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Results of the Modified Brunelli Tenodesis for Treatment of Scapholunate Instability: A Retrospective Study of 19 Patients
SCIENTIFIC ARTICLE
Results of the Modified Brunelli Tenodesis for Treatment of Scapholunate Instability: A Retrospective Study of 19 Patients Jean-François Chabas, MD, André Gay, MD, David Valenti, MD, Didier Guinard, MD, Régis Legre, PhD
Purpose Management of chronic scapholunate (SL) instability without osteoarthritis remains controversial. In order to recreate an SL interosseous linkage, some surgeons opt for a limited wrist arthrodesis, whereas others use soft tissue stabilization. The purpose of the current study was to review and assess the therapeutic benefit of the modified Brunelli tenodesis that used the flexor carpi radialis tendon to replicate the stabilizing ligaments of the scaphoid. Methods Between 2001 and 2005, 19 tenodesis procedures have been performed to correct dynamic or static SL instability without osteoarthritis. On average, patients had surgery 15 months after injury. The mean follow-up was 37 months. Results After surgery, 15 patients had no to mild pain with a mean visual analog scale score of 3 of 10. The average wrist motion was 50° extension, 41° flexion, 24° radial deviation, and 29° ulnar deviation (75%, 73%, 68%, and 86% of the uninvolved wrists, respectively). The grip strength was 78% of the uninvolved wrists. On radiographs, the mean static SL distance was 2.4 mm (2.8 mm before surgery). There was no widening of the SL gap compared to the immediate postoperative gap. The SL angle improved from a mean preoperative value of 61° to 53° immediately after surgery and rose again to 62° at the time of the review. One patient developed a scapholunate advanced collapse wrist stage 2. Conclusions Ligament reconstruction using tendon grafts gave satisfactory results to correct reducible chronic SL instability without osteoarthritis. This repair technique achieved a relatively pain-free wrist, with acceptable grip strength and normal SL distance but with a loss in the arc of motion and a loss of correction of SL angle. (J Hand Surg 2008;33A:1469–1477. Copyright © 2008 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Scapholunate ligament disruption, dynamic, static, tenodesis, wrist instability. term coined by Linscheid and colleagues in 19721— can be described as the loss of mechanical linkage between the scaphoid and the lunate. It is the most common carpal instability. When the injury is diagnosed acutely, the deformity is easily reducible, and the prognosis is
S
CAPHOLUNATE DISSOCIATION—a
more favorable.2 Unfortunately, the diagnosis is frequently delayed. Therefore, alterations in articular contacts and load bearing result in a progressive degeneration of joints (scapholunate advanced collapse).3 This progressive degenerative disease occurs first between the radial styloid and the scaphoid (stage 1A). Later,
From the Department of Hand Surgery and Reconstructive Limb Surgery, La Conception Teaching Hospital, Marseille, France.
Corresponding author: Jean-François Chabas, Hôpital La Conception, 147, Bd Baille, 13005 Marseille, France; e-mail: [email protected].
Received for publication October 23, 2007; accepted in revised form May 27, 2008.
0363-5023/08/33A09-0002$34.00/0 doi:10.1016/j.jhsa.2008.05.031
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
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arthritic changes widen and affect both the radioscaphoid joint (stage 1B) and the capitolunate joint (Stage 2). Management of chronic scapholunate (SL) dissociation without osteoarthritis remains controversial. The ligament remnants evolve into a retracted and disorganized fibrous stump, precluding a robust recovery.4 In order to repair an SL interosseous linkage, surgeons opt for either a limited wrist arthrodesis,5–12 a bone-ligament-bone graft,13–18 or soft tissue stabilization.19 –32 Ligament reconstruction using tendon grafts19 –24 or posterior capsulodesis25–32 is commonly used as a soft tissue stabilization technique. In our practice, we elected tenodesis, a technique described initially by Brunelli21 and modified by Van Den Abbeele,22 as our first choice. The aims of this technique are to (1) reconstruct the dysfunctional ligaments with a strip of the FCR tendon and (2) prevent further arthritis by correcting the flexion deformity of the scaphoid. It has been shown that this tendon reconstruction replicates the action of 3 ligaments (scaphotrapezio-trapezoidal ligament, dorsal portion of the SL interosseous ligament, and dorsal intercarpal ligament).23,24 Furthermore, by tensioning the dorsal radiocarpal ligament, the tendon restoration augments the distal–palmar connection of the scaphoid to the distal carpal row and reduces the ulnar translation of the lunate and triquetrum.23,24 The purpose of the current study was to review and assess the therapeutic benefit of the modified Brunelli tenodesis in a cohort of 19 patients with chronic SL dissociation without osteoarthritis. PATIENTS AND METHODS Patients The study is a retrospective follow-up analysis of 19 patients (16 men and 3 women) who were surgically treated for SL instability, in the same institution, from February 2002 to May 2005. The average age at surgery was 43 years (range 23–57). Nine patients had surgery on the dominant wrist. All the patients were still working before surgery. Twelve patients were employed in heavy manual labor. In 18 cases, the patient could recall a specific traumatic event, most frequently a fall on the outstretched hand. In 53% of the cases, the trauma occurred during professional activities. Before surgery, all patients reported pain. On the visual analog scale in which 0 represented no pain and 10 represented severe pain, the average score was 7.5 (range 3–10). They also complained of snapping (11/19), clicking (11/19), or weakness (18/19). Twelve patients were diagnosed as having a dynamic instability and 7 had a reducible static instability.4,35 On radiographs, the mean SL gap was 2.8 mm, the mean SL angle was 61°, the mean radiolu-
nate angle was 11°, and the mean carpal height ratio was 0.56. An arthrography or an arthroscan of the wrist was performed in 85% of patients to confirm the diagnosis and identify tears in the SL, triquetrolunate, and triangular fibrocartilage ligaments. All the patients had tears in the SL ligament visible on wrist arthrography or arthroscan. Nonetheless, 53% of these patients exhibited also a partial disruption of the triquetrolunate ligament (8/19) and a partial disruption of the triangular fibrocartilage (2/19). All these associated disruptions were managed conservatively. An arthroscopy was performed in only 10 patients when wrist arthrography or arthroscan failed to confirm the complete disruption of the SL ligament. The average time from injury to surgery was 15 months (range 2–108 months). The procedures were performed by 2 surgeons. Surgical procedure The first 6 surgical procedures (Fig. 1) started with a longitudinal incision centered over Lister’s tubercle. For the remaining 13 cases, a dorsal transverse incision was made over the radiocarpal joint. The transverse approach was chosen for cosmetic reasons and preservation of the dorsal reticular ligament. The dorsal sensory branches of the radial and ulnar nerves were identified and protected. The approach was continued between the third and fourth extensor compartments, reflecting the compartments subperiosteally. Arthrotomy was performed by a radially based capsular flap as described by Berger.33 The rotatory subluxation of the scaphoid was reduced by temporary K-wires in the scaphoid and the lunate was used as a joystick. A 3.2-mm drill hole was made from dorsal to palmar at the distal tubercle of the scaphoid. A transverse palmar incision was performed along the flexor carpi radialis (FCR) tendon sheath, proximal to the level of scaphoid tuberosity. The median palmar cutaneous nerve was carefully identified and protected. A second transverse palmar incision centered over the musculotendinous junction of the FCR tendon was required in order to harvest the radial halves. This distally based strip of the FCR tendon was passed through the scaphoid tunnel. We used the modification of Brunelli’s technique,21 in which the end of the tendon was inserted at the dorso-ulnar side of the radius, we used a modified technique described by Van Den Abbeele et al.,22 in which the FCR tendon slip was passed through a slit created in the dorsal radiocarpal in such a way that it did not cross the radiocarpal joint. Then it was sutured onto itself with nonabsorbable 3-0 sutures after reduction of the scaphoid and the lunate. Contrary to Van Den
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ee ff
bb cc
A
gg hh
dd
aa
A
B
B
C
C
FIGURE 1: Surgical procedure. A A dorsal approach to the carpal joint: a radially based capsular flap (a) is performed with a proximal incision along the fibers of the dorsal radiocarpal ligament (c) and the distal incision splitting the fibers of the dorsal intercarpal ligament (b). B A strip of FCR tendon (f) is passed through the scaphoid tunnel (e). We used temporary K-wires (d) as a joystick to reduce the rotatory subluxation of the scaphoid. C The tendon graft is passed through a slit created in the dorsal radiocarpal (h) in such a way that it did not cross the radiocarpal joint. Then it was sutured (g) onto itself with nonabsorbable 3-0 sutures after reduction of the scaphoid and the lunate.
Abbeele, the graft was not secured to the lunate by an suture anchor in our procedure. In the first 6 cases, the reduction was stabilized with 2 K-wires across the SL and the scaphocapitate joints. The dorsal interosseous nerve was excised in 17 cases. A short arm thumb spica cast with wrist extension was maintained for 6 weeks. Six weeks after surgery, wires were removed and gentle range of motion was initiated. Assessment All the patients were retrospectively identified, called back, and re-examined for this study by an independent examiner with a minimum 6 months of follow-up. No patient who had this procedure was lost to follow-up. All the patients who had this procedure during that time were included. The average length of the follow-up was 37 months (range 12– 60). During examination, we assessed pain, grip strength, range of motion, and wrist function using (1) the visual analog scale, (2) a Jamar dynamometer (we averaged 3 attempts and compared them with the results obtained from the unaffected contralateral wrist), (3) a standard goniometer, and (4) Disabilities of the Arm, Shoulder, and Hand score and Wrightington Hospital evaluation forms, respectively. For subjective evaluation, patients were asked whether they had felt improvement in the wrist and whether they would make the same choice at the time of the interview. Because many clinical preoperative data were missing, grip strength and range of motion were compared to the unaffected opposite side.
Posteroanterior and lateral radiographs were performed in order to measure the SL gap,36 the SL and radiolunate angles,1 and the carpal height ratio.47 These measurements were compared to the preoperative and immediate postoperative (day 2) values to assess the recurrence of SL diastasis and flexion of scaphoid and a carpal collapse. The SL gap was measured in the middle of the flat medial facet of the scaphoid.36 The SL angle was formed by the line tangential to the proximal and distal convexities of the palmar aspect of the scaphoid, and the line perpendicular to a line connecting the palmar and dorsal tips of the lunate.1 The radiolunate angle was formed by the longitudinal axis of the radius and the line perpendicular to a line connecting the palmar and dorsal tips of the lunate.1 Carpal height ratio was calculated by dividing the carpal height and the length of the third metacarpal. The carpal height is the distance between the base of the third metacarpal and the distal articular surface of the radius measured along the proximal projection of the longitudinal axis of the third metacarpal.47 The radioscaphoid and midcarpal joints were analyzed to observe any arthritic change. Patient evaluations and physical examinations for this study were completed by hand therapists, independent of the treating surgeons, in an effort to minimize any potential observer bias. Statistical analysis (subgroup analysis): The quantitative variables were compared by analysis of variance with a level of significance of p ⬍.05.
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7 6 5 4
Excellent Good Fair Poor
3 2 1 0 Dynamic n=12
Static n=7
No legal claim n=9
Legal claim n=10
FIGURE 2: Wrightington scores.
Results were analyzed in selected subgroups of patients including: ●
Medicolegal claim (n⫽10) versus no medicolegal claim (n⫽9) ● Severity of the disruption: dynamic instability (n⫽12) versus static instability (n⫽7) ● Surgical procedure: longitudinal incision and Kwire fixation (n⫽6) versus transverse incision and no fixation (n⫽13) ● Postoperative interval: less than 36 months (n⫽10) versus more than 36 months (n⫽9) to evaluate long-term results Differences were regarded as significant when p⬍.05. RESULTS Three patients noted complete pain relief. Twelve patients noted occasional mild pain that had no influence on their activity. Four patients had pain in most activities of daily life. The average postoperative pain score was 3 on the visual analog scale. During the examination, 50% of the patients felt subjective stiffness, whereas only 10% of the patients complained of weakness. Sixteen patients reported that they felt improvement in the wrist, and 17 patients mentioned they would have the surgery again, arguing that their condition would be worse without the surgery. Twelve patients returned to their preinjury activities, including heavy labor, with an average delay of 9 months. Four patients returned to work at a lighter level
of activity than before the surgery. Two patients were fired from their jobs, and 1 patient had retired. The average ranges of motion were 41° flexion (73% of contralateral side), 50° extension (75% of contralateral side), 24° radial deviation (68% of contralateral side), and 29° ulnar deviation (86% of contralateral side). The average hand grip strength relative to the contralateral side was 78%, whereas the pinch grip strength was 85%. The average Disabilities of the Arm, Shoulder, and Hand score was 30 on a scale of 100 (range 0 –91). The Wrightington Hospital evaluation score indicated that 9 patients ended up with excellent results, 6 patients with good results, 3 patients with fair results, and 1 patient with poor results (Fig. 2). We observed a trend toward improved recovery in the group without medicolegal claims (Table 1) with significant differences in extension, grip strength, and pain relief. There was no statistically significant difference in the functional outcomes between patients when (1) dynamic versus static instability (Table 2), (2) initial versus later surgical procedure (Table 3), and (3) short versus long postoperative interval (Table 4) were compared. Significant differences were seen only in radiological outcomes (Tables 2, 3, and 4). We observed a reduction of the SL distance on immediate postoperative x-rays: the mean SL distance was 2.4 mm (2.8 mm before surgery). At the time of review, there was no widening of the SL gap compared to the immediate postoperative value (Ta-
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TABLE 1.
Influence of Medicolegal Claim on Clinical and Radiological Outcomes No Medicolegal Claim (n ⫽ 9)
Medicolegal Claim (n ⫽ 10)
p Value
Flexion (°)
45
37
p ⬎ .05
Extension (°)
63
38
p ⫽ .003
Radial deviation (°)
29
20
p ⬎ .05
Ulnar deviation (°)
31
26
p ⬎ .05
Grip strength (kg)
44
26
p ⫽ .006
Pain (visual analog scale 0–10; 0 represents no pain, 10 represents severe pain)
1.4
4.4
p ⫽ .003
SL gap (Day 2)
2.4
2.4
p ⬎ .05
SL gap (Review)
2.7
2
p ⬎ .05
SL angle (Day 2)
52
54
p ⬎ .05
SL angle (Review)
64
60
p ⬎ .05
TABLE 2. Influence of Severity of the Lesion (Type of Instability) on Clinical and Radiological Outcomes Dynamic (n ⫽ 12)
Static (n ⫽ 7)
p Value
Flexion (°)
43
37
p ⬎ .05
Extension (°)
52
46
p ⬎ .05
Radial deviation (°)
27
19
p ⬎ .05
Ulnar deviation (°)
31
24
p ⬎ .05
Grip strength (kg)
37
31
p ⬎ .05
Pain (visual analog scale 0–10; 0 represents no pain, 10 represents severe pain)
2.5
3.9
p ⬎ .05
SL gap (Day 2)
2
3
p ⫽ .034
SL gap (Review)
1.8
3.2
p ⫽ .012
SL angle (Day 2)
52
54
p ⬎ .05
SL angle (Review)
62
62
p ⬎ .05
ble 5). The SL angle improved from a mean preoperative value of 61° to 53° immediately after surgery and rose again to 62° at the time of the review. The carpal height remained stable. In 5 wrists, we observed a recurrence of a dorsal tilt of the lunate with radiolunate angle greater than 15° or SL angle greater than 70°. One patient developed a scapholunate advanced collapse wrist stage 2, but this outcome was not considered by the patient as severely debilitating. There was no sign of scaphoid necrosis or fracture of the distal pole of the scaphoid (Fig. 3). Two patients developed postoperative pain dystrophies that needed further management by the pain clinic
and hand therapists. Two patients developed a neuroma (laceration of the dorsal sensory branch of the radial nerve for 1 patient and median palmar cutaneous nerve for the other) that needed scar exploration and neuroma excision. DISCUSSION Since the first report by Destot in 1926,37,38 numerous studies have demonstrated the biomechanical role of the SL complex on carpal motion and force transmission across the wrist. The stability of this couple depends on the SL interosseous ligament, especially its dorsal portion,39 but also on secondary scaphoid stabilizers. These stabilizers are either palmar with the radioscaphocapitate ligament and the scaphotrapezio-trapezoidal ligament40,41,42 or dorsal with the dorsal intercarpal and dorsal radiocarpal ligaments.43 A complete rotatory subluxation of the scaphoid was never observed when only the SL interosseous ligament was sectioned. Besides, static SL instability is noticed solely after a concomitant failure of the distal scaphotrapezio-trapezoidal ligament44,45 or the dorsal intercarpal ligament.46 Scapholunate dissociation is the most common instability pattern of the wrist and can, if untreated, lead to degenerative arthritis of the radiocarpal and, subsequently, of the midcarpal joint. The treatment of chronic SL instability without arthritis remains controversial, with no optimal procedure. The ideal surgical technique should be easy, reliable, and predictable, and should achieve a painfree wrist with preserved range of motion and grip strength, and a normal relationship between carpal bones, both in static and dynamic radiologic views. Any ligamentous reconstruction for complete SL
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TABLE 3.
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Influence of Surgical Procedure on Clinical and Radiological Outcomes Transverse Incision No Fixation (n ⫽ 13)
Longitudinal Incision Pin Fixation (n ⫽ 6)
p Value
Flexion (°)
43
37
p ⬎ .05
Extension (°)
50
51
p ⬎ .05
Radial deviation (°)
26
21
p ⬎ .05
Ulnar deviation (°)
28
31
p ⬎ .05
Grip strength (kg)
34
34
p ⬎ .05
Pain (visual analog scale 0–10; 0 represents no pain, 10 represents severe pain)
2.5
4
p ⬎ .05
SL gap (Day 2)
2
3.3
p ⫽ .015
SL gap (Review)
1.9
3.3
p ⫽ .008
SL angle (Day 2)
52
55
p ⬎ .05
SL angle (Review)
59
68
p ⬎ .05
TABLE 4.
Influence of Postoperative Interval on Clinical and Radiological Outcomes Postoperative Interval ⬍36 Months (n ⫽ 10)
Postoperative Interval ⬎36 Months (n ⫽ 9)
p Value
Flexion (°)
40
41
p ⬎ .05
Extension (°)
45
56
p ⬎ .05
Radial deviation (°)
24
24
p ⬎ .05
Ulnar deviation (°)
26
32
p ⬎ .05
Grip strength (kg)
30
39
p ⬎ .05
Pain (visual analog scale 0–10; 0 represents no pain, 10 represents severe pain)
3.2
2.8
p ⬎ .05
SL gap (Day 2)
1.8
3
p ⫽ .013
SL gap (Review)
1.7
p ⫽ .005
3.1
SL angle (Day 2)
52
54
p ⬎ .05
SL angle (Review)
55
68
p ⫽ .036
TABLE 5.
Radiological Outcomes Preoperative
Immediate Postoperative (Day 2)
Late Postoperative (Review)
SL gap (mm)
2.8
2.4
2.4
Carpal height ratio
0.56
0.53
0.55
SL angle (°)
61
53
62
RL angle (°)
11
8
10
separation must take into consideration all the stabilizing ligaments of the injured scaphoid and not exclusively the SL interosseous ligament.4 Various surgical procedures have been devised to restore the normal carpal alignment and ligamentous con-
straints: bone–ligament– bone autograft,13–18 limited arthrodesis,5–12 and soft tissue repair (dorsal capsulodesis25–32 or tendon graft19 –24). The purpose of this study is to determine whether the modified Brunelli procedure may still have its place
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FIGURE 3: Postoperative radiographs (A posteroanterior, B lateral, C ulnar, and D radial deviation views) at last follow-up visit (36 months) reveal the mobility of the scaphoid and the maintenance of its reduction in dynamic views (SL gap ⫽ 1.6 mm, SL angle ⫽ 59°).
among the soft tissue repairs for reconstructing the SL linkage. An alternative technique is the dorsal capsulodesis,25 which aims to stabilize the forceful flexion of the scaphoid by a flap of wrist capsule inserted into the distal pole of the scaphoid. This procedure is convenient and reliable. The Blatt capsulodesis tethers the scaphoid to the radius. In doing so, the Blatt capsulodesis crosses the radiocarpal joint and limits wrist flexion. Moreover, this procedure fails to correct directly the SL gap.29,30 Unsatisfactory results were reported by Wyrick,28 who considered that this procedure falls short in providing consistent pain relief and maintaining carpal alignment in patients with static SL instability.39,40 This inconvenience led Szabo41 and Schweizer42 to develop a procedure including the dorsal intercarpal ligament for SL reinforcement. In contrast to Blatt’s capsulodesis, this substitute procedure did not cross the radiocarpal joint and did not limit wrist flexion. In addition, by linking the proximal row as a functional unit, a decreased SL diastasis is achieved.44 In their study, Schweizer and Steiger42 reported 4 clinical outcomes that were improved when compared to our findings: pain relief (86% of patients had no to mild pain), average range of motion (84% of the uninvolved wrist), average grip strength (89% of the uninvolved wrist), and maintenance of reduction of SL angle. Nevertheless, 27% of the patients (6/22) showed either radioscaphoid or midcarpal degeneration. Degenerative changes were also observed by Szabo31 in a similar cohort but with a shorter mean follow-up (25 months vs 63 months). From the first reported tendon reconstruction of the SL ligament,19 the procedures have considerably evolved. At that time, the procedure provided unsatisfactory results because the holes drilled into poorly vascularized bone areas induced fractures or joint de-
generations. In addition, they used to cross either radiocarpal or midcarpal joints, which provided wrist stiffness. Although the so-called 4-bone ligament reconstruction20 was based on these 2 principles, Almquist reported satisfactory results. With respect to range of motion (flexion– extension, 89°) and grip strength (73% of the uninvolved wrist), his results are similar to ours. In addition, it must be highlighted that the reported percentage of patients who returned to their preinjury activities was increased in his study (86% vs 63%). However, this discrepancy could be explained by a high rate of patients with an unresolved medicolegal claim. Of note is the rate of failure (8%) that led to intercarpal fusion. Recently, Brunelli21 described a procedure based on the stabilization of both the proximal and the distal ends of the subluxating scaphoid with a strip of FCR that was passed through a tunnel in the distal pole of the scaphoid, pulled dorsally, reducing the scaphoid to its position, and sutured to the dorsal and ulnar edge of the radius. He reported satisfactory results at 1-year follow-up with improved grip strength (65% of the other hand) and a postoperative range of motion limited in flexion (25°) due to the final placing of the tendon onto the radius. In 1998, the method was modified by Van Den Abbeele,22 who anchored the tendon onto the dorsum of the lunate or onto the dorsal radiotriquetral ligament. The results of this short follow-up study (9 months) showed similar results when compared to our study in terms of pain relief, grip strength recovery, and range of motion. The authors also noticed that there was no change in the average SL angle before and after surgery. A significantly diminished recovery was noticed in patients with an unresolved medicolegal claim, as we have observed in our study (Table 1).
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In comparison to the previously published studies,23,24 we noticed similar or better results for grip strength recovery and pain relief, but poorer results for wrist mobility recovery and return to work. This discrepancy could possibly be explained by many patients awaiting settlement of compensation claims. As well, our technique differed from the previously published techniques. The graft was not secured to the lunate by a suture anchor. The modification of our surgical technique during the study failed to reveal any significant differences. Nevertheless, the former procedure was associated with some complications: the neuroma of a radial sensory branch during the removal of K-wires and the scapholunate advanced collapse wrist. The transverse approach was chosen for cosmetic reasons and preservation of the dorsal retinacular ligament. The relevance of this study could have been greater if we had possessed all the preoperative clinical data in order to efficiently assess the postoperative values. A mean follow-up of 37 months was probably not long enough to analyze the long-term efficiency of this technique. Nevertheless, no significant difference for the clinical assessment was observed when the postoperative interval was considered. We noticed an increase in the SL angle only in the group with a follow-up greater than 36 months. Our radiological results suggest a possible stretch of the tendon graft, particularly in the sagittal plane. This is not unexpected because, as it has been described previously, histological and mechanical properties of a tendon graft differ profoundly from those of a ligament.3 In addition, we observed only 1 patient who showed signs of degenerative osteoarthritis. In his study of 38 patients with an average follow-up of 46 months, Garcia-Elias34 related 7 patients with mild signs of degenerative osteoarthritis at the tip of the radial styloid and 2 with global osteoarthritis. The findings of the current study are in accordance with data from previously published works. We report encouraging results on pain relief, strength restoration, and satisfaction. In addition, from a surgeon’s point of view, this technique is reliable and easy to perform. Nevertheless, it may induce a stretch of the tendon graft and lead, in the long term, to deteriorating radiological results. Consequently, a long-term study is required to appreciate the full benefit of this procedure.
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collapse pattern of degenerative arthritis. J Hand Surg 1984;9A: 358 –365. Garcia-Elias M. Carpal instabilities and dislocations. In: Green DP, Hotchkiss RN, Pederson WC, eds. Operative hand surgery. Volume 1. 4th ed. New York: Churchill Livingstone, 2001:865–928. Watson HK, Hempton RF. Limited wrist arthrodeses. Part I: The triscaphoid joint. J Hand Surg 1980;5:320 –327. Fortin PT, Louis DS. Long-term follow-up of scaphoid-trapeziumtrapezoid arthrodesis. J Hand Surg 1993;18A:675– 681. Kleinman WB, Carroll C IV. Scapho-trapezio-trapezoid arthrodesis for treatment of chronic static and dynamic scapho-lunate instability: a 10-year perspective on pitfalls and complications. J Hand Surg 1990;15A:408 – 414. Chantelot C, Becquet E, Leconte F, Lahoude-Chantelot S, Prodomme G, Fontaine C. Scaphocapitate arthrodesis for chronic scapholunate instability: a retrospective study of 13 cases. Chir Main 2005;24:79 – 83 [in French]. Garcia-Elias M, Cooney WP, An KN, Linscheid RL, Chao EY. Wrist kinematics after limited intercarpal arthrodesis. J Hand Surg 1989; 14A:791–799. Rogers WD, Watson HK. Radial styloid impingement after triscaphe arthrodesis. J Hand Surg 1989;14A:297–301. Zubairy AI, Jones WA. Scapholunate fusion in chronic symptomatic scapholunate instability. J Hand Surg 2003;28B:311–314. Alnot JY, de Cheveigne C, Bleton R. Chronic, post-traumatic scaphoid-lunate instability treated by scaphoid-lunate arthrodesis. Ann Chir Main Memb Super 1992;11:107–118 [in French]. Weiss AP. Scapholunate ligament reconstruction using a bone-retinaculum-bone autograft. J Hand Surg 1998;23A:205–215. Cuenod P. Osteoligamentoplasty and limited dorsal capsulodesis for chronic scapholunate dissociation. Ann Chir Main Memb Super 1999;18:38 –53. Hofstede DJ, Ritt MJ, Bos KE. Tarsal autografts for reconstruction of the scapholunate interosseous ligament: a biomechanical study. J Hand Surg 1999;24A:968 –976. Davis CA, Culp RW, Hume EL, Osterman AL. Reconstruction of the scapholunate ligament in a cadaver model using a bone-ligamentbone autograft from the foot. J Hand Surg 1998;23A:884 – 892. Harvey EJ, Hanel D, Knight JB, Tencer AF. Autograft replacements for the scapholunate ligament: a biomechanical comparison of handbased autografts. J Hand Surg 1999;24A:963–967. Shin SS, Moore DC, McGovern RD, Weiss AP. Scapholunate ligament reconstruction using a bone-retinaculum-bone autograft: a biomechanic and histologic study. J Hand Surg 1998;23A:216 –221. Palmer AK, Dobyns JH, Linscheid RL. Management of post-traumatic instability of the wrist secondary to ligament rupture. J Hand Surg 1978;3:507–532. Almquist EE, Bach AW, Sack JT, Fuhs SE, Newman DM. Fourbone ligament reconstruction for treatment of chronic complete scapholunate separation. J Hand Surg 1991;16A:322–327. Brunelli GA, Brunelli GR. A new surgical technique for carpal instability with scapho-lunate dislocation. (Eleven cases). Ann Chir Main Memb Super 1995;14:207–213 [in French]. 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. 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 2006;31B:110 –117. Garcia-Elias M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique. J Hand Surg 2006;31A:125–134. Blatt G. Capsulodesis in reconstructive hand surgery. Dorsal capsulodesis for the unstable scaphoid and volar capsulodesis following excision of the distal ulna. Hand Clin 1987;3:81–102. Lavernia CJ, Cohen MS, Taleisnik J. Treatment of scapholunate
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27.
28.
29.
30.
31.
32.
33. 34.
35. 36.
dissociation by ligamentous repair and capsulodesis. J Hand Surg 1992;17A:354 –359. Wintman BI, Gelberman RH, Katz JN. Dynamic scapholunate instability: results of operative treatment with dorsal capsulodesis. J Hand Surg 1995;20A:971–979. Wyrick JD, Youse BD, Kiefhaber TR. Scapholunate ligament repair and capsulodesis for the treatment of static scapholunate dissociation. J Hand Surg 1998; 23B:776 –780. Deshmukh SC, Givissis P, Belloso D, Stanley JK, Trail IA. Blatt’s capsulodesis for chronic scapholunate dissociation. J Hand Surg 1999;24B:215–220. Moran SL, Cooney WP, Berger RA, Strickland J. Capsulodesis for the treatment of chronic scapholunate instability. J Hand Surg 2005; 30A:16 –23. Szabo RM, Slater RR Jr, Palumbo CF, Gerlach T. Dorsal intercarpal ligament capsulodesis for chronic, static scapholunate dissociation: clinical results. J Hand Surg 2002;27A:978 –984. Schweizer A, Steiger R. Long-term results after repair and augmentation ligamentoplasty of rotatory subluxation of the scaphoid. J Hand Surg 2002;27A:674 – 684. Berger RA, Bishop AT, Bettinger PC. New dorsal capsulotomy for the surgical exposure of the wrist. Ann Plast Surg 1995;35:54 –59. Slater RR Jr, Szabo RM, Bay BK, Laubach J. Dorsal intercarpal ligament capsulodesis for scapholunate dissociation: biomechanical analysis in a cadaver model. J Hand Surg 1999;24A:232–239. Taleisnik J. Current concepts review. Carpal instability. J Bone Joint Surg 1988;70A:1262–1268. Kindynis P, Resnick D, Kang HS, Haller J, Sartoris DJ. Demonstration of the scapholunate space with radiography. Radiology 1990; 175:278 –280.
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37. Destot E. The classic: injuries of the wrist: a radiological study. Clin Orthop Relat Res 2006;445:8 –14. 38. Destot E. The classic. Injuries of the wrist. A radiological study. Clin Orthop Relat Res 1986;202:3–11. 39. Sokolow C, Saffar P. Anatomy and histology of the scapholunate ligament. Hand Clin 2001;17:77– 81. 40. Short WH, Werner FW, Green JK, Masaoka S. Biomechanical evaluation of ligamentous stabilizers of the scaphoid and lunate. J Hand Surg 2002;27A:991–1002. 41. Short WH, Werner FW, Green JK, Masaoka S. Biomechanical evaluation of the ligamentous stabilizers of the scaphoid and lunate: Part II. J Hand Surg 2005;30A:24 –34. 42. Short WH, Werner FW, Green JK, Sutton LG, Brutus JP. Biomechanical evaluation of the ligamentous stabilizers of the scaphoid and lunate: part III. J Hand Surg 2007;32A:297–309. 43. Viegas SF, Yamaguchi S, Boyd NL, Patterson RM. The dorsal ligaments of the wrist: anatomy, mechanical properties, and function. J Hand Surg 1999;24A:456 – 468. 44. Boabighi A, Kuhlmann JN, Kenesi C. The distal ligamentous complex of the scaphoid and the scapho-lunate ligament. An anatomic, histological and biomechanical study. J Hand Surg 1993;18B:65– 69. 45. Bettinger PC, Smutz WP, Linscheid RL, Cooney WP III, An KN. Material properties of the trapezial and trapeziometacarpal ligaments. J Hand Surg 2000;25A:1085–1095. 46. Mitsuyasu H, Patterson RM, Shah MA, Buford WL, Iwamoto Y, Viegas SF. The role of the dorsal intercarpal ligament in dynamic and static scapholunate instability. J Hand Surg 2004;29A:279 –288. 47. McMurtry RY, Youm Y, Flatt AE. Kinematics of the wrist (II). J Bone Joint Surg 1972;54A:1612–1632.
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Results of the Modified Brunelli Tenodesis for Treatment of Scapholunate Instability: A Retrospective Study of 19 Patients Jean-François Chabas, MD, André Gay, MD, David Valenti, MD, Didier Guinard, MD, Régis Legre, PhD
Purpose Management of chronic scapholunate (SL) instability without osteoarthritis remains controversial. In order to recreate an SL interosseous linkage, some surgeons opt for a limited wrist arthrodesis, whereas others use soft tissue stabilization. The purpose of the current study was to review and assess the therapeutic benefit of the modified Brunelli tenodesis that used the flexor carpi radialis tendon to replicate the stabilizing ligaments of the scaphoid. Methods Between 2001 and 2005, 19 tenodesis procedures have been performed to correct dynamic or static SL instability without osteoarthritis. On average, patients had surgery 15 months after injury. The mean follow-up was 37 months. Results After surgery, 15 patients had no to mild pain with a mean visual analog scale score of 3 of 10. The average wrist motion was 50° extension, 41° flexion, 24° radial deviation, and 29° ulnar deviation (75%, 73%, 68%, and 86% of the uninvolved wrists, respectively). The grip strength was 78% of the uninvolved wrists. On radiographs, the mean static SL distance was 2.4 mm (2.8 mm before surgery). There was no widening of the SL gap compared to the immediate postoperative gap. The SL angle improved from a mean preoperative value of 61° to 53° immediately after surgery and rose again to 62° at the time of the review. One patient developed a scapholunate advanced collapse wrist stage 2. Conclusions Ligament reconstruction using tendon grafts gave satisfactory results to correct reducible chronic SL instability without osteoarthritis. This repair technique achieved a relatively pain-free wrist, with acceptable grip strength and normal SL distance but with a loss in the arc of motion and a loss of correction of SL angle. (J Hand Surg 2008;33A:1469–1477. Copyright © 2008 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Scapholunate ligament disruption, dynamic, static, tenodesis, wrist instability. term coined by Linscheid and colleagues in 19721— can be described as the loss of mechanical linkage between the scaphoid and the lunate. It is the most common carpal instability. When the injury is diagnosed acutely, the deformity is easily reducible, and the prognosis is
S
CAPHOLUNATE DISSOCIATION—a
more favorable.2 Unfortunately, the diagnosis is frequently delayed. Therefore, alterations in articular contacts and load bearing result in a progressive degeneration of joints (scapholunate advanced collapse).3 This progressive degenerative disease occurs first between the radial styloid and the scaphoid (stage 1A). Later,
From the Department of Hand Surgery and Reconstructive Limb Surgery, La Conception Teaching Hospital, Marseille, France.
Corresponding author: Jean-François Chabas, Hôpital La Conception, 147, Bd Baille, 13005 Marseille, France; e-mail: [email protected].
Received for publication October 23, 2007; accepted in revised form May 27, 2008.
0363-5023/08/33A09-0002$34.00/0 doi:10.1016/j.jhsa.2008.05.031
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1469
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arthritic changes widen and affect both the radioscaphoid joint (stage 1B) and the capitolunate joint (Stage 2). Management of chronic scapholunate (SL) dissociation without osteoarthritis remains controversial. The ligament remnants evolve into a retracted and disorganized fibrous stump, precluding a robust recovery.4 In order to repair an SL interosseous linkage, surgeons opt for either a limited wrist arthrodesis,5–12 a bone-ligament-bone graft,13–18 or soft tissue stabilization.19 –32 Ligament reconstruction using tendon grafts19 –24 or posterior capsulodesis25–32 is commonly used as a soft tissue stabilization technique. In our practice, we elected tenodesis, a technique described initially by Brunelli21 and modified by Van Den Abbeele,22 as our first choice. The aims of this technique are to (1) reconstruct the dysfunctional ligaments with a strip of the FCR tendon and (2) prevent further arthritis by correcting the flexion deformity of the scaphoid. It has been shown that this tendon reconstruction replicates the action of 3 ligaments (scaphotrapezio-trapezoidal ligament, dorsal portion of the SL interosseous ligament, and dorsal intercarpal ligament).23,24 Furthermore, by tensioning the dorsal radiocarpal ligament, the tendon restoration augments the distal–palmar connection of the scaphoid to the distal carpal row and reduces the ulnar translation of the lunate and triquetrum.23,24 The purpose of the current study was to review and assess the therapeutic benefit of the modified Brunelli tenodesis in a cohort of 19 patients with chronic SL dissociation without osteoarthritis. PATIENTS AND METHODS Patients The study is a retrospective follow-up analysis of 19 patients (16 men and 3 women) who were surgically treated for SL instability, in the same institution, from February 2002 to May 2005. The average age at surgery was 43 years (range 23–57). Nine patients had surgery on the dominant wrist. All the patients were still working before surgery. Twelve patients were employed in heavy manual labor. In 18 cases, the patient could recall a specific traumatic event, most frequently a fall on the outstretched hand. In 53% of the cases, the trauma occurred during professional activities. Before surgery, all patients reported pain. On the visual analog scale in which 0 represented no pain and 10 represented severe pain, the average score was 7.5 (range 3–10). They also complained of snapping (11/19), clicking (11/19), or weakness (18/19). Twelve patients were diagnosed as having a dynamic instability and 7 had a reducible static instability.4,35 On radiographs, the mean SL gap was 2.8 mm, the mean SL angle was 61°, the mean radiolu-
nate angle was 11°, and the mean carpal height ratio was 0.56. An arthrography or an arthroscan of the wrist was performed in 85% of patients to confirm the diagnosis and identify tears in the SL, triquetrolunate, and triangular fibrocartilage ligaments. All the patients had tears in the SL ligament visible on wrist arthrography or arthroscan. Nonetheless, 53% of these patients exhibited also a partial disruption of the triquetrolunate ligament (8/19) and a partial disruption of the triangular fibrocartilage (2/19). All these associated disruptions were managed conservatively. An arthroscopy was performed in only 10 patients when wrist arthrography or arthroscan failed to confirm the complete disruption of the SL ligament. The average time from injury to surgery was 15 months (range 2–108 months). The procedures were performed by 2 surgeons. Surgical procedure The first 6 surgical procedures (Fig. 1) started with a longitudinal incision centered over Lister’s tubercle. For the remaining 13 cases, a dorsal transverse incision was made over the radiocarpal joint. The transverse approach was chosen for cosmetic reasons and preservation of the dorsal reticular ligament. The dorsal sensory branches of the radial and ulnar nerves were identified and protected. The approach was continued between the third and fourth extensor compartments, reflecting the compartments subperiosteally. Arthrotomy was performed by a radially based capsular flap as described by Berger.33 The rotatory subluxation of the scaphoid was reduced by temporary K-wires in the scaphoid and the lunate was used as a joystick. A 3.2-mm drill hole was made from dorsal to palmar at the distal tubercle of the scaphoid. A transverse palmar incision was performed along the flexor carpi radialis (FCR) tendon sheath, proximal to the level of scaphoid tuberosity. The median palmar cutaneous nerve was carefully identified and protected. A second transverse palmar incision centered over the musculotendinous junction of the FCR tendon was required in order to harvest the radial halves. This distally based strip of the FCR tendon was passed through the scaphoid tunnel. We used the modification of Brunelli’s technique,21 in which the end of the tendon was inserted at the dorso-ulnar side of the radius, we used a modified technique described by Van Den Abbeele et al.,22 in which the FCR tendon slip was passed through a slit created in the dorsal radiocarpal in such a way that it did not cross the radiocarpal joint. Then it was sutured onto itself with nonabsorbable 3-0 sutures after reduction of the scaphoid and the lunate. Contrary to Van Den
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ee ff
bb cc
A
gg hh
dd
aa
A
B
B
C
C
FIGURE 1: Surgical procedure. A A dorsal approach to the carpal joint: a radially based capsular flap (a) is performed with a proximal incision along the fibers of the dorsal radiocarpal ligament (c) and the distal incision splitting the fibers of the dorsal intercarpal ligament (b). B A strip of FCR tendon (f) is passed through the scaphoid tunnel (e). We used temporary K-wires (d) as a joystick to reduce the rotatory subluxation of the scaphoid. C The tendon graft is passed through a slit created in the dorsal radiocarpal (h) in such a way that it did not cross the radiocarpal joint. Then it was sutured (g) onto itself with nonabsorbable 3-0 sutures after reduction of the scaphoid and the lunate.
Abbeele, the graft was not secured to the lunate by an suture anchor in our procedure. In the first 6 cases, the reduction was stabilized with 2 K-wires across the SL and the scaphocapitate joints. The dorsal interosseous nerve was excised in 17 cases. A short arm thumb spica cast with wrist extension was maintained for 6 weeks. Six weeks after surgery, wires were removed and gentle range of motion was initiated. Assessment All the patients were retrospectively identified, called back, and re-examined for this study by an independent examiner with a minimum 6 months of follow-up. No patient who had this procedure was lost to follow-up. All the patients who had this procedure during that time were included. The average length of the follow-up was 37 months (range 12– 60). During examination, we assessed pain, grip strength, range of motion, and wrist function using (1) the visual analog scale, (2) a Jamar dynamometer (we averaged 3 attempts and compared them with the results obtained from the unaffected contralateral wrist), (3) a standard goniometer, and (4) Disabilities of the Arm, Shoulder, and Hand score and Wrightington Hospital evaluation forms, respectively. For subjective evaluation, patients were asked whether they had felt improvement in the wrist and whether they would make the same choice at the time of the interview. Because many clinical preoperative data were missing, grip strength and range of motion were compared to the unaffected opposite side.
Posteroanterior and lateral radiographs were performed in order to measure the SL gap,36 the SL and radiolunate angles,1 and the carpal height ratio.47 These measurements were compared to the preoperative and immediate postoperative (day 2) values to assess the recurrence of SL diastasis and flexion of scaphoid and a carpal collapse. The SL gap was measured in the middle of the flat medial facet of the scaphoid.36 The SL angle was formed by the line tangential to the proximal and distal convexities of the palmar aspect of the scaphoid, and the line perpendicular to a line connecting the palmar and dorsal tips of the lunate.1 The radiolunate angle was formed by the longitudinal axis of the radius and the line perpendicular to a line connecting the palmar and dorsal tips of the lunate.1 Carpal height ratio was calculated by dividing the carpal height and the length of the third metacarpal. The carpal height is the distance between the base of the third metacarpal and the distal articular surface of the radius measured along the proximal projection of the longitudinal axis of the third metacarpal.47 The radioscaphoid and midcarpal joints were analyzed to observe any arthritic change. Patient evaluations and physical examinations for this study were completed by hand therapists, independent of the treating surgeons, in an effort to minimize any potential observer bias. Statistical analysis (subgroup analysis): The quantitative variables were compared by analysis of variance with a level of significance of p ⬍.05.
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7 6 5 4
Excellent Good Fair Poor
3 2 1 0 Dynamic n=12
Static n=7
No legal claim n=9
Legal claim n=10
FIGURE 2: Wrightington scores.
Results were analyzed in selected subgroups of patients including: ●
Medicolegal claim (n⫽10) versus no medicolegal claim (n⫽9) ● Severity of the disruption: dynamic instability (n⫽12) versus static instability (n⫽7) ● Surgical procedure: longitudinal incision and Kwire fixation (n⫽6) versus transverse incision and no fixation (n⫽13) ● Postoperative interval: less than 36 months (n⫽10) versus more than 36 months (n⫽9) to evaluate long-term results Differences were regarded as significant when p⬍.05. RESULTS Three patients noted complete pain relief. Twelve patients noted occasional mild pain that had no influence on their activity. Four patients had pain in most activities of daily life. The average postoperative pain score was 3 on the visual analog scale. During the examination, 50% of the patients felt subjective stiffness, whereas only 10% of the patients complained of weakness. Sixteen patients reported that they felt improvement in the wrist, and 17 patients mentioned they would have the surgery again, arguing that their condition would be worse without the surgery. Twelve patients returned to their preinjury activities, including heavy labor, with an average delay of 9 months. Four patients returned to work at a lighter level
of activity than before the surgery. Two patients were fired from their jobs, and 1 patient had retired. The average ranges of motion were 41° flexion (73% of contralateral side), 50° extension (75% of contralateral side), 24° radial deviation (68% of contralateral side), and 29° ulnar deviation (86% of contralateral side). The average hand grip strength relative to the contralateral side was 78%, whereas the pinch grip strength was 85%. The average Disabilities of the Arm, Shoulder, and Hand score was 30 on a scale of 100 (range 0 –91). The Wrightington Hospital evaluation score indicated that 9 patients ended up with excellent results, 6 patients with good results, 3 patients with fair results, and 1 patient with poor results (Fig. 2). We observed a trend toward improved recovery in the group without medicolegal claims (Table 1) with significant differences in extension, grip strength, and pain relief. There was no statistically significant difference in the functional outcomes between patients when (1) dynamic versus static instability (Table 2), (2) initial versus later surgical procedure (Table 3), and (3) short versus long postoperative interval (Table 4) were compared. Significant differences were seen only in radiological outcomes (Tables 2, 3, and 4). We observed a reduction of the SL distance on immediate postoperative x-rays: the mean SL distance was 2.4 mm (2.8 mm before surgery). At the time of review, there was no widening of the SL gap compared to the immediate postoperative value (Ta-
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TABLE 1.
Influence of Medicolegal Claim on Clinical and Radiological Outcomes No Medicolegal Claim (n ⫽ 9)
Medicolegal Claim (n ⫽ 10)
p Value
Flexion (°)
45
37
p ⬎ .05
Extension (°)
63
38
p ⫽ .003
Radial deviation (°)
29
20
p ⬎ .05
Ulnar deviation (°)
31
26
p ⬎ .05
Grip strength (kg)
44
26
p ⫽ .006
Pain (visual analog scale 0–10; 0 represents no pain, 10 represents severe pain)
1.4
4.4
p ⫽ .003
SL gap (Day 2)
2.4
2.4
p ⬎ .05
SL gap (Review)
2.7
2
p ⬎ .05
SL angle (Day 2)
52
54
p ⬎ .05
SL angle (Review)
64
60
p ⬎ .05
TABLE 2. Influence of Severity of the Lesion (Type of Instability) on Clinical and Radiological Outcomes Dynamic (n ⫽ 12)
Static (n ⫽ 7)
p Value
Flexion (°)
43
37
p ⬎ .05
Extension (°)
52
46
p ⬎ .05
Radial deviation (°)
27
19
p ⬎ .05
Ulnar deviation (°)
31
24
p ⬎ .05
Grip strength (kg)
37
31
p ⬎ .05
Pain (visual analog scale 0–10; 0 represents no pain, 10 represents severe pain)
2.5
3.9
p ⬎ .05
SL gap (Day 2)
2
3
p ⫽ .034
SL gap (Review)
1.8
3.2
p ⫽ .012
SL angle (Day 2)
52
54
p ⬎ .05
SL angle (Review)
62
62
p ⬎ .05
ble 5). The SL angle improved from a mean preoperative value of 61° to 53° immediately after surgery and rose again to 62° at the time of the review. The carpal height remained stable. In 5 wrists, we observed a recurrence of a dorsal tilt of the lunate with radiolunate angle greater than 15° or SL angle greater than 70°. One patient developed a scapholunate advanced collapse wrist stage 2, but this outcome was not considered by the patient as severely debilitating. There was no sign of scaphoid necrosis or fracture of the distal pole of the scaphoid (Fig. 3). Two patients developed postoperative pain dystrophies that needed further management by the pain clinic
and hand therapists. Two patients developed a neuroma (laceration of the dorsal sensory branch of the radial nerve for 1 patient and median palmar cutaneous nerve for the other) that needed scar exploration and neuroma excision. DISCUSSION Since the first report by Destot in 1926,37,38 numerous studies have demonstrated the biomechanical role of the SL complex on carpal motion and force transmission across the wrist. The stability of this couple depends on the SL interosseous ligament, especially its dorsal portion,39 but also on secondary scaphoid stabilizers. These stabilizers are either palmar with the radioscaphocapitate ligament and the scaphotrapezio-trapezoidal ligament40,41,42 or dorsal with the dorsal intercarpal and dorsal radiocarpal ligaments.43 A complete rotatory subluxation of the scaphoid was never observed when only the SL interosseous ligament was sectioned. Besides, static SL instability is noticed solely after a concomitant failure of the distal scaphotrapezio-trapezoidal ligament44,45 or the dorsal intercarpal ligament.46 Scapholunate dissociation is the most common instability pattern of the wrist and can, if untreated, lead to degenerative arthritis of the radiocarpal and, subsequently, of the midcarpal joint. The treatment of chronic SL instability without arthritis remains controversial, with no optimal procedure. The ideal surgical technique should be easy, reliable, and predictable, and should achieve a painfree wrist with preserved range of motion and grip strength, and a normal relationship between carpal bones, both in static and dynamic radiologic views. Any ligamentous reconstruction for complete SL
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TABLE 3.
THE MODIFIED BRUNELLI TENODESIS
Influence of Surgical Procedure on Clinical and Radiological Outcomes Transverse Incision No Fixation (n ⫽ 13)
Longitudinal Incision Pin Fixation (n ⫽ 6)
p Value
Flexion (°)
43
37
p ⬎ .05
Extension (°)
50
51
p ⬎ .05
Radial deviation (°)
26
21
p ⬎ .05
Ulnar deviation (°)
28
31
p ⬎ .05
Grip strength (kg)
34
34
p ⬎ .05
Pain (visual analog scale 0–10; 0 represents no pain, 10 represents severe pain)
2.5
4
p ⬎ .05
SL gap (Day 2)
2
3.3
p ⫽ .015
SL gap (Review)
1.9
3.3
p ⫽ .008
SL angle (Day 2)
52
55
p ⬎ .05
SL angle (Review)
59
68
p ⬎ .05
TABLE 4.
Influence of Postoperative Interval on Clinical and Radiological Outcomes Postoperative Interval ⬍36 Months (n ⫽ 10)
Postoperative Interval ⬎36 Months (n ⫽ 9)
p Value
Flexion (°)
40
41
p ⬎ .05
Extension (°)
45
56
p ⬎ .05
Radial deviation (°)
24
24
p ⬎ .05
Ulnar deviation (°)
26
32
p ⬎ .05
Grip strength (kg)
30
39
p ⬎ .05
Pain (visual analog scale 0–10; 0 represents no pain, 10 represents severe pain)
3.2
2.8
p ⬎ .05
SL gap (Day 2)
1.8
3
p ⫽ .013
SL gap (Review)
1.7
p ⫽ .005
3.1
SL angle (Day 2)
52
54
p ⬎ .05
SL angle (Review)
55
68
p ⫽ .036
TABLE 5.
Radiological Outcomes Preoperative
Immediate Postoperative (Day 2)
Late Postoperative (Review)
SL gap (mm)
2.8
2.4
2.4
Carpal height ratio
0.56
0.53
0.55
SL angle (°)
61
53
62
RL angle (°)
11
8
10
separation must take into consideration all the stabilizing ligaments of the injured scaphoid and not exclusively the SL interosseous ligament.4 Various surgical procedures have been devised to restore the normal carpal alignment and ligamentous con-
straints: bone–ligament– bone autograft,13–18 limited arthrodesis,5–12 and soft tissue repair (dorsal capsulodesis25–32 or tendon graft19 –24). The purpose of this study is to determine whether the modified Brunelli procedure may still have its place
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FIGURE 3: Postoperative radiographs (A posteroanterior, B lateral, C ulnar, and D radial deviation views) at last follow-up visit (36 months) reveal the mobility of the scaphoid and the maintenance of its reduction in dynamic views (SL gap ⫽ 1.6 mm, SL angle ⫽ 59°).
among the soft tissue repairs for reconstructing the SL linkage. An alternative technique is the dorsal capsulodesis,25 which aims to stabilize the forceful flexion of the scaphoid by a flap of wrist capsule inserted into the distal pole of the scaphoid. This procedure is convenient and reliable. The Blatt capsulodesis tethers the scaphoid to the radius. In doing so, the Blatt capsulodesis crosses the radiocarpal joint and limits wrist flexion. Moreover, this procedure fails to correct directly the SL gap.29,30 Unsatisfactory results were reported by Wyrick,28 who considered that this procedure falls short in providing consistent pain relief and maintaining carpal alignment in patients with static SL instability.39,40 This inconvenience led Szabo41 and Schweizer42 to develop a procedure including the dorsal intercarpal ligament for SL reinforcement. In contrast to Blatt’s capsulodesis, this substitute procedure did not cross the radiocarpal joint and did not limit wrist flexion. In addition, by linking the proximal row as a functional unit, a decreased SL diastasis is achieved.44 In their study, Schweizer and Steiger42 reported 4 clinical outcomes that were improved when compared to our findings: pain relief (86% of patients had no to mild pain), average range of motion (84% of the uninvolved wrist), average grip strength (89% of the uninvolved wrist), and maintenance of reduction of SL angle. Nevertheless, 27% of the patients (6/22) showed either radioscaphoid or midcarpal degeneration. Degenerative changes were also observed by Szabo31 in a similar cohort but with a shorter mean follow-up (25 months vs 63 months). From the first reported tendon reconstruction of the SL ligament,19 the procedures have considerably evolved. At that time, the procedure provided unsatisfactory results because the holes drilled into poorly vascularized bone areas induced fractures or joint de-
generations. In addition, they used to cross either radiocarpal or midcarpal joints, which provided wrist stiffness. Although the so-called 4-bone ligament reconstruction20 was based on these 2 principles, Almquist reported satisfactory results. With respect to range of motion (flexion– extension, 89°) and grip strength (73% of the uninvolved wrist), his results are similar to ours. In addition, it must be highlighted that the reported percentage of patients who returned to their preinjury activities was increased in his study (86% vs 63%). However, this discrepancy could be explained by a high rate of patients with an unresolved medicolegal claim. Of note is the rate of failure (8%) that led to intercarpal fusion. Recently, Brunelli21 described a procedure based on the stabilization of both the proximal and the distal ends of the subluxating scaphoid with a strip of FCR that was passed through a tunnel in the distal pole of the scaphoid, pulled dorsally, reducing the scaphoid to its position, and sutured to the dorsal and ulnar edge of the radius. He reported satisfactory results at 1-year follow-up with improved grip strength (65% of the other hand) and a postoperative range of motion limited in flexion (25°) due to the final placing of the tendon onto the radius. In 1998, the method was modified by Van Den Abbeele,22 who anchored the tendon onto the dorsum of the lunate or onto the dorsal radiotriquetral ligament. The results of this short follow-up study (9 months) showed similar results when compared to our study in terms of pain relief, grip strength recovery, and range of motion. The authors also noticed that there was no change in the average SL angle before and after surgery. A significantly diminished recovery was noticed in patients with an unresolved medicolegal claim, as we have observed in our study (Table 1).
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In comparison to the previously published studies,23,24 we noticed similar or better results for grip strength recovery and pain relief, but poorer results for wrist mobility recovery and return to work. This discrepancy could possibly be explained by many patients awaiting settlement of compensation claims. As well, our technique differed from the previously published techniques. The graft was not secured to the lunate by a suture anchor. The modification of our surgical technique during the study failed to reveal any significant differences. Nevertheless, the former procedure was associated with some complications: the neuroma of a radial sensory branch during the removal of K-wires and the scapholunate advanced collapse wrist. The transverse approach was chosen for cosmetic reasons and preservation of the dorsal retinacular ligament. The relevance of this study could have been greater if we had possessed all the preoperative clinical data in order to efficiently assess the postoperative values. A mean follow-up of 37 months was probably not long enough to analyze the long-term efficiency of this technique. Nevertheless, no significant difference for the clinical assessment was observed when the postoperative interval was considered. We noticed an increase in the SL angle only in the group with a follow-up greater than 36 months. Our radiological results suggest a possible stretch of the tendon graft, particularly in the sagittal plane. This is not unexpected because, as it has been described previously, histological and mechanical properties of a tendon graft differ profoundly from those of a ligament.3 In addition, we observed only 1 patient who showed signs of degenerative osteoarthritis. In his study of 38 patients with an average follow-up of 46 months, Garcia-Elias34 related 7 patients with mild signs of degenerative osteoarthritis at the tip of the radial styloid and 2 with global osteoarthritis. The findings of the current study are in accordance with data from previously published works. We report encouraging results on pain relief, strength restoration, and satisfaction. In addition, from a surgeon’s point of view, this technique is reliable and easy to perform. Nevertheless, it may induce a stretch of the tendon graft and lead, in the long term, to deteriorating radiological results. Consequently, a long-term study is required to appreciate the full benefit of this procedure.
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