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Scapholunate ligament repair and capsulodesis for the treatment of static scapholunate dissociation
SCAPHOLUNATE LIGAMENT REPAIR AND CAPSULODESIS FOR THE TREATMENT OF STATIC SCAPHOLUNATE DISSOCIATION J. D. WYRICK, B. D. YOUSE and T. R. KIEFHABER
From the Department of Orthopaedic Surgery, University of Cincinnati and Cincinnati Hand Surgery Specialists, Cincinnati, USA Twenty-four patients were treated with scapholunate ligament repair and dorsal capsulodesis for scapholunate dissociation. Seventeen patients were available for follow-up at an average of 30 months. The average interval between injury and surgery was 3 months. At final follow-up, no patients were pain-free. Average total wrist motion was 60% and grip strength 70% of the opposite normal side. The average preoperative scapholunate angle was 78 ° and was corrected to a normal 47 ° at surgery. The average final scapholunate angle was 72 °, which was not significantly different from the preoperative value. The scapholunate gap likewise was not significantly changed postoperatively. Only two patients had an excellent or good outcome using a clinical grading system, and six out of 17 scored good or excellent using a radiographic grading system. In conclusion, repair of the scapholunate ligament with dorsal capsulodesis failed to provide consistent pain relief and maintain carpal alignment in patients with static scapholunate instability.
Journal of Hand Surgery (British and European Volume, 1998) 23B: 6:776-780 The indications for the procedure included a history of trauma, pain in the wrist, tenderness over the SL joint, a positive Watson's test (Watson and Black, 1987), and radiographic evidence of SL instability (SL diastasis greater than 3 mm and/or SL angle greater than 60°). In 13 patients a SL ligament repair was combined with a dorsal capsulodesis, while the other four had repair of the SL ligament only. The clinical follow-up evaluation was performed by an independent observer who questioned the patients regarding pain, satisfaction with the procedure and return to work status. Measurements of range of motion (ROM) of the wrist and grip strength were obtained and compared with the opposite normal side. The patients were evaluated with a grading system modified from Green and O'Brien (1978) as reported by Glickel and Millender (1984). The clinical grades were based on a scoring system which assigned points from 0 to 4 corresponding to failure and to an excellent result respectively (Table 1). Similarly a radiographic grading system assigned scores for SL gap, cortical ring sign, foreshortening of the scaphoid, capitolunate (CL) angle, SL angle, presence of dorsally intercalated segment instability (DISI) or volar intercalated segment instability (VISI), and osteoarthritis (Glickel and Millender, 1984). Biplanar radiographs obtained at final follow-up were graded by three observers and compared with preoperative and initial postoperative radiographs (Table 2).
Scapholunate dissociation or rotatory subluxation of the scaphoid is the most common type of carpal instability and is a leading cause of wrist arthritis from scapholunate advanced collapse (Watson and Ballet, 1984). If the condition is recognized early, many feel it can be repaired and the likely progression to arthritis halted (Goldner, 1982; Palmer et al. 1978). The treatment of scapholunate dissociation is challenging and a number of procedures have been proposed. Watson et al. (1986) have had success with the scaphotrapeziotrapezoid fusion, but others report less predictable results with the procedure (Kleinman and Carroll, 1990). Blatt (1987) used the technique of dorsal capsulodesis to stabilize the forceful palmar flexion of the distal pole of the scaphoid by a check rein mechanism. Excellent results have been reported following scapholunate (SL) ligament repair and dorsal capsulodesis for scapholunate dissociation regardless of the time elapsed between injury and surgery (Lavernia et al. 1992). Our experience in treating scapholunate dissociation with SL ligament repair and capsulodesis has not been satisfying and this study presents our findings. PATIENTS AND M E T H O D S
Twenty-four patients with scapholunate dissociation were treated with SL ligament repair and capsulodesis. Seventeen patients were available for follow-up examination at an average of 30 months postoperatively (range, 12-84 months). The average age was 35 years (range, 19-51), and 16 were male and one female. Ten patients were manual labourers and the other seven were in professional fields. The dominant hand was involved in ten and the non-dominant in seven. The most common mechanism of injury was a fall on the outstretched hand (11), followed by lifting (3) or a hyperextension injury (3). The average time between injury and surgery was 3 months (range, 3 days to 16 months).
Surgical technique
The surgical technique was similar to that described by Lavernia et al. (1992). The only modification was the use of Mitek (Johnson and Johnson, Westwood, MA, USA) suture anchors to repair the SL ligament and the dorsal capsule to the scaphoid. Postoperatively, the patients were immobilized until the pins were taken out 776
SL REPAIR AND CAPSULODESIS
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Table 1--Clinical grading system
Table 2--Radiographic grading system
Pain
Scapholunate gap: (2) < 2 m m (0) > 2 m m
(4) N o pain (3) Occasional mild pain; no interference with activity (2) Pain with overuse of lifting; n o t severe enough to decrease activity (1) Pain with overuse or lifting; severe e n o u g h to decrease activity (0) Severe debilitating pain or rest pain R O M (total flexion and extension c o m p a r e d with uninvolved wrist) (4) 100% (3) 75% to 100% (2) 50% to 75% (1) 25% to 50% (0) 0% to 25% Grip strength (4) (3) (2) (1) (0)
(compared with uninvolved wrist) 100% 75% to 100% 50% to 75% 25% to 50% 0% to 25%
Patient satisfaction (4) Excellent (3) G o o d (2) Fair (1) Poor (0) Failure Overall scores Excellent 15 to 16 G o o d 11 to 14 Fair 7 to 10 Poor < 6
Note." Scores in each category are added.
at 10 weeks. Range of motion and strengthening exercises were then started and unrestricted activity permitted at 6 months.
RESULTS Clinical Results
Cortical ring sign: (2) Absent (0) Present Foreshortened scaphoid: (2) Absent : (0) Present CL angle: (2) 0 ° to 10 ° (1) 10 ° to 20 ° (0) 20 ° SL angle: (2) < 70 ° (DISI); > 40 ° (VISI) (1) 70 ° to 80 ° (DISI); 30 ° to 40 ° (VlSI) (0) > 80 ° (DISI); < 30 ° (VlSI) DISI/VISI: (2) Absent (1) Borderline (0) Present Osteoarthritis: (3) Absent (2) 1+ (1) 2+
(0) 3+ Overall scores: Excellent 14 to 15 G o o d 11 to 13 Fair 7 to 10 Poor < 6
Table 3--Average ranges of motion
Affected Extension Flexion Radial deviation Ulnar deviation Total arc
44 ° 47 ° 5° 28 ° 131 o
Opposite 72 ° 77 ° 17 ° 48 ° 220 °
Percentage 61 6l 26 58 60
No patients stated they were completely free of pain. Seven patients reported they continued to have pain even at rest. Surprisingly, nine patients stated they would have the surgery again because they felt they would be worse without it. The total arc of motion including flexion, extension, radial and ulnar deviation was decreased to 60% of the opposite normal wrist (Table 3). Average grip strength was 71% compared with the opposite wrist.
Six patients who were heavy labourers had to change jobs. Four patients involved in heavy labour returned to their previous position. The other seven were not affected in their return to work.
Clinical grades
Radiographs
The average overall clinical score was 8 which is in the fair category. Only two patients scored in the good to excellent range whereas 15 patients scored fair to poor.
The average preoperative SL and CL angles were 78 ° (range, 45-95 °) and 15° (range, 0-35 °) respectively, and the SL gap was 4 mm (range, 2-6 ram). The initial
Return to work
778
postoperative film showed an average corrected SL angle of 47 ° (range, 30-77°), CL angle of 5° (range, 0~20°), and SL gap of 2 mm (range, 1-3 mm). At final follow-up, the average SL angle was 72 ° (range, 58-103°), the CL angle was 17° (range, 2-37°), and the SL gap was 3 mm (range, 0-8 mm). The follow-up values did not differ significantly from the preoperative measurements.
Radiographic grades The grades correspond to the above measurements in that there was no significant difference between the preoperative grade and the final follow-up. The average preoperative grade was 6.8, the initial average grade was 13 and the final grade was 7.1. Only two patients improved radiographically; one went from poor (score = 5) to good (score = 11), and one went from poor (score = 3) to fair (score = 7). In the initial postoperative radiographs, all but one patient was corrected to the excellent to good range. This correction was not maintained, however (Fig 1).
Secondary operations Four patients have required further surgery for relief of pain; two required proximal row carpectomy, and two have had total wrist fusions.
Complications One patient had a pin tract infection requiring pin removal at 3 weeks. The wrist subsequently collapsed into a dorsiflexion instability posture, but despite reporting severe pain in the wrist, he returned to his previous job as a welder. DISCUSSION The primary goals in the treatment of SL dissociation must be stabilization of the carpal bones in proper alignment and maintenance of wrist mobility. However, the best way to attain these goals is still unknown. There have been many reports of successful treatment of this problem, but the results have not been ,corroborated by other surgeons. Early reports on scaphotrapeziotrapezoid arthrodesis in the treatment of SL dissociation were very promising (Eckenrode et al, 1986; Kleinman, 1987; Kleinman et al. 1982; Watson et al. 1986; Watson and Black, 1987). However, with longer follow-up, the limitations and pitfalls of this procedure were realized and other techniques were investigated (Eckenrode et al. 1986; Kleinman and Carroll, 1990). Soft tissue repairs and reconstructions are popular because they attempt to restore the normal kinematics of the wrist (Almquist et al. 1991; Blatt, 1987; Glickel and Millender, 1984; Goldner, 1982; Lavernia et al. 1992).
THE J O U R N A L OF H A N D SURGERY VOL. 23B No. 6 DECEMBER 1998
However, these procedures have also produced inconsistent results. Blatt (1987) reported excellent results in 12 patients treated with dorsal capsulodesis. All patients had excellent range of motion, grip strength, and none had recurrent subluxation. More recently, Lavernia et al (1992) reported on 21 patients treated with SL ligament repair with a dorsal capsulodesis. The average time from injury to surgery was 17 months with an average followup of 3 years. All patients reported decreased pain, no significant decrease in range of motion, and overall satisfaction with the procedure. In no patient did the condition progress to advanced carpal collapse. Our surgical approach to the problem of SL dissociation has been similar to Lavernia et al. (1992); however, our results are vastly different. At an average of 30 months follow-up, 60% of our patients still have pain with activities of daily living. Even more disturbing is the finding that the excellent carpal alignment obtained at surgery was not maintained. The final SL and CL angles of 72 ° and 17° respectively were not significantly different from the preoperative values of 78 ° and 15 ° . Obviously this repair cannot withstand the large forces this instability places upon it. Why are these results so poor compared to the previous studies? Patient selection appears to play the most important role in outcome. In the series by Lavernia et al (1992) the average preoperative SL angle was 62 °, which is only slightly above the normal range of 30 ° to 60 ° as defined by Linscheid et al. (1972). The average postoperative SL angle was 57 °, which is also not significantly different from the preoperative measurement in their patients. Their series must include fewer patients with true rotatory subluxation of the scaphoid as their average preoperative SL angle was 62 ° versus 72 ° in the current series. This may represent treatment of patients with dynamic instability rather than static instability as reported here (Taleisnik, 1988). Since the patients in this series did so poorly with regard to improved clinical grading, it is difficult to make recommendations about who may benefit from this operation. The degree of instability in this group of patients obviously could not be controlled by repair of the SL ligament with a capsulodesis. William Cooney (personal communication) has recommended the following criteria in the treatment of patients with SL dissociation by soft tissue repair or reconstruction. Patients should: 1) be less than 1 year from injury; 2) not be involved in heavy manual labour; 3) have a SL angle of less than 70°; and 4) have a SL gap of less than 5 ram. Possibly by using these strict criteria, the outcome may become more predictable. In conclusion, scapholunate ligament repair and dorsal capsulodesis cannot be recommended for the treatment of static scapholunate dissociation. The procedure may be useful in patients with mild instability. Further studies comparing soft tissue reconstructions and limited intercarpal fusions are needed to determine the best treatment for static scapholunate dissociation.
SL REPAIR AND CAPSULODESIS
779
Fig 1 Failed SL ligament repair and capsulodesis. (A,B) Radiographs 2 months following injury demonstrating static SL dissociation. (C,D) Two weeks following SL repair and capsulodesis demonstrating good reduction and normal alignment. (E,F) Two years postoperative radiographs demonstrating loss of alignment and collapse to original position.
780
References Almquist EE, Bach AW, Sack JT, Fnhs SE, Newman DM (1991). Four-bone ligament reconstruction for treatment of chronic scapholunate separation. Journal of Hand Surgery, 16A: 322-327. Blatt G (1987). Capsulodesis in reconstructive hand surgery. Dorsal capsulodesis for the unstable scaphoid and volar capsulodesis following excision of the distal ulna. Hand Clinics, 3:81-102. Eckenrode JF, Louis DS, Greene TL, (1986). Scaphoid-trapezium-trapezoid fusion in the treatment of chronic scapholunate instability. Journal of Hand Surgery, 1 IA: 497-502. Glickel SZ, Millender LH (1984). Ligamentous reconstruction for chronic intercarpal instability. Journal of Hand Surgery, 9A: 514-527. Goldner JL (1982). Treatment of carpal instability without joint fusion - current assessment. Journal of Hand Surgery, 7:325 326. Green DP, O'Brien ET (1978). Open reduction of carpal dislocation: Indications and operative techniques. Journal of Hand Surgery, 3: 250-265. Kleinman WB (1987). Management of chronic rotary subluxation of the scaphoid by scapho-trapezio-trapezoid arthrodesis. Hand Clinics, 3:113-133. Kleinman WB, Carroll C (1990). Scaphotrapezio-trapezoid arthrodesis for treatment of chronic static and dynamic scapho-lunate instability: A 10-year perspective on pitfalls and complications. Journal of Hand Surgery, 15A: 408-414. Kleinman WB, Steichen JB, Strickland JW (1982). Management of chronic rotary subluxation of the scaphoid by scapho-trapezio-trapezoid arthrodesis. Journal of Hand Surgery, 7: 125-136.
THE JOURNAL OF HAND SURGERY VOL. 23B No. 6 DECEMBER 1998 Lavernia CJ, Cohen MS, Taleisnik J (1992). Treatment of scapholunate dissociation by ligamentous repair and capsulodesis. Journal of Hand Surgery, 17A: 354-359. Linscheid RL, Dobyns JH, Beabout JW, Bryan RS (1972). Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. Journal of Bone and Joint Surgery, 54A: 1612-1632. Palmer AK, Dobyns JH, Linscheid RL (1978). Management of post-traumatic instability of the wrist secondary to ligament rupture. Journal of Hand Surgery, 3:507 532. Taleisnik J (1988). Current concepts review. Carpal instability. Journal of Bone and Joint Surgery, 70A: 1262-1268. Watson HK, Ballet FL (1984). The SLAC wrist: Scapholunate advanced collapse pattern of degenerative arthritis. Journal of Hand Surgery, 9A: 358-365. Wa|son HK, Black DM (1987). Instabilities of the wrist. Hand Clinics, 3:103 111. Watson HK, Ryu J, Akelman E (1986). Limited triscaphoid intercarpal arthrodesis for rotatory subluxation of the scaphoid. Journal of Bone and Joint Surgery, 68A: 345-349.
Received: 8 October 1997 Accepted after revision.27 March 1998 J. D. Wyrick MD, Universityof Cincinnati, Department of Orthopaedic Surgery,231 Bethesda Avenue,ML 212, Cincinnati, OH 45267-0212, USA. E-mail: [email protected] © 1998The British Societyfor Surgeryof the Hand
From the Department of Orthopaedic Surgery, University of Cincinnati and Cincinnati Hand Surgery Specialists, Cincinnati, USA Twenty-four patients were treated with scapholunate ligament repair and dorsal capsulodesis for scapholunate dissociation. Seventeen patients were available for follow-up at an average of 30 months. The average interval between injury and surgery was 3 months. At final follow-up, no patients were pain-free. Average total wrist motion was 60% and grip strength 70% of the opposite normal side. The average preoperative scapholunate angle was 78 ° and was corrected to a normal 47 ° at surgery. The average final scapholunate angle was 72 °, which was not significantly different from the preoperative value. The scapholunate gap likewise was not significantly changed postoperatively. Only two patients had an excellent or good outcome using a clinical grading system, and six out of 17 scored good or excellent using a radiographic grading system. In conclusion, repair of the scapholunate ligament with dorsal capsulodesis failed to provide consistent pain relief and maintain carpal alignment in patients with static scapholunate instability.
Journal of Hand Surgery (British and European Volume, 1998) 23B: 6:776-780 The indications for the procedure included a history of trauma, pain in the wrist, tenderness over the SL joint, a positive Watson's test (Watson and Black, 1987), and radiographic evidence of SL instability (SL diastasis greater than 3 mm and/or SL angle greater than 60°). In 13 patients a SL ligament repair was combined with a dorsal capsulodesis, while the other four had repair of the SL ligament only. The clinical follow-up evaluation was performed by an independent observer who questioned the patients regarding pain, satisfaction with the procedure and return to work status. Measurements of range of motion (ROM) of the wrist and grip strength were obtained and compared with the opposite normal side. The patients were evaluated with a grading system modified from Green and O'Brien (1978) as reported by Glickel and Millender (1984). The clinical grades were based on a scoring system which assigned points from 0 to 4 corresponding to failure and to an excellent result respectively (Table 1). Similarly a radiographic grading system assigned scores for SL gap, cortical ring sign, foreshortening of the scaphoid, capitolunate (CL) angle, SL angle, presence of dorsally intercalated segment instability (DISI) or volar intercalated segment instability (VISI), and osteoarthritis (Glickel and Millender, 1984). Biplanar radiographs obtained at final follow-up were graded by three observers and compared with preoperative and initial postoperative radiographs (Table 2).
Scapholunate dissociation or rotatory subluxation of the scaphoid is the most common type of carpal instability and is a leading cause of wrist arthritis from scapholunate advanced collapse (Watson and Ballet, 1984). If the condition is recognized early, many feel it can be repaired and the likely progression to arthritis halted (Goldner, 1982; Palmer et al. 1978). The treatment of scapholunate dissociation is challenging and a number of procedures have been proposed. Watson et al. (1986) have had success with the scaphotrapeziotrapezoid fusion, but others report less predictable results with the procedure (Kleinman and Carroll, 1990). Blatt (1987) used the technique of dorsal capsulodesis to stabilize the forceful palmar flexion of the distal pole of the scaphoid by a check rein mechanism. Excellent results have been reported following scapholunate (SL) ligament repair and dorsal capsulodesis for scapholunate dissociation regardless of the time elapsed between injury and surgery (Lavernia et al. 1992). Our experience in treating scapholunate dissociation with SL ligament repair and capsulodesis has not been satisfying and this study presents our findings. PATIENTS AND M E T H O D S
Twenty-four patients with scapholunate dissociation were treated with SL ligament repair and capsulodesis. Seventeen patients were available for follow-up examination at an average of 30 months postoperatively (range, 12-84 months). The average age was 35 years (range, 19-51), and 16 were male and one female. Ten patients were manual labourers and the other seven were in professional fields. The dominant hand was involved in ten and the non-dominant in seven. The most common mechanism of injury was a fall on the outstretched hand (11), followed by lifting (3) or a hyperextension injury (3). The average time between injury and surgery was 3 months (range, 3 days to 16 months).
Surgical technique
The surgical technique was similar to that described by Lavernia et al. (1992). The only modification was the use of Mitek (Johnson and Johnson, Westwood, MA, USA) suture anchors to repair the SL ligament and the dorsal capsule to the scaphoid. Postoperatively, the patients were immobilized until the pins were taken out 776
SL REPAIR AND CAPSULODESIS
777
Table 1--Clinical grading system
Table 2--Radiographic grading system
Pain
Scapholunate gap: (2) < 2 m m (0) > 2 m m
(4) N o pain (3) Occasional mild pain; no interference with activity (2) Pain with overuse of lifting; n o t severe enough to decrease activity (1) Pain with overuse or lifting; severe e n o u g h to decrease activity (0) Severe debilitating pain or rest pain R O M (total flexion and extension c o m p a r e d with uninvolved wrist) (4) 100% (3) 75% to 100% (2) 50% to 75% (1) 25% to 50% (0) 0% to 25% Grip strength (4) (3) (2) (1) (0)
(compared with uninvolved wrist) 100% 75% to 100% 50% to 75% 25% to 50% 0% to 25%
Patient satisfaction (4) Excellent (3) G o o d (2) Fair (1) Poor (0) Failure Overall scores Excellent 15 to 16 G o o d 11 to 14 Fair 7 to 10 Poor < 6
Note." Scores in each category are added.
at 10 weeks. Range of motion and strengthening exercises were then started and unrestricted activity permitted at 6 months.
RESULTS Clinical Results
Cortical ring sign: (2) Absent (0) Present Foreshortened scaphoid: (2) Absent : (0) Present CL angle: (2) 0 ° to 10 ° (1) 10 ° to 20 ° (0) 20 ° SL angle: (2) < 70 ° (DISI); > 40 ° (VISI) (1) 70 ° to 80 ° (DISI); 30 ° to 40 ° (VlSI) (0) > 80 ° (DISI); < 30 ° (VlSI) DISI/VISI: (2) Absent (1) Borderline (0) Present Osteoarthritis: (3) Absent (2) 1+ (1) 2+
(0) 3+ Overall scores: Excellent 14 to 15 G o o d 11 to 13 Fair 7 to 10 Poor < 6
Table 3--Average ranges of motion
Affected Extension Flexion Radial deviation Ulnar deviation Total arc
44 ° 47 ° 5° 28 ° 131 o
Opposite 72 ° 77 ° 17 ° 48 ° 220 °
Percentage 61 6l 26 58 60
No patients stated they were completely free of pain. Seven patients reported they continued to have pain even at rest. Surprisingly, nine patients stated they would have the surgery again because they felt they would be worse without it. The total arc of motion including flexion, extension, radial and ulnar deviation was decreased to 60% of the opposite normal wrist (Table 3). Average grip strength was 71% compared with the opposite wrist.
Six patients who were heavy labourers had to change jobs. Four patients involved in heavy labour returned to their previous position. The other seven were not affected in their return to work.
Clinical grades
Radiographs
The average overall clinical score was 8 which is in the fair category. Only two patients scored in the good to excellent range whereas 15 patients scored fair to poor.
The average preoperative SL and CL angles were 78 ° (range, 45-95 °) and 15° (range, 0-35 °) respectively, and the SL gap was 4 mm (range, 2-6 ram). The initial
Return to work
778
postoperative film showed an average corrected SL angle of 47 ° (range, 30-77°), CL angle of 5° (range, 0~20°), and SL gap of 2 mm (range, 1-3 mm). At final follow-up, the average SL angle was 72 ° (range, 58-103°), the CL angle was 17° (range, 2-37°), and the SL gap was 3 mm (range, 0-8 mm). The follow-up values did not differ significantly from the preoperative measurements.
Radiographic grades The grades correspond to the above measurements in that there was no significant difference between the preoperative grade and the final follow-up. The average preoperative grade was 6.8, the initial average grade was 13 and the final grade was 7.1. Only two patients improved radiographically; one went from poor (score = 5) to good (score = 11), and one went from poor (score = 3) to fair (score = 7). In the initial postoperative radiographs, all but one patient was corrected to the excellent to good range. This correction was not maintained, however (Fig 1).
Secondary operations Four patients have required further surgery for relief of pain; two required proximal row carpectomy, and two have had total wrist fusions.
Complications One patient had a pin tract infection requiring pin removal at 3 weeks. The wrist subsequently collapsed into a dorsiflexion instability posture, but despite reporting severe pain in the wrist, he returned to his previous job as a welder. DISCUSSION The primary goals in the treatment of SL dissociation must be stabilization of the carpal bones in proper alignment and maintenance of wrist mobility. However, the best way to attain these goals is still unknown. There have been many reports of successful treatment of this problem, but the results have not been ,corroborated by other surgeons. Early reports on scaphotrapeziotrapezoid arthrodesis in the treatment of SL dissociation were very promising (Eckenrode et al, 1986; Kleinman, 1987; Kleinman et al. 1982; Watson et al. 1986; Watson and Black, 1987). However, with longer follow-up, the limitations and pitfalls of this procedure were realized and other techniques were investigated (Eckenrode et al. 1986; Kleinman and Carroll, 1990). Soft tissue repairs and reconstructions are popular because they attempt to restore the normal kinematics of the wrist (Almquist et al. 1991; Blatt, 1987; Glickel and Millender, 1984; Goldner, 1982; Lavernia et al. 1992).
THE J O U R N A L OF H A N D SURGERY VOL. 23B No. 6 DECEMBER 1998
However, these procedures have also produced inconsistent results. Blatt (1987) reported excellent results in 12 patients treated with dorsal capsulodesis. All patients had excellent range of motion, grip strength, and none had recurrent subluxation. More recently, Lavernia et al (1992) reported on 21 patients treated with SL ligament repair with a dorsal capsulodesis. The average time from injury to surgery was 17 months with an average followup of 3 years. All patients reported decreased pain, no significant decrease in range of motion, and overall satisfaction with the procedure. In no patient did the condition progress to advanced carpal collapse. Our surgical approach to the problem of SL dissociation has been similar to Lavernia et al. (1992); however, our results are vastly different. At an average of 30 months follow-up, 60% of our patients still have pain with activities of daily living. Even more disturbing is the finding that the excellent carpal alignment obtained at surgery was not maintained. The final SL and CL angles of 72 ° and 17° respectively were not significantly different from the preoperative values of 78 ° and 15 ° . Obviously this repair cannot withstand the large forces this instability places upon it. Why are these results so poor compared to the previous studies? Patient selection appears to play the most important role in outcome. In the series by Lavernia et al (1992) the average preoperative SL angle was 62 °, which is only slightly above the normal range of 30 ° to 60 ° as defined by Linscheid et al. (1972). The average postoperative SL angle was 57 °, which is also not significantly different from the preoperative measurement in their patients. Their series must include fewer patients with true rotatory subluxation of the scaphoid as their average preoperative SL angle was 62 ° versus 72 ° in the current series. This may represent treatment of patients with dynamic instability rather than static instability as reported here (Taleisnik, 1988). Since the patients in this series did so poorly with regard to improved clinical grading, it is difficult to make recommendations about who may benefit from this operation. The degree of instability in this group of patients obviously could not be controlled by repair of the SL ligament with a capsulodesis. William Cooney (personal communication) has recommended the following criteria in the treatment of patients with SL dissociation by soft tissue repair or reconstruction. Patients should: 1) be less than 1 year from injury; 2) not be involved in heavy manual labour; 3) have a SL angle of less than 70°; and 4) have a SL gap of less than 5 ram. Possibly by using these strict criteria, the outcome may become more predictable. In conclusion, scapholunate ligament repair and dorsal capsulodesis cannot be recommended for the treatment of static scapholunate dissociation. The procedure may be useful in patients with mild instability. Further studies comparing soft tissue reconstructions and limited intercarpal fusions are needed to determine the best treatment for static scapholunate dissociation.
SL REPAIR AND CAPSULODESIS
779
Fig 1 Failed SL ligament repair and capsulodesis. (A,B) Radiographs 2 months following injury demonstrating static SL dissociation. (C,D) Two weeks following SL repair and capsulodesis demonstrating good reduction and normal alignment. (E,F) Two years postoperative radiographs demonstrating loss of alignment and collapse to original position.
780
References Almquist EE, Bach AW, Sack JT, Fnhs SE, Newman DM (1991). Four-bone ligament reconstruction for treatment of chronic scapholunate separation. Journal of Hand Surgery, 16A: 322-327. Blatt G (1987). Capsulodesis in reconstructive hand surgery. Dorsal capsulodesis for the unstable scaphoid and volar capsulodesis following excision of the distal ulna. Hand Clinics, 3:81-102. Eckenrode JF, Louis DS, Greene TL, (1986). Scaphoid-trapezium-trapezoid fusion in the treatment of chronic scapholunate instability. Journal of Hand Surgery, 1 IA: 497-502. Glickel SZ, Millender LH (1984). Ligamentous reconstruction for chronic intercarpal instability. Journal of Hand Surgery, 9A: 514-527. Goldner JL (1982). Treatment of carpal instability without joint fusion - current assessment. Journal of Hand Surgery, 7:325 326. Green DP, O'Brien ET (1978). Open reduction of carpal dislocation: Indications and operative techniques. Journal of Hand Surgery, 3: 250-265. Kleinman WB (1987). Management of chronic rotary subluxation of the scaphoid by scapho-trapezio-trapezoid arthrodesis. Hand Clinics, 3:113-133. Kleinman WB, Carroll C (1990). Scaphotrapezio-trapezoid arthrodesis for treatment of chronic static and dynamic scapho-lunate instability: A 10-year perspective on pitfalls and complications. Journal of Hand Surgery, 15A: 408-414. Kleinman WB, Steichen JB, Strickland JW (1982). Management of chronic rotary subluxation of the scaphoid by scapho-trapezio-trapezoid arthrodesis. Journal of Hand Surgery, 7: 125-136.
THE JOURNAL OF HAND SURGERY VOL. 23B No. 6 DECEMBER 1998 Lavernia CJ, Cohen MS, Taleisnik J (1992). Treatment of scapholunate dissociation by ligamentous repair and capsulodesis. Journal of Hand Surgery, 17A: 354-359. Linscheid RL, Dobyns JH, Beabout JW, Bryan RS (1972). Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. Journal of Bone and Joint Surgery, 54A: 1612-1632. Palmer AK, Dobyns JH, Linscheid RL (1978). Management of post-traumatic instability of the wrist secondary to ligament rupture. Journal of Hand Surgery, 3:507 532. Taleisnik J (1988). Current concepts review. Carpal instability. Journal of Bone and Joint Surgery, 70A: 1262-1268. Watson HK, Ballet FL (1984). The SLAC wrist: Scapholunate advanced collapse pattern of degenerative arthritis. Journal of Hand Surgery, 9A: 358-365. Wa|son HK, Black DM (1987). Instabilities of the wrist. Hand Clinics, 3:103 111. Watson HK, Ryu J, Akelman E (1986). Limited triscaphoid intercarpal arthrodesis for rotatory subluxation of the scaphoid. Journal of Bone and Joint Surgery, 68A: 345-349.
Received: 8 October 1997 Accepted after revision.27 March 1998 J. D. Wyrick MD, Universityof Cincinnati, Department of Orthopaedic Surgery,231 Bethesda Avenue,ML 212, Cincinnati, OH 45267-0212, USA. E-mail: [email protected] © 1998The British Societyfor Surgeryof the Hand