion is composed primarily of fibro-cartilage, extending into the cleftbetween the scaphoid and lunate and isanalogous to the knee meniscus. Thethin palmar region consists of oblique-ly oriented collagen fascicles, just dor-sal to the long radiolunate ligament. Anisolated injury to the intrinsic scaphol-unate portion will not result in diasta-sis.4

Kozin5 reported that additionalinjury to the extrinsic ligaments--thevolar radioscaphocapitate, long radio-lunate, and short radiolunate liga-ment-is required to demonstrateradiographic diastasis. Acute injuriesmay be severe enough to cause imme-diate diastasis. Less severe injuries,which are common, may lead to grad-ual extrinsic ligament attrition. Patientswith such injuries do not developscapholunate widening and carpalinstability for weeks or even monthsafter injury.

Extrinsic Portion of the Scapho-lunate Ligament Complex. The radio-scaphocapitate ligament extends fromthe radial styloid through a groove inthe waist of the scaphoid to the palmaraspect of the capitate. It functions as afulcrum around which the scaphoidrotates. The long radiolunate ligament

runs parallel to the radioscaphocapi-tate, extending from the palmar rim ofthe distal part of the radius to the radi-al margin of the palmar horn of thelunate. The space of Poifier is the inter-val located between the radioscapho-capitate and long radiolunate ligamentsat the midcarpal joint. The short radio-lunate ligament is contiguous with pal-mar fibers of the tfiangulofibrocartilagecomplex, originating from the palmarmargin of the distal radius and insertinginto the proximal palmar surface of thelunate. The radioscapholunate ligament(ligament of Testut) is a synoviallyinvested neurovascular pedicle derivedfrom the anterior interosseous and radi-al arteries and anterior interosseousnerve.

Dorsal ligaments also contribute towrist stability. The dorsal radiocarpalligament Originates from the dorsalmargin of the distal :radius and insertsat the lunate, lunotriquetral inter-osseous ligament, and dorsal tubercleof the triquetrum. ~[’he dorsal inter-carpal ligament originates from the tfi-quetrum and extends radially to insertinto the lunate, the dorsal groove of thescaphoid, and the trapezium.

KinematicsWrist motion is commonly described

as having two degrees of freedom: flex-ion and extension in the sagittal planeand ulnar and radial deviation in thefrontal plane. The wrist motors primari-ly attach distally into the bases of themetacarpals.

During flexion ar~d extension, thecarpal rows tend to ar~gulate simultane-ously. Cineradiograms show that theproximal and distal rows angulate equal-ly in flexion and extension.6 Duringradial and ulnar deviation, more motionoccurs between the distal and proximalrows than at the radiocarpal joint. Withradial deviation to 20°, a concomitant25° palmar angulation of the proximalrow also is present. With ulnar devia-tion, 25° of dorsiflexion occurs.

A number of theories have emergedexplaining the complex intercarpalmovements that occur during wrist

motion; the two main theories are thecolumnar theory7 and the ring theory.8

Both were devised prior to cineradiolo-gy and neither fully explains wristkinematics. A combination of these twotheories may provide the best model.9

Because the proximal carpal :rowhas no direct tendon attachments, it canbe thought of as an intercalated seg-ment. Landsmeer~° demonstrated thatintercalated segments fall into a zigzagcollapse pattern with compressive load-ing. Linscheid et al2 noted that thelunate tends to dorsiflex relative to thedistal radius and capitate as thescaphoid is destabilized, thus forming adorsiflexed intercalated segment insta-bility pattern deformity. A capitolunateangle >15° is considered abnormal.The scaphoid flexes to accommodatethe shortened carpal length.

Mechanism of Injury

Wrist instabilities involving thescapholunate joint have been dividedinto dynamic and static categories. Twodistinct types of incomplete ligamen-tous injury may produce a dynamicscapholunate instability pattern: 1) lim-ited volar interosseous and radio-scaphoid ligament failure, and 2)scapholunate interosseous and radio-scaphoid elongation without ligamentfailure. Both injuries result in dynamiccarpal instabilities during wrist motionwithout altering the static bony align-ment at rest.

Mayfield et al~ reported a laborato-ry study in which cadaveric wrists andforearms were used to demonstrateinjury to the scapholunate interval.Frozen cadaveric specimens were usedin simulating a fall on the outstretchedhand causing wrist extension, ulnardeviation, and intercarpal supination.Under these loading conditions, thescapholunate joint was the first carpaljoint to be injured. Ligamentous injurythen progressed around the lunate toproduce sequential instability of thescapholunate, capitolunate, and ~ri-quetrolunate. Four stages of progressiveperilunar instability were described:¯ Stage I: Scapholunate dissociation

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BLOOM ET AL REVIEW

caused by injury to the scapholunateinterosseous and palmar radioscapho-capitate ligaments,

¯ Stage II: Dislocation of the capito-lunate joint through the space ofPoirier.

¯ Stage III: Separation of the tri-quetrum from the lunate with asso-ciated injury to the lunotriquetraland ulnotriquetral ligaments.

¯ Stage IV: Palmar lunate dislocationdue to injury to the dorsal radio-carpal ligament.Variants may occur. Radial styloid~

transscaphoid, transcapitate, and trans-triquetral fractures may be associatedwith perilunate injuries. In these frac-ture dislocation variants, the injury pat-tern is still believed to be a progressionfrom radial to ulnar arc. On the ulnarside of the wrist, the plane of failureinvolves the lunotriquetral ligament,palmar ulnocarpal ligaments, and ulnarstyloid process.

DIAGNOSISAccurate Clinical Evaluation

Wrist injuries with initially normalradiographs are frequently designatedas "sprains." The severity of such a"sprained" wrist may be underestimat-ed and scapholunate ligament injuryunder-diagnosed owing to the normal,initial radiographs. These injuries usu-ally are protected until they becomeasymptomatic, but pain persists insome patients. In such patients, furtherevaluation is necessary to determinewhether partial ligament injuries andinstability are present. This conclusionis documented by a report of a consecu-tive series of 100 cases with a wristinjury (excluding fractures) seen in emergency department, in which 19patients demonstrated an increased gapradiographically on the clenched fistview.12 Of these 19 patients, 5 had sig-nificant scapholunate instability.

A detailed history of the mechanismof injury is important. For instance, ifthe patient fell with the wrist in a pal-mar-flexed position, it is less likely thatan injury to the scaphoid or scapholu-nate ligament has occurred because the

volar scapholunate ligament is not pri-marily loaded. On the other hand, rup-ture of the dorsal radioulnar ligamentmay have occurred if the wrist was in apronated position. A fall on the dorsi-flexed wrist, with localization ofpainful symptoms at the thenar emi-nence, will lead to scapholunate insta-bility.

On physical examination, the exactarea of tenderness must be localized.Palpation of the wrist includes theanatomic snuffbox. Tenderness in thisregion is a classic sign of scaphoidfracture. If scapholunate ligamentinjury is present, tendemess may bepresent in the snuffbox, but tends to begreatest at the proximal end of thesnuffbox under the extensor carpiradialis longus tendon. Occasionally,an associated click or a sensation ofgiving way may be present if firm pres-sure is applied)3

In scapholunate dissociation, a dis-tinct sulcus may sometimes be palpateddorsally between the scaphoid andlunate while slight’Jy flexing andextending the wrist. Watson et al~4

described a maneuver to provoke thescapholunate instability that occurswith wrist loading. This is known as the"Watson shift test," in which the wristis moved from ulnar to radial deviationwith pressure applied to the distal poleof the scaphoid. The test is positive if aclick is produced dorsoradially in thescapholunate joint. Pain or laxity dur-ing this maneuver may be more subtleindications of scapholunate ligamentinjury.

Radiographic and Other DiagnosticStudies

Anteroposterior (AP) and lateralradiographs of the wrist usually are thefirst diagnostic study obtained)~ On theAP wrist radiograph, an interval >3 mmsuggests a scapholunate ligament injury.On the lateral view, the normal scapho-lunate angle (angle of Alexander) is °

(range: 30°-60°). In scapholunate disso-ciation, a dorsal intercalated segmentinstability pattern is seen. This resultsfrom disruption of the scapholunate lig-

ament and the extrinsic volar scapho-lunate ligaments. The vertical lunateaxis extends beyond 15°. The scaphoidrotates palmarly, and the scapholunateangle increases beyond 60°.

In patients with dynamic wrist insta-bility, routine wrist radiographs arenormal. Special radiographic views,such as the clenched fist view, in whichcompression is transmitted across thewrist, demonstrate widening at thescapholunate joint. Scapholunatewidening may also be demonstrated bycineradiography or 6-view motionstudies of the wrist. 2 Widening of thescapholunate interval is accentuatedwith the wrist in ulnar deviation. As thewrist moves into radial deviation, thescaphoid flexes and becomes perpen-dicular to the plane of the radius. The"signet ring sign" is produced when thedistal scaphoid pole is imaged "end-on." Beckenbaugh13 noted that if ascapholunate gap is present in ulnardeviation, it may often close in radialdeviation.

Arthrography can be used to studythe integrity of the carpal ligaments.Midcarpal, radiocarpal, and distalradioulnar arthrography, the so-calledtriple-phase test, may reveal interrnp-tion of the intrinsic intercarpal liga-ments. Contrast material injected intothe midcarpal joint does not normallycross into the radiocarpal joint unlessan intrinsic ligament tear is present.Unfortunately, arthrography is associ-ated with false positive and false nega-tive results, which may render interpre-tation difficult.

Magnetic resonance imaging (MRI)can be used to survey the wrist for liga-ment tears. The images obtained aredetailed, but difficulties in correlatingoccult MRI findings with patient symp-toms and arthroscopic and operativefindings have led to less reliance onthis study.

Wrist arthroscopy has the highestsensitivity and specificity among thespecial studies group in diagnosing thecarpal ligament injuries responsible forcarpal instability. This modality ismore accurate than arthrography or


ORTHOPEDICS FEBRUARY 2003 VOL 26 NO 2

MRI for detecting the site and extent ofligament injuries. 15 The radiocarpaland midcarpal joints may be examinedand the intercarpal joints probed. Incases of scapholunate dissociation, thediagnosis is confirmed if the probe orarthroscope can be passed between themidcarpal and radiocarpal joints.

Treatment

The management of patients withacute scapholunate dissociation variesamong surgeons, but the optionsinclude closed reduction and castimmobilization; cldsed or open reduc-tion and percutaneous Kirschner wirefixation; open reduction; direct repairof the scapholunate ligament and sup-port of the repair with K-wires, capsu-lodesis, or both; and open reductionand replacement of the scapholunateligament with tendon graft, sutureanchors, or some other structuraldevice. It is important to re-establish anormal scapholunate relationship toprevent abnormal wrist kinematics orcollapse that may lead to articular sur-face wear and post-traumatic arthritis.16

The preferred method of treatmentis open reduction of the carpus througha dorsal approach, placement of at leasttwo 0.045-inch K-wires to pin thescaphoid to the lunate and capitate, anddirect repair of the scapholunate liga-ment. Ligament repair is performedwith direct suture for ligaments torn intheir midsubstance or with pulloutsutures or suture anchors for ligamentsavulsed from bone. The reductionshould be protected and supported withcast immobilization for at least 8weeks.

The feasibility of secondary liga-mentous repair (>3 weeks post-injury)depends on identification of a substan-tial, reparable scapholunate inter-osseous ligament and reduction of thepalmarly flexed scaphoid withoutextensive dissection. The extent towhich the scaphoid becomes fixed inpalmar flexion depends on the magni-tude of the initial capsular injury andthe scarfing and capsular contracture,which increase over time. Closed

reduction alone or closed reduction andpercutaneous pin fixation are not uni-formly successful in maintaining carpalalignment and achieving satisfactorylong-term outcomes in wrists withacute scapholunate instability.

Late diagnosis is frequent, owing tothe incipient nature .of the symptoms.Closed treatment has been of littlevalue except in those patients withminimal symptoms. Man.y treatmentshave been proposed :for reconstructionof the symptomatic chronic scapho-lunate injury. Some surgeons advocatetechniques that prevent scaphoid flex-ion during wrist motion by joining thedistal and proximal row by fusion toprevent collapse, while others advocatesoft-tissue reconstruction using intrin-sic or extrinsic tissue:. In 1987, Blatt~7

described a method of surgical stabi-lization of the wrist with a dorsal cap-sulodesis. This technique is an indirectsoft-tissue reconstruction in which aradius-based flap of wrist capsule isinserted into the distal pole of thescaphoid, which prevents the scaphoidfrom collapsing into excessive flexion.

In 1967, Petersen and Lipscomb18

recommended arthrodesis of thescaphoid, trapezium, and trapezoid astreatment for rotatory subluxation ofthe scaphoid. Watson et aP9 empha-sized that the position of the scaphoidin scaphoid, trapezium, and trapezoidarthrodesis must be approximately 45°

from the long axis of the forearm whenviewed laterally. If fused in a more ver-tical position, or in line with the fore-arm, wrist motion may be significantlylimited, owing to ~Ihe incongruousalignment of the scaphoid surface inrelation to the elliptical fossa of theradius. The scaphoid, trapezium, andtrapezoid fusion madintains a neutralscaphoid position between the proxi-mal and distal carpal rows. Scaphoid,trapezium, and trapezoid fusion is con-traindicated in an arthrfic wrist.

Other intercarpal or limited wristfusions have been tried. Scapholunatefusion has been criticized because itproduces an unacceptable limitation inwrist motion.2° High bending moments

also cause high nonunion rates. Scapho-capitate fusion locks the scaphoid intoposition by the immobile articulationbetween the capitate and middle meta-carpal; it also creates a load-bearingcolumn across the fusion site that mayaccelerate wear and subsequently pro-duce arthritic changes in the radio-scaphoid joint.

MATERIALS AND METHODSMedline and Science Citation Index

computer searches of the literaturewere performed using the terms"scapholunate dissociation," "carpalinstability," and "scapholunate liga-ment." All English language citationsbetween 1965 and 2000 were retrievedand reviewed. The references fromeach article were used to gain addition-al citations.

All studies using scapholunate m~.at-

merits with sample sizes of ~>2 wereincluded. The surgical treatmentgroups were divided into soft-tissuerepairs and primary fusions. All soft-tissue reconstructions (eg, dorsal cap-sulodesis and tendon weave) weregrouped under the soft-tissue category,and all limited intercarpal fusions (eg,scaphoid, trapezium, and trapezoid andscapholunate) were grouped in thefusion category. Dynamic and staticinstabilities were included. Studies inwhich a type of intercarpal arthrodesiswas performed for a variety of diag-noses (eg, degenerative joint diseaseand Keinbock’s disease) were reviewed;and, if possible, only those patients withthe diagnosis of scapholunate dissocia-tion were included in the study.Similarly, patients identified as havingperilunate dislocations were excluded.

Only rarely were bilateral proce-dures performed in the same patient.When this occurred, the patient numberwas counted as two.

The most useful and most frequentlylisted data groups were analyzed:patient number; duration of symptomsprior to surgery; length of follow-up;percentage of postoperative flexion-extension arc compared to the nonin-volved side; percentage of grip strength


BLOOM ET AL REVIEW

compared to the noninvolved side; pres-ence or absence of painful symptoms;and complications. Additional datagroups, which were inconsistentlydescribed by investigators, were notanalyzed but included data such asmillimeters of scapholunate diastasis;range of motion in ulnar and radialdeviation; patient satisfaction; return tousual, preinjury activities or return towork status; and radiographic evidenceof reduction, arthrosis, and bony union.Complications were described ratherthan reported as a rate. When onlyabsolute range of motion data were pro-vided, a 150° flexion-extension arc wasused as the normal value for the unin-volved side.t°

RESULTSThe 212 Medline and Scientific

Citation Index references yielded 91articles pertinent to the treatment ofscapholunate dissociation. Of these, 35studies included patient data. A total of27 studies between 1978 and 2000 metcriteria for inclusion in the scapholu-nate dissociation treatment groups. Allinvestigations were noncontrolled,nonrandomized case series. Seventeenstudies involved soft-tissue scapholu-nate reconstructions (n=386 patients)and 10 studies reported limited inter-carpal fusions (n=126 patients). Tables1 and 2 detail the studies and collecteddata from the soft-tissue reconstructionand arthrodesis groups, respectively.

DISCUSSIONA recent surge of interest in the wrist

has been noted. Knowledge about thejoint, both its normal function andinjury patterns, has increased exponen-tially. Wrist anatomy is now well under-stood, and current kinematic theoriesare believed to be reasonably accurate.Wrist ligament injures have been alarge focus of research; impressivequantities of data have accumulatedover the past three decades. Improvedclinical evaluation and imaging tech-niques have facilitated diagnosis.

New management techniques haveevolved in response to increased under-

standing of wrist trauma. Operativerepairs are more logical, and most aredesigned to merge the new knowledgeon wrist injures with basic orthopedicprinciples, Nevertheless, despite a vastamount of surgical experience and anumber of reports in the literature, noconsensus exists on the best operationfor a chronic scapholunate dissocia-tion. The surgeon is still faced withmany choices. The purpose of thisstudy was to try to narrow the choiceand, specifically, to determine whetherone avenue of management (soft-tissueprocedures) was superior to the other(limited wrist fusions) for chronicscapholunate dissociation.

The management of patients withscapholunate dissociation varies accord-ing to how soon the patient presentsafter injury. If the dialNosis is made inthe acute injury stage, the options fortreatment include:¯ closed reduction and cast immobi-

lization,¯ closed reduction and percutaneous

K-wire fixation,¯ open reduction with direct repair of

the scapholunate ligament, and¯ open reduction and repair of the

scapholunate ligan~ent with tendongraft, anchor sutures, or some otherstructural device.It is important to correct concurrent

scapholunate deforrnity. Otherwise,alterations of wrist kinematics andabnormal articular stuface loading canultimately cause scapholunate advancedcollapse and post-traumatic arthritis.16

The primary challenge with acutescapholunate ligament injuries is mak-ing an early diagnosis. Most patientswho present with chronic radial-sidedwrist pain report a history of mild wristinjury. In many cases, patients do notseek medical attentiort. Other patients,seen in emergency rooms or doctors’offices and diagnosed as having a mildwrist sprain, are treated with reassur-ance or short-term splinting and earlymovement. The proportion of thesemild wrist sprains progressing todynamic scapholunal:e instability isunknown. Similarly, it is not known

whether dynamic scapholunate insta-bility progresses to static scapholunateinstability with radiographic seParationof the scapholunate joint; and eventual-ly, such patients then develop scapho-lunate advanced collapse (SLAC) wristpattern degenerative arthritis. It is gen-erally thought, that progressionoccurs--at least in the more sew~recases--but that it takes a long time(often 15-25 years) for SLAC wrist pat-tem degenerative arthritis to becomesevere enough to need surgical man-agement. A long interval between theonset of pain is associated withscapholunate dissociation and the indi-cations for salvage surgery for post-traumatic SLAC wrist pattern arthritis.

Limited wrist fusion, total wristarthrodesis, and proximal row carpec-tomy are used in the management ofSLAC wrist arthritis. The results ofthese procedures are well established,reasonably predictable, and usually sat-isfactory. Each procedure, however,leaves the patient with some residualwrist impairment, usually in the formof loss of motion, strength, power, andendurance. Therefore, the goal is toidentify patients with scapholunateinstability early and offer a reliableoperative procedure, which ideallywould restore function and alleviatepain.

The most commonly recommendedsurgical procedures for scapholunatedissociation in the absense of arthritisare the Blatt capsulodesis, scaphoidtenodesis, tendon reconstruction of thescapholunate ligament, and scaphoid,trapezium, trapezoid fusion. Other pro-cedures, including arthroscopic jointdebridement, autogenous bone-retinac-ulum-bone ligament reconstruction, andscapholunate or scaphocapitate fusion,are less commonly performed (Tables and 2).

Reports on the surgical treatment ofscapholunate dissociation have variedfrom those that describe the technicalaspects of an operation to others thatreport the results of multiple patientstreated using a single method. It is dif-ficult to identify the best method


ORTHOPEDICS,, FEBRUARY 2003 VOL 26 NO 2

TABLE 1

Treatment of Scapholunate Dissociation With Soft-Tissue Repair/Reconstruction

Study

Time to Range of Grip No. PatientsType of No. Surgery Follow-Up Motion Strength With Painful

Reconstruction Patients (mos)* (mos)* (%)* (%)* Symptoms ComplicationsBlatt17 Dorsal radioscaphoid 12 83.3 80

capsulodesisPalmer et a121 ECRL/B tenodesis 30 >1 45.6 72.5 76.4 4%through scaphoidGlickel & ECRB or other wrist 21 13.2 25.4 72.3 71.1 19Millender22 extensor tenodesis

dorsal & palmarConyers23 Palmar reconstruction 28 2.4 19.2 76 82 6

with K-wiresAlmquist et a124 ECRB tenodesis through 36 4 57.6 74.2 73 23radius, lunate, capitate,

scaphoidLavernia et al2s Dorsal radioscaphoid 21 1 7 33 75.3 106 2capsulodesisWintman et a126 Dorsal radioscaphoid 19 17 31 90 87 2capsulodesisUhl et a127 Dorsal radioscaphoid 35 24 56 85

capsulodesis,scapholunate repair,suture anchors

Van Den Abbeele FCR tenodesis scaphoid 22 9 61 58 5et a128 to lunateWeiss29 Bone-retinaculum-bone 19 43.2 88.8 38t 3

Wyrick et al3° Capsutodesis, 17 3 30 60 70 Allscapholunate repair

Deshmukh et a131 Dorsal radioscaphoid 44 58 22 59.5 65.1 23capsulodesis

Saffar et a132 Scapholunate repair, 37 7.2 27 79.2 78tenodesis, capsulodesis

Bickert et al~3 Scapholunate repair with 12 1.3 18 78 81mini-anchor sutures

Brunelli et al~4 FCR tenodesis distal 13 (6-24) 30o-60° 65 2scaphoid into dorsalradius

Cuenod3s Bone-ligament-bone 3 8 11.6 75.5 94.6with capsulodesis

Muermans et a136 Dorsal radioscaphoid 17 23.8 30 63.4 19.4/30.6§ 4capsulodesis

Total 386 17.6 31 ..6 71.4 76.7

83%:I:

Infection (n=l)

Lac. dorsal sensory br.radial nerve (n=l);R/O infection (n=l)

None

None

Forearm cellulites (n=l);EPL subluxation (n=l)

Pin tract infection (n=2);wrist sepsis (n=l)

RSD (n=2)

Neuropraxia dorsalsensory br. radial nerve(n=5); skin breakdown(n=l)

Pin tract infection (n=l)

Regional pain syndrome(n=3); pin-site infection(n=2)

Avascular necrosis oflunate (n=l)

None

Infection (n=l); RSD(n=2)

Abbreviations: ECRB=extensor carpi radialis brevis, ECRL=extensor carpi radialis longus, EPL=extensor pollicis longus, FCR=flexor carpiradialis, R/O=rule out, and RSD=reflex-sympathetic dystrophy.*Average.tlrnproved in 38%.~;Decrease.

§Pounds preoperatively~pounds postoperatively.

because no report describes valid com-parative results between different

methods. In fact, no report documentsthe efficacy of surgical management.

This investigation was undertakenbecause we believed that an under-standing of the pros and cons of the twoprocedures and a detailed knowledge of

their outcomes were important but

poorly understood clinical issues.Insufficient evidence was available forproper and satisfactory evaluation ofthe procedures.

Our initial plan was to collect datafrom multiple reported studies, pool thedata, and perform a meta-analysis.

Dickerson and Berlin 46 defined meta-analysis as "the statistical analysis of alarge collection of analysis results forthe purpose of integrating the find-ings." Our study found that the litera-ture on scapholunate dissociation was

not sufficiently homogeneous for meta-analysis, thus the evidence-based

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TABLE 2

Treatment of Scapholunate Dissociation With Limited Intercarpal Arthrodesis

Time to Range of Grip No. PatientsType of No. Surgery Follow-Up Motion Strength With Painful

Study Arthrodesis Patients(mos)* (mos)* (%)* (%)* Symptoms Complications

Watson et a119 Triscaphe 30 29 47 79.5 92 0 Transient RSD (n=3)Hastings & Scapholunate 3 25.3 57.6 80.7 99 0 NoneSilver3z

Eckenrode38 9 18 19 62.5 74 3Kieinman39 41 14.7 56 65 2

TriscapheTriscaphe

Hom & Ruby4° Scapholunate 7 48.7 71.9 88 4

Watson & Triscaphe 4 6.7 20.25 80 0Hempton41

Watson et a142 Triscaphe I 9 60Kleinman et a143 Triscaphe 12 17 >24 60 20t IRotman et a144 Scaphocapitolunate16 9.6 25 43.7 68.1 Ibs 6Uematsu4s Scaphoid-lunate- 3 10.3 22.6 38.8 30.6 kg 0

capitate-triquetrumTotal 126 17.9 43.2. 65.7 88.5

Pyarthrosis, osteomyelitis(n--2); avascularnecrosis of the lunate(n=l)

Neuropraxia dorsalsensory br. radial nerve(n=l); neuroma (n=l)

None

NoneDeep infection (n=2)

Abbreviations: ECRB=extensor carpi radialis brevis, ECRL=extensor carpi n~dialis longus, EPL=extensor pollicis longus, FCR=flexor carpiradialis, and RSD=reflex symapthetic dystrophy.*Average.~flmproved.

assessment was used. Evidence-basedassessment is an epidemiologicalmethod that has been developed foranalyzing the ~trength of objectivedata, subjective results, and other infor-mation obtained from the literature.

The results of this study showed thatthe literature on the surgical manage-ment of scapholunate dissociation isnot strong from the epidemiologicalpoint of view. Of the 212 reportsobtained from the literature search,only 27 fulfilled the entry criteria forthis study. All of the other reports con-cerned different aspects of scapholu-nate dissociation, such as its diagnosisor treatments that were described butno patient data were provided. All 27reports concerned with soft-tissue pro-cedures or limited wrist fusion proce-dures were case-series studies.

It is impossible to draw hard conclu-sions from a heterogeneous set of case-series studies. It is always possible thatconclusions are inaccurate becauseresults may be a matter of chancealone. At best, an evidence-basedassessment of this type of literature

may allow the reviewer to see trends.It was useful to divide the surgical

management of scapholunate dissocia-tion into two broacl general cate-gories-soft-tissue procedures andbony fusions. Soft-tissue reconstruc-tions are attractive because, theoretical-ly, they most accurately restore normalanatomy: ligament reconstruction for aligamentous injury. The surgeon shouldrecognize that the viscoelasticity oftendons is less than that of the liga-ments they replace. Skeletal proce-dures, on the other hand, have are morepredictable and more permanent. Forvarious reasons, it appears that neitherstrategy is ideal. Each has its ownstrengths and weakne~;ses.

The literature suggests that surgicalmanagement tends to !improve patients’symptoms. This is best illustrated in theseries of Wintman et ~:1.26 None of theirpatients reached a satisfactory outcomewith the nonoperative treatmentdescribed. These aut]hors emphasizedthat the patients’ subjective pain ratingsand subjective functional outcomesimproved following surgery. In the

majority of patients in this series, painfrequency was reduced from "painthroughout the day" preoperatively to"slightly greater than once a month" atthe time of review. Subjective function-al status also was markedly improved,such as brushing teeth, brushing hair,opening car doors, sweeping, shovel-ing, throwing, and using a screwdriver.Interestingly, subjective improvementswere more dramatic than changes inthe objective data, such as range ofmotion and~strength.

The literature also documents anumber of other important points,which have been gleaned from surgicalexperience. In children, wrist ligamentinjuries generally are believed to beless common than skeletal injuries.Zimmerman and Weiland47 noted thatepiphyseal injuries about the wrist aremore frequently recognized than isolat-ed ligamentous injuries. They recom-mend soft-tissue procedures rather thanintercarpal arthrodesis for the skeletal-ly immature wrist to minimize the pos-siblity of premature growth arrest.

One problem with soft-tissue recon-


ORTHOPEDICS~

FEBRUARY 2003 VOL 26 NC)

stmction is its lack of durability. Saffaret a132 abandoned the use of tendongrafts for scapholunate ligament repairbecause they believed the procedureprovided unacceptable results in termsof motion, grip strength, and radio-graphic findings. When the scapholu-nate gap was >4 mm or when thescaphoid was not reducible, they pre-fenced limited carpal arthrodesis.Glickel and Millender22 noted that theradiographic appearance of thescapholunate gap and scapholunateangle did not appear to improve signif-icantly after soft-tissue reconstruction.He postulated that repairs stretched outover time, and neither tendon grafts orligamentous sutures could withstandthe forces generated across the carpusin normal activity.

Proponents of skeletal procedureshave argued that they are more pre-dictable and permanent. Opponents ofarthrodesis base their arguments princi-pally on the associated long-term alter-ations in carpal kinematics that theysuspect will occur. It is assumed thataltered kinematics will produce abnor-mal loading and lead to post-traumaticarthritis, however, no objective evi-dence for this exists. It is nevertheless agenerally accepted orthopedic princi-ple, and untreated carpal disruptions,which lead to dorsal intercalated seg-ment instability, have been shown todeteriorate to a SLAC wrist pattemp0st-traumatic arthritis.16

Kleinman and Carroll48 warn that, intheir experience, patients with subtlepreoperative radiographic degenerativechanges within the radiocarpal or inter-carpal joints are not candidates for alimited scaphoid, trapezium, and trape-zoid arthodesis.

Augsburger et a149 studied radio-carpal loading characteristics afterscaphoid, trapezium, and trapezoidfusion in a laboratory setting. Theyused pressure sensitive film to measureradiocarpal contact characteristics afterdifferent surgical simulations in cadav-eric wrists. They observed that thescaphoid, trapezium, and trapezoidfusion unloads the lunate by creating a

rigid column from the metacarpals.Their study also demonstrated that thetendon-weave procedure producedcontact pressure similar to that of theintact wrist. The weakness in theirstudy was that ligamentous stretchingor the effect of scar formation could notbe taken into consideration.

The good results of soft-tissuereconstructions and skeletal proce-dures must be balanced against thepresence of associated complications.Complications are variably reported inthe literature; no standard definitionexists as to what constitutes a compli-cation. Complication rates vary con-siderably, indicating great heterogene-ity between studies. Described compli-cations include reflex sympathetic dys-trophy, skeletal nouunion, varioustypes of mechanical pain, and infec-tions that were mostly superficial(involving pin tracts). In some reports,it was difficult to differentiate compli-cations from "less than satisfactory"results.

Kleinman and Cm~:ol148 reported a52% complication rate in 47 consecu-tive scaphoid, trapezium, and trapezoidfusions for chronic.’ and dynamicscapholunate instability over 10 years.They pointed out that it is important topay close attention to technical details.For instance, failure to close thescapholunate diastasis or imperfectscaphoid realignment results in pro-gressive radiocarpal degeneration. Theyrecommended 3 months of immobiliza-tion to minimize risk c,f nonunion. Theyalso noted that K-wires used for skele-tal fixation should be buried beneath theskin. They believed this reduced the riskof pin tract infection and the potentialcomplication of carpal, osteomyelitis.

Scapholunate fusions have beenassociated with nonunion rates as highas 47%.50 The relatively high nonunionrate is attributed to the fact that only asmall contact area exists between thetwo bones and also to the predicted highmechanical forces in the region. Homand Ruby4° urged, however, that sur-geons carefully review the results ofscapholunate fusion. They noted that

failure to achieve radiographic fusiondid not necessarily correlate with pooroutcome. The clinical results in somepatients with failed scapholunate fusionwere still good, suggesting that a fibrousunion may afford adequate stability.

CONCLUSIONThis evidence-based assessment of

the literature on scapholunate dissocia-tion was used to test the hypothesis thatsoft-tissue repairs of scapholunate dis-sociation produce better results thanlimited wrist fusions. Results demon-strated that the literature is too hetero-geneous and individual reports are :notepidemiologically strong enough tosupport or refute the hypothesis. Theliterature reflected a great deal of surgi-cal experience and also demonstratedtrends, which can be useful guides togood management decisions.

It is, therefore, still not possible toobjectively recommend one surgicalapproach over another. Each describedtechnique has strengths and weakness-es. Few differences are noted betweenthe results of soft-tissue reconstruc-tions and skeletal reconstructions, how-ever, no comparisons between the twoexist. Both interventions are logical.The results obtained from the individ-ual operations were predictable. Insome circumstances, one method rnaybe chosen over another, eg, in children.Some surgeons prefer to perform soft-tissue reconstruction first because thiscan be converted to fusion if it is unsat-isfactory.

Our basic understanding of wristanatomy, kinematics, mechanism ofinjury, natural history, and diagnosis ofwrist ligament injuries exceeds ourability to select the best treatmentchoice. The choice of operation is stilllargely determined by the experienceand bias of the individual surgeon.Randomized, controlled, multicenter,clinical trials comparing different man-agement strategies for patients withscapholunate dissociation are needed.

REFERENCES1. Perry BH. A current perspective into the


BLOOM ET AL

surgical management of chronic scapholunateinstability: results of a survey study. Presented at:the 55th Annual Meeting of the American Societyfor Surgery of the Hand; October 5-7, 2000;Seattle, Wash.

2. Linscheid RL, Dobyns JH, Beabout .JW,Bryan RS. Traumatic instability of the wrist.Diagnosis, classification, and pathomechanics. JBone Joint Surg Am. 1972; 54:1612-1632.

3. Berger RA. The gross and histologicanatomy of the scapholunate interosseous liga-ment. J Hand Surg Am. 1996; 21:170-178.

4. Berger RA, Blair WF, Crowninshield RD,Flatt AE. The scapholunate ligament. J HandSurg Am. 1982; 7:87-91.

5. Kozin SH. The role of arthroscopy inscapholunate instability. Hand Clin. 1999; 15:435-444.

6. Sarrafian SK, Melamed JL, GoshgadanGM. Study of wrist motion in flexion and exten-sion. Clin Orthop. 1977; 126:153-159.

7. Navarro A. Anatomy and physiology ofthe carpus. Anales del lnstituto de ClinicaQuirurgica y Cirugia Experimental (Montevideo,Uraguay). 1935; 1:166-189.

8. Lichtman DM, Schneider JR, SwaffordAR, Mack GR. Ulnar midcarpal instability--clinical and laboratory analysis. J Hand Surg Am.1981; 6:515-523.

9. Craigen MA, Stanley JK. Wrist kinemat-ics. Row, column or both? J Hand Surg Br. 1995;20:165-170.

10. Landsmeer JM. Studies in the anatomy ofarticulation, I: the equilibrium of the "intercalat-ed" bone. Acta Morphol Neerl Scand. 1961;3:287-303.

I 1. Mayfield JK, Johnson RP, Kilcoyne RK.Carpal dislocations: pathomechanics and pro-gressive peritunar instability. J Hand Surg Am.1980; 5:226-241.

12. Jones WA. Beware of the sprained wrist.The incidence and diagnosis of scapholunate insta-bility. J Bone Joint Surg Br. 1988; 70:293-297.

13. Beckenbaugh RD. Accurate evaluationand management of the painful wrist followinginjury. An approach to carpal instability~ OrthopClin North Am. 1984; 15:289-306.

14. Watson HK, Ashmead D IV, MakhloufMV. Examination of the scaphoid. J Hand SurgAm. 1988; 13:657-660.

15. Schadel-Hopfner M, Iwinska-Zelder J,Braus T, Bohringer G, Klose KJ, Gotzen L. MRIversus arthroscopy in the diagnosis of scapholu-nate ligament injui2¢. J Hand Surg Br. 2001; 26:17-21.

16. Watson HK, Ballet FL. The SLAC wrist:scapholunate advanced collapse pattern of degen-erative arthritis. JHandSurgAm. 1984; 9:358-365.

17. Blatt G. Capsulodesis in reconstructivehand surgery. Dorsal capsulodesis for the unstablescapboid and volar capsutodesis following exci-sion of the distal ulna. Hand Clin. 1987; 3:81-102.

18. Peterson HA, Lipscomb PR. Intercarpalarthrodesis. Arch Surg. 1967; 95:127-134.

19. Watson HK, Ryu J, Akelman E. Limitedtriscaphoid intercarpal arthrodesis for rotatorysubluxation of the scaphoid. J Bone Joint SurgAm. 1986; 68:345-349.

20. Watson HI(, Belniak R, Garcia-Elias M.Treatment of scapholunate dissociation: pre-ferred 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 thewrist secondary to ligament rupture. J Hand SurgAm. 1978; 3:507-532.

22. Glickel SZ, Millencler LH. Ligamentousreconstruction for chronic intercarpal instability.J Hand Surg Am. 1984; 9:.’;14-527.

23. Conyers DJ. Scapholunate interosseousreconstruction and imbrication of palmar liga-ments. J Hand Surg Am. 1990; 15:690-700.

24. Almquist EE, Bach AW, Sack Jr, FuhsSE, Newman DM. Four-bone ligament recon-struction for treatment of chronic completescapholunate separation. J Hand Surg Am. 1991 ;16:322-327.

25. Lavernia C J, Cohen MS, Taleisnik J.Treatment of scapholunate dissociation by liga-mentous repair and capsulodesis. J Hand SurgAm. 1992; 17:354-359.

26. Wintman BI, Gelberman RH, Katz JN.Dynamic scapholunate instability: results ofoperative treatment with dorsal capsulodesis. JHand Surg Am. 1995; 20:971-979.

27. Uhl RL, Williamson SC, Bowman MW,Sotereanos DG, Osterman AL. Dorsal capsutode-sis using suture anchors. Am J Orthop. 1997;26:547-548.

28. Van Den Abbeele I(L, Loh YC, StanleyJK, Trail IA. Early results of a modified Brunelliprocedure for scapholunate instability. J HandSurg Br. 1998; 23:258-261.

29. Weiss AP. Scapholunate ligament recon-struction using a bone-re:tinaculum-bone auto-graft. JHandSurgAm. 1998; 23:205-215.

30. Wyrick JD, Stern PJ, Kiefhaber TR.Motion-preserving procedures in the treatment ofscapholunate advanced collapse wrist: proximalrow carpectomy versus four-comer atthrodesis. JHand Surg Am. 1995; 20:9.65-970.

31. Deshmukh SC, Givissis P, Belloso D,Stanley JK, Trail IA. Blatt’s capsulodesis forchronic scapholunate dissociation. J Hand SurgBr. 1999; 24:215-220.

32. Saffar P, Sokolow C,, Duclos L. Soft tissuestabilization in the management of chronic scapho-lunate instability without osteoarthritis. A 15-yearseries. Acta Orthop Belg. 1999; 65:424-433.

33. Bickert B, Sauerbiier M, Germann G.Scapholunate ligament repair using the Mitekbone anchor. J Hand Surg i~r. 2000; 25:188-192.

34. Brunelli GA, Brunelli GR. A new tech-nique to correct carpal ins~:ability with scaphoid

REVIEW

rotary subluxation: a preliminary report. J HandSurg Am. 1995; 20:$82-$85.

35. Cuenod P. Osteoligamentoplasty and lim-ited dorsal capsulodesis for chronic scapholunatedissociation. Ann Chir Main Memb Super. 1999;18:38-53.

36. Muermans S, De Smet L, Van RansbeeckH. Blatt dorsal capsulodesis for scapholunateinstability. Acta Orthop Belg. 1999; 65:434-439.

37. Hastings DE, Silver RL. Intercarpalarthrodesis in the management of chronic carpalinstability after trauma. J Hand Surg Am. 1984;9:834-840.

38. Eckenrode JF, Louis DS, Greene TL.Scaphoid-trapezium-trapezoid fusion in the treat-merit of chronic scapholunate instability. J HandSurg Am. 1986; 11:497-502.

39. Kleinman WB. Long-term study of chron-ic scapho-lunate instability treated by scapho-trapezio-trapezoid arthrodesis. J Hand Surg Am.1989; 14:429-445.

40. Horn S, Ruby LK. Attempted scapholu-hate arthrodesis for chronic seapholunate dissoci-ation. JHand SurgAm. 1991; 16:334-339.

41. Watson HK, Hempton RF. Limited wristarthrodeses, I: the triscaphoid joint. J Hand SurgAm. 1980; 5:320-327.

42. Watson HK, Goodman ML, Johnson TR.Limited wrist arthrodesis, II: intercarpal andradiocarpal combinations. J Hand Surg Am.1981; 6:223-233.

43. Kleinman WB, Steichen JB, StdckIandJW. Management of chronic rotary subluxationof the scaphoid by scapho-trapezio-trapezoidarthrodesis. J Hand Surg Am. 1982; 7:125-136.

44. Rotman MB, Manske PR, Pruitt DL,Szerzinski J. Scaphocapitolunate arthrodesis. JHand Surg Am. 1993; 18:26-33.

45. Uematsu A. Intercarpal fusion for treat-merit 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. Scapho-lunate dissociation in the skeletally immaturecarpus. J Hand Surg Am. 1990; 15:701-705.

48. Kleinman Vv’B, Carroll C IV. Scapho-tmpezio-trapezoid arthrodesis for treatment ofchronic static and dynamic scapho-lunate insta-bility: a 10-year perspective on pitfalls and com-plications. JHand SurgAm. 1990; 15:408-414.

49. Augsburger S, Necking L, Horton J, BachAW, Tencer AF. A comparison of scaphoid-trapezium-trapezoid fusion and four-bone tendonweave for scapholunate dissociation. J HandSurg Am. 1992; 17:360-369. ~

50. Larsen CF, Jacoby RA, McCabe SJ.Nonunion rates of limited carpal arthrodesis: ameta-analysis of the literature. J Hand Surg Am.1997; 22:66-73.

wvvw.orthobluejournal.com 203

ORTHOPEDICS FEBRUARY 2003 VOL 26 NO 2

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204

The Treatment of Chronic ScapholunateDissociation: An Evidence-Based

Assessment of the Literature

1. The thickest, strongest portion of the scapho-lunate interosseous ligament is located:

A. Distally.B. Proximally.C. Palmarly.D. Dorsally.

2. A dorsal intercalated segment instability pat-tern seen on wrist radiographs indicates disrup-tion of the scapholunate interosseous ligamentarid 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 scaphoidflexes is the:

A. Short radiolunate.B. Long radiolunate.C. Dorsal intercarpat.D. Radioscaphocapitate.

4. The range of a normal scapholunate angle is:A, 10°-40°.

B. 200-50°.

C. 300-60°.D. 40o-70°.

5. An abnormal scapholunate interval as seen onan anteroposterior wrist radiograph is:

A. >2 ram.B. >3 mm.C. >4 ram.D. >5 ram.

6. Which of the following most accuratelydescribes the Watson shift test used in the clinicalexamination for scapholunate dissociation?

A. A click is perceived as the wrist is passivelyflexed and extended.

B. A click is perceived as the wrist is passivelymoved from radial to ulnar deviation with theexaminer placing pressure at the proximal poleof the scaphoid.

C. A click is perceived as the wrist is passivelymoved from ulnar to radial deviation with theexaminer placing pressure at the distal pole ofthe scaphoid.

D. A click is perceived when the wrist is passivelybrought from a supinated position into a pronat-ed position and the examiner places pressure atthe volar aspect of the lunate.

ORTHOPEDICS

R E G S "- R A "" O N F O R M

7. Which modality has the highest sensitivity andspecificity in diagnosing carpal injuries that leadto intercarpal instability?

ABC. Triple-phase wrist arthrogram.D, :Wrist cineradiology.

8. The greatest complication associated withscapholunate arthrodesis is:

A. Infection.B. Advanced degenerative changes.C. Pain.D. Nonunion.

9. Transfixing Kirschner wires through thescapholunate joint may most likely cause inadver-tent injury to the:

A. Ulnar artery.B. Median nerve.C. Dorsal sensory branch radial nerve.D. Dorsal sensory branch ulnar nerve,

10. In performing a triscaphe arthrodesis, what isthe optimal position of the scaphoid with respectto the long axis of the forearm viewed laterally?

A. 30°.

B. 45°.

C. 60°.

D. 90°.

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