Arthroscopic management of scapholunate complex injuries associated with distal radius fractures.

Scapholunate complex injuries are the most frequent lesions associated with distal radius fractures and the treatment algorithm according to the stage of the instability remains controversial. However, there is an admitted consensus around the necessary treatment of the associated high-grade instabilities. They occur frequently in young patients after high energy trauma, and not treated, they can lead to chronic wrist pain and eventually to scapholunate advanced collapse. The routine use of the arthroscopy provides an accurate intraoperative staging of the lesions and allows a tailored treatment depending on the severity of the scapholunate instability.

Arthroscopic suture in the management of palmar midcarpal instability.

Aims: Patients with midcarpal instability are difficult to manage. It is a rare condition, and few studies have reported the outcomes of surgical treatment. No prospective or retrospective study has reported the results of arthroscopic palmar capsuloligamentous suturing. Our aim was to report the results of a prospective study of arthroscopic suture of this ligament complex in patients with midcarpal instability. Methods: This prospective single-centre study was undertaken between March 2012 and May 2022. The primary outcome was to evaluate the functional outcomes of arthroscopic palmar midcarpal suture. The study included 12 patients, eight male and four female, with a mean age of 27.5 years (19 to 42). They were reviewed at three months, six months, and one year postoperatively. Results: There was a significant improvement in flexion, extension, grip strength, abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire score, and pain, in all patients. After telephone contact with all patients in March 2023, at a mean follow-up of 3.85 years (2.2 to 6.25), no patient had a persistent or recurrent clunk. Conclusion: Arthroscopic suture of the midcarpal capsuloligamentous complex represents a minimally invasive, easy, and reproducible technique for the management of patients with midcarpal instbility, with a clear improvement in function outcomes and no complications.

Radiologic Evolution after Scapholunate Dorsal Capsulodesis for Chronic Tears.

Background Many debates are still ongoing for the management of chronic scapholunate (SL) injuries. We have proposed an arthroscopic technique of dorsal capsulodesis with good clinical results. We now propose a radiological follow-up. Purpose To determine if arthroscopic dorsal capsulodesis can improve the radiographic SL angle and maintain this correction over time. Methods From January 2020 to January 2021, we included every patient with an SL instability and sorted them according to the European Wrist Arthroscopy Society (EWAS) classification. All patients had bilateral X-rays with a measurement of the radiolunate (RL) and SL angles for both the pathologic and healthy side. We also included patients with lunotriquetral or triangular fibrocartilage complex lesions. The exclusion criteria were the presence of arthritis and persistent intraoperative SL instability after capsulodesis. An arthroscopic dorsal capsulodesis was performed in all patients as originally described by Mathoulin. The RL and SL angles were then again measured on the immediate postoperative X-ray, and then again at 3, 6, and 12 months postoperatively. The statistical analysis was done using a paired Student's t -test with 145 degrees of freedom and α = 0.05. Results We included a total of 146 patients with a 1-year follow-up. Both the RL angle and the SL angles approach the healthy side at 12 months postoperatively. The RL angle has increased from -7.23 degrees to 4.37 degrees; the difference is still statistically significative, but it is almost equal to the healthy side (5.16 degrees). The SL angle has lowered from 74.55 to 54.95; the difference is still statistically and radiologically significative (6.788 degrees) but has been lowered by 74.3%. Conclusion This study shows that this technique can normalize the dorsal intercalated segment instability (DISI) over time without the need for any pinning or invasive ligament reconstructive surgery. Level of Evidence Level IV, cohort study. Clinical Relevance Dorsal capsulodesis should be considered in all reducible SL injuries, even when DISI is present.

Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of "0," "5," and "10" reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of "8" or higher for 80% or more of the panelists. RESULTS: Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds. CONCLUSIONS: Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC. CLINICAL RELEVANCE STATEMENT: MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries. KEY POINTS: • Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.

Surgical Technique: Wide Arthroscopic Dorsal Capsuloligamentous Repair for Advanced Scapholunate Instability.

In the most advanced cases of scapholunate instability with dynamic or static signs, classical arthroscopic repair seems impossible. Ligamentoplasties or open surgery procedures are technically demanding, hampered by significant operative complications and often stiffening. Therapeutic simplification is therefore necessary for the management of these complex cases of advanced scapholunate instability. We propose a minimally invasive, reliable, and easily reproducible solution that requires little equipment other than arthroscopic material.

Wide arthroscopic dorsal capsuloligamentous repair in patients with severe scapholunate instability.

A conventional arthroscopic capsuloligamentous repair is a reliable surgical solution in most patients with scapholunate instability. However, this repair does not seem to be sufficient for more advanced injuries. The aim of this study was to evaluate the functional results of a wide arthroscopic dorsal capsuloligamentous repair (WADCLR) in the management of severe scapholunate instability. This was a prospective single-centre study undertaken between March 2019 and May 2021. The primary outcome was the evaluation of the reduction of the radiological deformity and the functional outcomes after WADCLR. A secondary outcome was the evaluation of the effectiveness of this technique in patients with the most severe instability (European Wrist Arthroscopy Society (EWAS) stage 5). The patients were reviewed postoperatively at three, six, and 12 months. The study included 112 patients (70 male and 42 female). Their mean age was 31.6 years (16 to 55). A total of three patients had EWAS stage 3A injuries, 12 had stage 3B injuries, 29 had stage 3C injuries, 56 had stage 4 injuries, and 12 had stage 5 injuries. There was a significant improvement of the radiological signs in all patients with a return to normal values. There was also a significant improvement in all aspects of function except for flexion, in which the mean increase was negligible (0.18° on average). There was also a significant improvement in all criteria for patients with a stage 5 injury, except for some limitation of extension, flexion, and radial and ulnar deviation, although these showed a trend towards improvement (except for flexion). WADCLR is a minimally invasive, easy, and reproducible technique with few complications, offering a clear improvement in function and a reduction in the radiological deformity at one year postoperatively.

Arthroscopic Radiocarpal Tendinous Inter-Position for Grade 2 Scapholunate Advanced Collapse - Surgical Technique.

Grade 2 scapholunate advanced collapse (SLAC 2) can be treated by proximal row carpectomy with satisfactory results. However, this method is invasive and can limit function. The senior author had proposed an arthroscopic alternative with tendon interposition between the radius and proximal carpal row (arthroscopic interposition tendon arthroplasty [AITA]). However, this arthroscopic technique is technically difficult and requires a risky palmar arthroscopic portal. We report a modification of AITA, the one-loop arthroscopic radiocarpal tendon inter-position (1L-ARTI) that is simpler and needs only dorsal arthroscopic portals. Level of Evidence: Level V (Therapeutic).

Arthroscopic Midcarpal Tendon Interposition: A New Technique for Capitolunate Constraints.

Conflicts of the capitolunate, causing midcarpal pain from friction can be isolated (e.g., avascular necrosis of the proximal pole of the capitate [AVNC], palmar midcarpal instability [PMCI]) or form part of a framework of more complex osteoarthritis phenomena (e.g., scaphoid pseudarthrosis [SNAC], and lesions of the scapholunate capsuloligamentous complex [SLAC]). We group in the term "conflict" all of the causes (with intact cartilage or not) causing midcarpal pain by friction. Treatment by capitolunar arthrodesis can be effective, but inevitably stiffening. In other more specific cases (i.e., AVNC), replacement of the proximal pole of the capitate with a synthetic implant or a tendon has shown variable results. In this work, we propose a management of these conflicts with a conservative arthroscopic technique, including capitolunate tendon interposition. We describe arthroscopic midcarpal tendon interposition (AMTI) for capitolunate conflicts. This technique prevents stiffness due to arthrodesis, but good experience in wrist arthroscopy is required to perform this operation.

History of Wrist Arthroscopy.

Wrist arthroscopy has a rich history, drawing on contributions from around the world. Its foundation was laid in Japan with Kenji Takagi and Masaki Watanabe, who developed the arthroscope and the techniques for arthroscopy. Across several decades they advanced the optic and lighting technology, allowing the miniaturization which made wrist arthroscopy technologically feasible. A safe and standardized technique for wrist arthroscopy was evolved by Terry Whipple, Gary Poehling, and James Roth in the 1980s, and they shared this with their fellow surgeons through courses and publications. The techniques then spread across the world, leading to widespread uptake and exploration of new therapeutic possibilities. The worldwide spread of wrist arthroscopy was accelerated by the European Wrist Arthroscopy Society (EWAS), founded in 2005 by Christophe Mathoulin. The Asia Pacific Wrist Association (APWA), founded by PC Ho in 2015, also extended the progression of wrist arthroscopy. This article brings together this history and tells the global story of its development through the recollections of those involved. The manuscript includes some amazing videos of the early historical arthroscopy. There are also videos of Gary and Terry describing some of their special memories of the early politics, developments, and evolution of wrist arthroscopy.

Arthroscopic Repair of the Dorsal Intercarpal Ligament Detachment from the Scaphoid.

Background The dorsal intercarpal ligament, whose role in dorsal stability of the wrist has been shown, can be harmed in case of injury to the dorsal scapholunate complex. However, dorsal intercarpal ligament injury also seems to exist isolated posttraumatic forms of dorsal intercarpal ligament rupture, much rarer, through bony avulsion on its scaphoid insertion. The authors report the first description of this lesion, and propose a technique for arthroscopic repair. Description of Technique Radiocarpal arthroscopy will confirm the bony avulsion of the dorsal intercarpal ligament from the scaphoid. Under arthroscopic control, an anchor can be placed into the dorsal aspect of the scaphoid and the ligament can be reattached along with the dorsal capsule. Patients and Methods Between 2018 and 2020, seven patients underwent arthroscopic repair of this particular injury. They presented a painful preoperative wrist with decreased range of motion, and were treated arthroscopically, with anchored reinsertion of the ligament on the scaphoid. Results After a mean follow-up period of 12 months, arthroscopic repair showed decreased pain (6.7 to 0.2), improved range of motion in flexion (66 to 82 degrees) and extension (57 to 87 degrees°), and improved Disabilities of the Arm, Shoulder, and Hand (DASH) score (68.45 to 2.23). Conclusions This lesion has so far never been reported in the literature, and seems mechanically different from more common injuries of the scapholunate complex and dorsal capsulo-scapholunate septum with which dorsal intercarpal ligament ruptures are frequently associated. Arthroscopic repair with an anchor is possible without difficulty and seems to give very good results at 1-year follow-up (normal strength and range of motion).

Interdisciplinary consensus statements on imaging of scapholunate joint instability.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of '0', '5' and '10' reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of '8' or higher for 80% or more of the panellists. RESULTS: Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available. CONCLUSIONS: Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability. KEY POINTS: • Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability. • Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability. • Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

Scapholunate injuries: challenging existing dogmas in anatomy and surgical techniques.

The management of scapholunate injuries and dissociation remains debatable. Traditional methods of fixation had centred around open procedures, but advances in wrist arthroscopic techniques has redefined both major anatomical findings and operative approaches. This article challenges two main existing dogmas: first, the anatomy of the scapholunate ligament and second, the management of these injuries. For the first, we propose that scapholunate stability is in fact maintained by a whole anatomic complex, consisting of well-defined capsuloligamentous structures and extrinsic ligaments, and that the scapholunate ligament itself probably has a limited role. For the second, we challenge the notion that scapholunate injuries often require open procedures and propose that mini-invasive arthroscopic dorsal repair of the scapholunate complex is an efficient technique and sufficient for achieving long-term stability.

Arthroscopic Bone Graft for Intraosseous Lunate Bone Ganglion.

Intraosseous lunate bone ganglia (ILBG) are known to be a cause of chronic wrist pain and disability. Standard treatment consists of curettage and autologous bone grafting. Open procedures have shown good results with few recurrences, but with frequent stiffness or persistent pain. Arthroscopic techniques are more recent and seem very reliable. Several arthroscopic techniques have been reported for ILBG approach and treatment. The present study describes an approach that preserves all the lunate cartilage of both radiocarpal and midcarpal surfaces. The surgical technique allows easy and direct access to the bone ganglia, passing through the intermediate portion of the scapholunate ligament, with the scope in the 1-to-2 portal and instrumentation through the 3-to-4 portal. The rest of the procedure is straightforward: curettage and bone grafting are performed through this specific approach, similarly to other techniques. This an easy and accurate approach that avoids any damage to the major cartilage surfaces of the lunate, with easy and reliable access to the intraosseous lunate bone ganglion, allowing cyst curettage and autologous bone graft in a proper and noninvasive way.

Role of wrist arthroscopy in scapholunate dissociation.

Scapholunate ligament tear is most frequently encountered in the aftermath of trauma in supination and extension of the wrist. It generates chronic instability, leading to osteoarthritis. It may be associated with fracture of the distal epiphysis of the radius or of the scaphoid. These lesions are often difficult to diagnose, especially in early stages. Treatment of chronic scapholunate ligament lesions before onset of osteoarthritis is a challenge for the surgeon. To date, recommendations are for open reconstruction or repair, which can improve pain and grip strength, but very often at the cost of wrist stiffness. The advent of arthroscopy has completely changed the understanding and treatment of these lesions. The present review focuses on recent contributions to the anatomy of the scapholunate complex and the anatomopathology of these dissociations, and explores classical treatments and the emerging role of arthroscopy. We shall seek to answer five questions: (1) What are the anatomical bases of the scapholunate complex, (2) What is the initial clinical and paraclinical work-up for scapholunate dissociations, and how are they to be classified, (3) What are the classical treatments for scapholunate dissociation, (4) What are the technical principles and results of arthroscopic treatment, (5) What are the limits and perspectives of arthroscopic treatment?