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Avascular Necrosis of the Scaphoid After Three-Ligament Tenodesis for Scapholunate Dissociation: Case Report
SCIENTIFIC ARTICLE
Avascular Necrosis of the Scaphoid After ThreeLigament Tenodesis for Scapholunate Dissociation: Case Report Luc De Smet, MD, PhD, Raf Sciot, MD, PhD, Ilse Degreef, MD, PhD An unusual complication after tenodesis for scapholunate instability (Brunelli’s technique) is described. More than 1 year after the procedure, a fracture of the scaphoid with collapse was observed. Further examination concluded there was avascular necrosis of the scaphoid. The patient was treated with a proximal row carpectomy. (J Hand Surg 2011;36A:587–590. Copyright © 2011 by the American Society for Surgery of the Hand. All rights reserved.) Key words Avascular necrosis, complication, scaphoid, scapholunate ligament, wrist.
been proposed to treat scapholunate ligament injuries in the chronic stage, from soft tissue repair and reconstruction to partial arthrodesis and even salvage procedures such as proximal row carpectomy and wrist arthrodesis. In the 1970s and 1980s, most surgical techniques focused on closing the scapholunate gap. In 1995, Brunelli and son1,2 reported a tenodesis technique with the flexor carpi radialis (FCR). In the original description, a strip of the FCR was brought dorsally through the scaphoid and fixed to the radius. In 1998, the Wrightington group3 and Garcia Elias et al4 reported modifications, by fixing the tendon strip dorsally into the lunate. In general, good results were obtained in these and other series.5–7 Complications were few. We report an unusual complication, avascular necrosis (AVN) of the scaphoid after this procedure. A case of AVN of the scaphoid was reported after a Blatt capsulodesis.8
S
EVERAL PROCEDURES HAVE
From the University Hospitals, Leuven, Belgium. Received for publication July 29, 2010; accepted in revised form November 23, 2010. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Luc De Smet, MD, PhD, University Hospital, Department of Orthopedic Surgery, U.Z. Pellenberg, Weligerveld, 1, B-3212 Lubbeek (Pellenberg) Belgium; e-mail: [email protected]. 0363-5023/11/36A04-0003$36.00/0 doi:10.1016/j.jhsa.2010.11.043
CASE REPORT A 28-year-old, right-handed man was seen for wrist pain. He had a fall on the outstretched hand 22 weeks previously. The pain was localized on the radial border. Function was good. Watson’s shift test was positive. The plain radiographs demonstrated a wide scapholunate gap (5.5 mm) and an increased scapholunate angle (72°) (Fig. 1). The diagnosis of subacute scapholunate dissociation was made, and because the patient requested a stable wrist for his sports (badminton), a 3-ligament tenodesis, according to the Garcia Elias et al4 technique, was planned and performed. A longitudinal incision of the skin of 7 cm was made. The extensor retinaculum was divided over the third compartment, and the extensor pollicis longus was retracted radially. The fourth and fifth compartments were detached from the radius without opening them and were retracted ulnarly. A Berger ligament-sparing capsulotomy9 was performed. The cartilage of the carpals and radius seemed macroscopically healthy. The scaphoid could be reduced easily with manual pressure on the proximal pole, without the need for further dissection. A 3.2-mm drill hole was made in the scaphoid from the waist of the scaphoid, aiming to the distal pole volarly. A palmar Russe approach was made through the bed of the FCR. The hole was retrieved. A distally based radial strip— 8 cm long— of the FCR was harvested. The FCR strip was brought through the tunnel in the scaphoid from volar to dorsal, over the dorsal aspect of the lunate, through a split in the dorsal radiotriquetral
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 587
588
AVASCULAR NECROSIS OF THE SCAPHOID AFTER THREE-LIGAMENT TENODESIS FOR SCAPHOLUNATE DISSOCIATION
FIGURE 2: Schematic presentation of the procedure.
FIGURE 1: Preoperative radiographs with the usual findings of a static scapholunate dissociation.
ligament, and turned back. A bony anchor in the dorsal side of the scaphoid and one in the dorsal side of the lunate were used to fix this tendon strip (Fig. 2). The scaphoid was reduced, the sutures were tightened, and a 1.2-mm K-wire was drilled in the distal third of the scaphoid toward the capitate. Intraoperative radiographs confirmed the reduction and the correct position of the K-wire and bone anchors. A short-arm cast was applied. Six weeks after surgery, the cast and K-wire were removed. The patient was instructed to mobilize the wrist for 2 weeks, after which a more intensive mobilization with a physical therapist was done for 8 weeks. The 6 weeks postoperative radiograph (just before K-wire removal) demonstrated a closure of the gap (Fig. 3). The patient could resume his professional activities and his sports at 4.5 months after surgery. At that moment, the range of motion reached an extension of 70°, a flexion of 40°, a radial deviation of 5°, and an ulnar deviation of 25°. The gripping force was 30 kg (42 kg left side). There was no pain. The result was judged good, and there was no necessity for radiographs. Routinely, a radiographic control is scheduled at 6 and 12 months after surgery, but the patient did not keep these appointments. We saw him again 14 months after surgery, with increased wrist pain. The plain radiograph (Fig. 4)
FIGURE 3: Postoperative radiograph with the presence of bone anchors and the scaphocapitate pinning.
showed a fracture, with collapse of the scaphoid. The fracture was located proximal to the path of the K-wire. We suspected an, AVN,) of the scaphoid. On magnetic resonance imaging (Fig. 5), a low signal on the T1- and T2-weighted images suggested AVN of the proximal 2/3 of the scaphoid (no contrast was used). A proximal row carpectomy was performed. Intraoperative biopsies confirmed the diagnosis of AVN (Fig. 6). The postoperative course was uneventful. The final outcome (at 2 years and 5 months) of the wrist was satisfactory. There was no pain. The patient returned to his previous job and sports. The wrist had a functional range of motion: extension 45°, flexion 80°. The gripping force was 15 kg (versus 42 kg on the left side).
JHS 䉬 Vol A, April
AVASCULAR NECROSIS OF THE SCAPHOID AFTER THREE-LIGAMENT TENODESIS FOR SCAPHOLUNATE DISSOCIATION
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FIGURE 5: Magnetic resonance image demonstrating the absence of vascularity of the proximal two thirds of the scaphoid.
FIGURE 4: Radiographs, 14 months after surgery, with a collapse of the scaphoid.
DISCUSSION Taleisnik and Kelly,10 Gelberman and Menon,11 and Gelberman and Gross12 have studied the vascularity of the carpus extensively. They could demonstrate a blood supply at risk for the scaphoid. The proximal pole has the blood supply from a dorsal branch of the radial artery entering in the dorsal ridge of the scaphoid and running retrogradely. According to these authors, the major part of the scaphoid has a type I intraosseous blood supply, meaning that only 1 vessel is responsible for supplying the larger part of the scaphoid. More distally, a palmar branch of the radial artery supplies the distal part of scaphoid (tuberculum). With the Brunelli technique, several steps can be held responsible for jeopardizing the vascularity of the scaphoid. For adequate visualization and reduction of the rotatory subluxation, extensive dissection of the scaphoid is performed freeing it from all soft tissue adherences. This in itself can interfere with the blood supply, although the reduction of the scaphoid in this case was easy, without the need for aggressive dissection. Afterward, through a separate volar incision, a tunnel is drilled into the longitudinal axis of the scaphoid, with the potential danger of injuring the delicate intraosseous vascularity of the bone. Also a K-wire
FIGURE 6: Histology of the scaphoid.
through the distal third and a drill for the bone anchor in the proximal third are possible causes for the problems that occurred. The second hole for the bone anchor seems not to cause problems because the necrosis started more distally. Despite these threats, we are not aware of other reports of AVN after this procedure. Recently, Berschback et al12 reported a similar case of AVN of the scaphoid after a capsulodesis (Blatt) stabilization of a scapholunate dissociation. They stated that the dissection of the scaphoid was responsible for the vascular compromise of the scaphoid, which is a common feature in our case. Because in Blatt’s procedure there is no tunnel through the scaphoid, it is less likely that this has caused the AVN. The authors suggest to
JHS 䉬 Vol A, April
590
AVASCULAR NECROSIS OF THE SCAPHOID AFTER THREE-LIGAMENT TENODESIS FOR SCAPHOLUNATE DISSOCIATION
take care during the dissection, so as not to interfere with the capsular attachments at the wrist level of the scaphoid, because the vascular branches from the radial artery go into the bone. The oblique direction of a bone tunnel of 3.2-mm diameter4 is probably less safe than a tunnel in the distal pole, perpendicular to the axis of the scaphoid, as described in the original study.1 Therefore, we now turned back to this tunnel placement with drill bits smaller than 3.2 mm and more adapted to the size of the scaphoid (between 2 and 2.5 mm). We do think that the hole for the bone anchor in the proximal scaphoid is an additional risk factor. REFERENCES 1. Brunelli GA, Brunelli GR. A new technique to correct carpal instability with scaphoid rotary subluxation: a preliminary report. J Hand Surg 1995;20A:S82–S85. 2. Brunelli GA, Brunelli GR. A new surgical technique for carpal instability with scapho-lunar dislocation (Eleven cases). Ann Chir Main Memb Super 1995;14:207–213.
3. Van Den Abbeele KL, Loh YC, Stanley JK, Trail IA. Early results of a modified Brunelli procedure for scapholunate instability. J Hand Surg 1998;23B:258 –261. 4. Garcia-Elias M, Lluch A, Stanley JA. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique. J Hand Surg 2006;31A:125–134. 5. Almquist E, Bach A, Sack J, Fuhs S, Newman D. Four-bone ligament reconstruction for treatment of chronic complete scapholunate separation. J Hand Surg 1991;16A:322–327. 6. Bloom HT, Freeland AE, Bowen V, Mrkonjic L. The treatment of chronic scapholunate dissociation: an evidence-based assessment of the literature. Orthopedics 2003;26:195–203. 7. De Smet L, Van Hoonacker P. Treatment of chronic, static scapholunate dissociation with the modified Brunelli technique: preliminary results. Act Orthop Belg 2007;73:188 –191. 8. Berschback J, Kalainov D, Bednar H. Osteonecrosis of the scaphoid after scapholunate interosseous ligament repair and dorsal capsulodesis. A case report. J Hand Surg 2010;35A:732–735. 9. Berger R, Bishop A, Bettinger P. New dorsal capsulotomy for the surgical exposure of the wrist. Ann Plast Surg 1995;35:54 –59. 10. Taleisnik J, Kelly P. The extraosseous and intraosseous blood supply of the scaphoid bone. J Bone Joint Surg 1966;48A:1125–1137. 11. Gelberman R, Menon J. The vascularity of the scaphoid bone. J Hand Surg 1980;5:508 –513. 12. Gelberman R, Gross M. The vascularity of the wrist. Clin Orthop Relat Res 1986;202:40 – 49.
JHS 䉬 Vol A, April
Avascular Necrosis of the Scaphoid After ThreeLigament Tenodesis for Scapholunate Dissociation: Case Report Luc De Smet, MD, PhD, Raf Sciot, MD, PhD, Ilse Degreef, MD, PhD An unusual complication after tenodesis for scapholunate instability (Brunelli’s technique) is described. More than 1 year after the procedure, a fracture of the scaphoid with collapse was observed. Further examination concluded there was avascular necrosis of the scaphoid. The patient was treated with a proximal row carpectomy. (J Hand Surg 2011;36A:587–590. Copyright © 2011 by the American Society for Surgery of the Hand. All rights reserved.) Key words Avascular necrosis, complication, scaphoid, scapholunate ligament, wrist.
been proposed to treat scapholunate ligament injuries in the chronic stage, from soft tissue repair and reconstruction to partial arthrodesis and even salvage procedures such as proximal row carpectomy and wrist arthrodesis. In the 1970s and 1980s, most surgical techniques focused on closing the scapholunate gap. In 1995, Brunelli and son1,2 reported a tenodesis technique with the flexor carpi radialis (FCR). In the original description, a strip of the FCR was brought dorsally through the scaphoid and fixed to the radius. In 1998, the Wrightington group3 and Garcia Elias et al4 reported modifications, by fixing the tendon strip dorsally into the lunate. In general, good results were obtained in these and other series.5–7 Complications were few. We report an unusual complication, avascular necrosis (AVN) of the scaphoid after this procedure. A case of AVN of the scaphoid was reported after a Blatt capsulodesis.8
S
EVERAL PROCEDURES HAVE
From the University Hospitals, Leuven, Belgium. Received for publication July 29, 2010; accepted in revised form November 23, 2010. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Luc De Smet, MD, PhD, University Hospital, Department of Orthopedic Surgery, U.Z. Pellenberg, Weligerveld, 1, B-3212 Lubbeek (Pellenberg) Belgium; e-mail: [email protected]. 0363-5023/11/36A04-0003$36.00/0 doi:10.1016/j.jhsa.2010.11.043
CASE REPORT A 28-year-old, right-handed man was seen for wrist pain. He had a fall on the outstretched hand 22 weeks previously. The pain was localized on the radial border. Function was good. Watson’s shift test was positive. The plain radiographs demonstrated a wide scapholunate gap (5.5 mm) and an increased scapholunate angle (72°) (Fig. 1). The diagnosis of subacute scapholunate dissociation was made, and because the patient requested a stable wrist for his sports (badminton), a 3-ligament tenodesis, according to the Garcia Elias et al4 technique, was planned and performed. A longitudinal incision of the skin of 7 cm was made. The extensor retinaculum was divided over the third compartment, and the extensor pollicis longus was retracted radially. The fourth and fifth compartments were detached from the radius without opening them and were retracted ulnarly. A Berger ligament-sparing capsulotomy9 was performed. The cartilage of the carpals and radius seemed macroscopically healthy. The scaphoid could be reduced easily with manual pressure on the proximal pole, without the need for further dissection. A 3.2-mm drill hole was made in the scaphoid from the waist of the scaphoid, aiming to the distal pole volarly. A palmar Russe approach was made through the bed of the FCR. The hole was retrieved. A distally based radial strip— 8 cm long— of the FCR was harvested. The FCR strip was brought through the tunnel in the scaphoid from volar to dorsal, over the dorsal aspect of the lunate, through a split in the dorsal radiotriquetral
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 587
588
AVASCULAR NECROSIS OF THE SCAPHOID AFTER THREE-LIGAMENT TENODESIS FOR SCAPHOLUNATE DISSOCIATION
FIGURE 2: Schematic presentation of the procedure.
FIGURE 1: Preoperative radiographs with the usual findings of a static scapholunate dissociation.
ligament, and turned back. A bony anchor in the dorsal side of the scaphoid and one in the dorsal side of the lunate were used to fix this tendon strip (Fig. 2). The scaphoid was reduced, the sutures were tightened, and a 1.2-mm K-wire was drilled in the distal third of the scaphoid toward the capitate. Intraoperative radiographs confirmed the reduction and the correct position of the K-wire and bone anchors. A short-arm cast was applied. Six weeks after surgery, the cast and K-wire were removed. The patient was instructed to mobilize the wrist for 2 weeks, after which a more intensive mobilization with a physical therapist was done for 8 weeks. The 6 weeks postoperative radiograph (just before K-wire removal) demonstrated a closure of the gap (Fig. 3). The patient could resume his professional activities and his sports at 4.5 months after surgery. At that moment, the range of motion reached an extension of 70°, a flexion of 40°, a radial deviation of 5°, and an ulnar deviation of 25°. The gripping force was 30 kg (42 kg left side). There was no pain. The result was judged good, and there was no necessity for radiographs. Routinely, a radiographic control is scheduled at 6 and 12 months after surgery, but the patient did not keep these appointments. We saw him again 14 months after surgery, with increased wrist pain. The plain radiograph (Fig. 4)
FIGURE 3: Postoperative radiograph with the presence of bone anchors and the scaphocapitate pinning.
showed a fracture, with collapse of the scaphoid. The fracture was located proximal to the path of the K-wire. We suspected an, AVN,) of the scaphoid. On magnetic resonance imaging (Fig. 5), a low signal on the T1- and T2-weighted images suggested AVN of the proximal 2/3 of the scaphoid (no contrast was used). A proximal row carpectomy was performed. Intraoperative biopsies confirmed the diagnosis of AVN (Fig. 6). The postoperative course was uneventful. The final outcome (at 2 years and 5 months) of the wrist was satisfactory. There was no pain. The patient returned to his previous job and sports. The wrist had a functional range of motion: extension 45°, flexion 80°. The gripping force was 15 kg (versus 42 kg on the left side).
JHS 䉬 Vol A, April
AVASCULAR NECROSIS OF THE SCAPHOID AFTER THREE-LIGAMENT TENODESIS FOR SCAPHOLUNATE DISSOCIATION
589
FIGURE 5: Magnetic resonance image demonstrating the absence of vascularity of the proximal two thirds of the scaphoid.
FIGURE 4: Radiographs, 14 months after surgery, with a collapse of the scaphoid.
DISCUSSION Taleisnik and Kelly,10 Gelberman and Menon,11 and Gelberman and Gross12 have studied the vascularity of the carpus extensively. They could demonstrate a blood supply at risk for the scaphoid. The proximal pole has the blood supply from a dorsal branch of the radial artery entering in the dorsal ridge of the scaphoid and running retrogradely. According to these authors, the major part of the scaphoid has a type I intraosseous blood supply, meaning that only 1 vessel is responsible for supplying the larger part of the scaphoid. More distally, a palmar branch of the radial artery supplies the distal part of scaphoid (tuberculum). With the Brunelli technique, several steps can be held responsible for jeopardizing the vascularity of the scaphoid. For adequate visualization and reduction of the rotatory subluxation, extensive dissection of the scaphoid is performed freeing it from all soft tissue adherences. This in itself can interfere with the blood supply, although the reduction of the scaphoid in this case was easy, without the need for aggressive dissection. Afterward, through a separate volar incision, a tunnel is drilled into the longitudinal axis of the scaphoid, with the potential danger of injuring the delicate intraosseous vascularity of the bone. Also a K-wire
FIGURE 6: Histology of the scaphoid.
through the distal third and a drill for the bone anchor in the proximal third are possible causes for the problems that occurred. The second hole for the bone anchor seems not to cause problems because the necrosis started more distally. Despite these threats, we are not aware of other reports of AVN after this procedure. Recently, Berschback et al12 reported a similar case of AVN of the scaphoid after a capsulodesis (Blatt) stabilization of a scapholunate dissociation. They stated that the dissection of the scaphoid was responsible for the vascular compromise of the scaphoid, which is a common feature in our case. Because in Blatt’s procedure there is no tunnel through the scaphoid, it is less likely that this has caused the AVN. The authors suggest to
JHS 䉬 Vol A, April
590
AVASCULAR NECROSIS OF THE SCAPHOID AFTER THREE-LIGAMENT TENODESIS FOR SCAPHOLUNATE DISSOCIATION
take care during the dissection, so as not to interfere with the capsular attachments at the wrist level of the scaphoid, because the vascular branches from the radial artery go into the bone. The oblique direction of a bone tunnel of 3.2-mm diameter4 is probably less safe than a tunnel in the distal pole, perpendicular to the axis of the scaphoid, as described in the original study.1 Therefore, we now turned back to this tunnel placement with drill bits smaller than 3.2 mm and more adapted to the size of the scaphoid (between 2 and 2.5 mm). We do think that the hole for the bone anchor in the proximal scaphoid is an additional risk factor. REFERENCES 1. Brunelli GA, Brunelli GR. A new technique to correct carpal instability with scaphoid rotary subluxation: a preliminary report. J Hand Surg 1995;20A:S82–S85. 2. Brunelli GA, Brunelli GR. A new surgical technique for carpal instability with scapho-lunar dislocation (Eleven cases). Ann Chir Main Memb Super 1995;14:207–213.
3. Van Den Abbeele KL, Loh YC, Stanley JK, Trail IA. Early results of a modified Brunelli procedure for scapholunate instability. J Hand Surg 1998;23B:258 –261. 4. Garcia-Elias M, Lluch A, Stanley JA. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique. J Hand Surg 2006;31A:125–134. 5. Almquist E, Bach A, Sack J, Fuhs S, Newman D. Four-bone ligament reconstruction for treatment of chronic complete scapholunate separation. J Hand Surg 1991;16A:322–327. 6. Bloom HT, Freeland AE, Bowen V, Mrkonjic L. The treatment of chronic scapholunate dissociation: an evidence-based assessment of the literature. Orthopedics 2003;26:195–203. 7. De Smet L, Van Hoonacker P. Treatment of chronic, static scapholunate dissociation with the modified Brunelli technique: preliminary results. Act Orthop Belg 2007;73:188 –191. 8. Berschback J, Kalainov D, Bednar H. Osteonecrosis of the scaphoid after scapholunate interosseous ligament repair and dorsal capsulodesis. A case report. J Hand Surg 2010;35A:732–735. 9. Berger R, Bishop A, Bettinger P. New dorsal capsulotomy for the surgical exposure of the wrist. Ann Plast Surg 1995;35:54 –59. 10. Taleisnik J, Kelly P. The extraosseous and intraosseous blood supply of the scaphoid bone. J Bone Joint Surg 1966;48A:1125–1137. 11. Gelberman R, Menon J. The vascularity of the scaphoid bone. J Hand Surg 1980;5:508 –513. 12. Gelberman R, Gross M. The vascularity of the wrist. Clin Orthop Relat Res 1986;202:40 – 49.
JHS 䉬 Vol A, April