Automatic analysis of the scapholunate distance using 4DCT imaging: normal values in the healthy wrist.

AIM: Early diagnosis of scapholunate ligament (SLL) injuries is crucial to prevent progression to debilitating osteoarthritis. Four-Dimensional Computed Tomography (4DCT) is a promising dynamic imaging modality for assessing such injuries. Capitalizing on the known correlation between SLL injuries and an increased scapholunate distance (SLD), this study aims to develop a fully automatic approach to evaluate the SLD continuously during wrist motion and to apply it to a dataset of healthy wrists to establish reference values. MATERIALS AND METHODS: 50 healthy wrists were analysed in this study. All subjects performed radioulnar deviation (RUD), flexion-extension (FE), and clenching fist (CF) movements during 4DCT acquisition. A novel, automatic method was developed to continuously compute the SLD at five distinct locations within the scapholunate joint, encompassing a centre, volar, dorsal, proximal, and distal measurement. RESULTS: The developed algorithm successfully processed datasets from all subjects. Our results showed that the SLD remained below 2 mm and exhibited minimal changes (median ranges between 0.3 mm and 0.65 mm) during RUD and CF at all measured locations. During FE, the volar and dorsal SLD changed significantly, with median ranges of 0.90 and 1.27 mm, respectively. CONCLUSION: This study establishes a unique database of normal SLD values in healthy wrists during wrist motion. Our results indicate that, aside from RUD and CF, FE may also be important in assessing wrist kinematics. Given the labour-intensive and time-consuming nature of manual analysis of 4DCT images, the introduction of this automated algorithm enhances the clinical utility of 4DCT in diagnosing dynamic wrist injuries.

Free medial femoral condyle osteocutaneous flap for repairing stage IIIB osteonecrosis of the lunate: a case report.

BACKGROUND: There are several surgical options for osteonecrosis of the lunate, and confirming the effectiveness of various surgical methods remains challenging. Here, we present a case of stage IIIB osteonecrosis of the lunate repaired with a free medial femoral condyle osteocutaneous flap. CASE PRESENTATION: A 43-year-old male construction worker was admitted to our hospital due to right wrist pain, impaired mobility, and pain aggravated by activity for 10 months. The patient was diagnosed with stage IIIB osteonecrosis of the lunate based on the orthopantomogram and magnetic resonance imaging of the right wrist. Considering the patient's medical history, physical examination, auxiliary examination, and wishes, reconstruction was performed using a free medial femoral condyle osteocutaneous flap. After the flap survived completely, the K-wires were removed one month after the operation, the external brace was removed two months after the operation, and functional wrist rehabilitation was initiated. After six months of follow-up, the wrist swelling and pain resolved, and the reconstructed lunate bone was viable. Additionally, the last follow-up was conducted in the sixth month after surgery; the affected hand grip strength improved from about 70% (28 kg) to 80% (32 kg) compared with the healthy side (40 kg); the visual analog scale score decreased from 6.5 points before the operation to 1 point; and the MAYO score increased from 60 points before the operation to 85 points. CONCLUSIONS: The success of this case reinforces the potential of the free medial femoral condyle osteocutaneous flap as a new treatment option for stage IIIB osteonecrosis of the lunate and further expands the existing treatment options. Using a free medial femoral condyle osteocutaneous flap to reconstruct the lunate and restore the carpal anatomy may.

Lunate-capitate arthrodesis for scaphoid nonunion: a comparative study.

BACKGROUND: Scaphoid nonunion advanced collapse (SNAC) injuries are frequently associated with irreversible degenerative wrist arthritic changes that necessitate surgical intervention. Midcarpal fusion remains the mainstay of the management of SNAC II and III injuries. A successful four-corner fusion (4CF) relies on a stable lunate-capitate fusion (LCF). There have been reports of management relying solely on LCF. The outcomes of LC- and 4 C-fusions in SNAC injuries were not widely documented. The objective of this research is to provide valuable insights into the effectiveness of both fusion procedures in the management of SNAC II and III wrist injuries, with a focus on reporting associated complications, functional and radiological outcomes. PATIENTS AND METHODS: This retrospective study encompassed 65 patients diagnosed with SNAC II and III wrist injuries who underwent limited wrist fusion procedures between 2015 and 2024, with a minimum of 2 years of postoperative follow-up. Exclusion criteria encompassed patients with carpal instability, prior wrist surgical interventions, and scapholunate advanced collapse. Following the fusion procedure performed, patients were stratified into two groups: the LCF group consisting of 31 patients, and the 4CF group comprising 34 patients. Preoperative and intraoperative data were retrieved from the patient's medical records. At their final follow-up appointments, patients underwent comprehensive radiographic and clinical evaluations. Clinical outcomes including hand grip strength, range of motion, the Disabilities of the Arm, Shoulder, and Hand Score, and the Mayo Modified Wrist Score, were compared between groups. Any associated complications were reported. RESULTS: The average healing time was 74.7 ± 15.6 and 72.2 ± 13.2 days for the LCF and 4CF groups, respectively. At the final visit, all patients showed functional improvement relative to their preoperative status, with comparable wrist range of motions observed in both groups. The functional wrist scores were slightly better in the LCF patients (P > 0.05). The average grip strength was significantly greater in the LCF group (P = 0.04), with mean strength values of 86.8% and 82.1% of the contralateral side, for the LCF and 4CF groups, respectively. CONCLUSION: The LCF is not less efficient than the 4CF in the treatment of SNAC II and III wrist injuries. Through a less time-consuming procedure, LCF can efficiently provide comparable results to 4CF. LEVEL OF EVIDENCE: level IV evidence.

Scapholunate Ligament Reconstruction With Internal Brace Augmentation Techniques for Chronic Scapholunate Dissociation: A Clinical Follow-up Study.

INTRODUCTION: The scapholunate ligament is the most important stabilizer of the scapholunate articulation. The management of chronic irreversible injuries of this ligament in the absence of preexisting arthritis of the wrist joint remains controversial. Recently, surgeons introduced a novel surgical technique using an internal brace (IB). Several biomechanical studies on this technique have been conducted using cadavers; however, very few studies have discussed the results in detail in actual clinical practice. Therefore, herein, we investigated the radiological and functional results of patients who underwent IB augmentation as a treatment for chronic scapholunate dissociation. METHODS: This retrospective study was conducted from April 2018 to May 2022. Twenty-two patients with chronic scapholunate dissociation were treated using the IB augmentation technique, of whom 17 were followed-up for at least 1 year. Radiological results, including scapholunate distance, scapholunate angle, and radioscaphoid angle, were collected. Furthermore, clinical parameters, such as the visual analog scale (preoperative and at final follow-up), the Disabilities of the Arm, Shoulder, and Hand scores (preoperatively and at 3, 6, and 12 months postoperatively), and Mayo wrist scores (preoperative and at final follow-up), were measured. RESULTS: The scapholunate distance increased significantly in the affected wrist compared to the unaffected wrist, which improved after reconstruction in all wrist positions ( P < 0.05). Compared to the unaffected wrist, the scapholunate angle increased significantly in all positions ( P < 0.05) except for extension ( P = 0.535) and improved after reconstruction in all wrist positions. The radioscaphoid angle significantly increased compared to the angle of the unaffected wrist in all positions ( P < 0.05) except for extension ( P = 0.602) and clenched fist ( P = 0.556). This angle improved after reconstruction in all wrist positions except for extension ( P = 0.900). The visual analog scale score (7-2, preoperatively and at final follow-up) and Mayo wrist score (53-82, preoperatively and at final follow-up) improved after surgery. The Disabilities of the Arm, Shoulder, and Hand scores also improved after surgery (68, 53, 30, 7, preoperatively and at 3, 6, and 12 months postoperatively). CONCLUSIONS: This study revealed that scapholunate ligament reconstruction using an autologous tendon and suture tape is a good reconstruction technique that can improve clinical symptoms and radiographic parameters with a shorter operation time and fewer complications than other reconstruction methods.

Four-Corner Fusion Versus Proximal Row Carpectomy for Scapholunate Advanced Collapse and Scaphoid Nonunion Advanced Collapse Wrist: A Systematic Review and Meta-Analysis.

PURPOSE: Although proximal row carpectomy (PRC) has increasingly been shown to have superior features to four-corner fusion (4CF), individual surgeons may remain convinced of the superiority of one procedure based on personal experience and individual biases. Hence, we sought to perform an updated meta-analysis with some of the largest studies to date to compare outcomes and complications between these procedures in the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists. METHODS: A systematic review and meta-analysis was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, Embase, Web of Science, and Cochrane were queried for articles on PRC and 4CF performed for scapholunate advanced collapse and scaphoid nonunion advanced collapse wrist. Primary outcomes included wrist range of motion; grip strength; outcome measures, including Disabilities of Arm, Shoulder, and Hand and Quick Disabilities of Arm, Shoulder, and Hand scores, Patient-Rated Wrist and Hand Evaluation, and visual analog scale pain scores; and surgical complications. RESULTS: Sixty-one studies reported on 3,174 wrists, of which 54% were treated with PRC and 46% were treated with 4CF. The weighted mean follow-up was 61 months (range, 12-216 months). Meta-analysis comparing PRC and 4CF demonstrated that PRC had significantly greater postoperative extension; ulnar deviation; postoperative improvement in extension, flexion, ulnar deviation; and visual analog scale score. No comparisons showed significant differences in grip strength. The percentage of wrists requiring arthrodesis was 5.2% for PRC and 11% for 4CF. There was an 8.9% (57/640 wrists) 4CF nonunion rate and 2.2% (17/789) hardware removal rate after 4CF. CONCLUSIONS: In the treatment of scapholunate advanced collapse and scaphoid nonunion advanced collapse wrists, PRC results in better outcomes and a lower complication rate compared to 4CF. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

One-Year Outcomes of the Anatomical Front and Back Reconstruction for Scapholunate Dissociation.

PURPOSE: Anatomical front and back (ANAFAB) reconstruction addresses the critical volar and dorsal ligaments associated with scapholunate dissociation. We hypothesized that patients with symptomatic, chronic, late-stage scapholunate dissociation would demonstrate improvements in all radiographic parameters and patient-reported outcomes (PROMs) after ANAFAB reconstruction. METHODS: From 2018 to 2021, 21 ANAFAB reconstructions performed by a single surgeon were followed prospectively, with 20 patients having a minimum follow-up of 12 months. In total, 17 men and four women were included, with an average age of 49 years. Three patients had modified Garcia-Elias stage 3 disease, eight stage 4, seven stage 5, and three stage 7. ANAFAB reconstruction of intrinsic and extrinsic ligament stabilizers was performed using a hybrid synthetic tape/tendon graft in a transosseous reconstruction. Pre- and postoperative radiographic parameters, grip, pinch strength, the Patient-Rated Wrist Evaluation, PROMIS Upper Extremity Function, and PROMIS Pain Interference outcome measures were compared. RESULTS: Mean follow-up was 17.9 months (range: 12-38). Radiographic parameters were improved at follow-up, including the following: scapholunate angle (mean 75.3° preoperatively to 69.2°), scapholunate gap (5.9-4.2 mm), dorsal scaphoid translation (1.2-0.2 mm), and radiolunate angle (13.5° to 1.8°). Mean Patient-Rated Wrist Evaluation scores for pain and function decreased from 40.6 before surgery to 10.4. We were unable to detect a significant difference in grip or pinch strength or radioscaphoid angle with the numbers tested. There were two minor complications, and two complications required re-operations, one patient who was converted to a proximal row carpectomy for failure of fixation, and one who required tenolysis/arthrolysis for arthrofibrosis. CONCLUSIONS: At 17.9-month average follow-up, radiographic and patient-reported outcome parameters improved after reconstruction of the critical dorsal and volar ligament stabilizers of the proximal carpal row with the ANAFAB technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Carpal instability after partial trapeziectomy, total trapeziectomy and the resection of the distal scaphoid pole: a cadaveric study.

INTRODUCTION: Non-dissociative carpal instability (CIND) may lead to severe functional impairment. Destabilisation of the scapho-trapezial-trapezoidal (STT) ligament complex seems to result in a CIND. MATERIALS AND METHODS: In one group with eight cadaver arms, distal scaphoid pole was resected with the adjacent ligaments. In the other eight cadavers, hemitrapeziectomy was performed followed by total trapeziectomy. CT scans were performed in different wrist positions, and the changed positions of the scaphoid, lunate and capitate were measured in comparison to non-operated wrists. RESULTS: Mainly in clenched fist position, dissociation between proximal and distal row can be determined after total trapeziectomy and resection of distal scaphoid pole. Capitate rotates dorsally up to 24°, the scaphoid up to 17° and the lunate up to 7° compared to the non-operated wrists. Resection of the distal scaphoid pole results in dorsal rotation of capitate and scaphoid of about 14° and the lunate 8°. Relative scapholunate and capitolunate angle increased significantly after total trapeziectomy, especially in clenched fist position. After scaphoid pole resection, significant SL and CL angles changes could be seen in almost every wrist position. CONCLUSION: Destabilisation of the STT ligament complex by total trapeziectomy or distal scaphoid pole resection results in dissociation of the proximal and distal carpal row without instability within the proximal or distal row, corresponding to a CIND. LEVEL OF EVIDENCE: III.

Radiographic evaluation of radial flexion osteotomy effect on static scapholunate instability: a preliminary cadaveric study.

INTRODUCTION: The optimal treatment of chronic scapholunate instability has yet to be established. Scapholunate ligament grafts are still far from being the ideal solution. We conducted an experimental study to evaluate whether flexion-opening wedge osteotomy of the distal radius improves misalignment and avoids rotatory subluxation of the scaphoid in a cadaveric model of static scapholunate dissociative instability. MATERIALS AND METHODS: Radiographic studies were performed on 15 cryopreserved specimens after recreating a model of scapholunate instability by division of the scapholunate interosseous ligament (SLIL) and secondary stabilizers, taking radiographs at baseline, after the instability model, and after distal radius osteotomy. Static and dynamic (under controlled tendon traction) anteroposterior and lateral views were obtained to measure the length (in mm) of the carpal scaphoid and scapholunate interval, scapholunate angle, radio-lunate angle, and palmar tilt of the distal joint surface of the radius and to measure the dorsal scaphoid translation by the concentric circles method. The Wilcoxon test was used for statistical comparisons. RESULTS: The scapholunate interval was significantly decreased after osteotomy in all static anteroposterior views and in all lateral views under tendon traction. Dorsal scaphoid translation was significantly reduced in static lateral view in extension and in dynamic lateral view under 5-pound flexor carpi radialis tendon tension controlled by a digital dynamometer. CONCLUSIONS: Flexion-addition osteotomy of the distal radius appears to improve carpal alignment parameters in a cadaveric model of static scapholunate instability, achieving similar values to those obtained before instability.

Ligamentoplasty in scapholunate instability: short-term results of the "all dorsal scapholunate repair" technique.

Injury to the scapholunate complex is the cause of scapholunate instability which can lead to radiocarpal and medio-carpal osteoarthritis. Several ligamentoplasty techniques have been reported for the treatment of chronic scapholunate instability before the osteoarthritis stage. The objective of this study was to assess the short-term results of an "all dorsal scapholunate repair" ligamentoplasty. We report the clinical, radiological and functional results of a retrospective study including 21 patients, operated between June 2019 and December 2020 for a stage 3 or 4 scapholunate instability according to the Garcia Elias classification. With a follow-up of 14.2 months, the pain was 0.1/10 according to the VAS at rest and 4/10 during exercise. Wrist strength was measured at 65% of the opposite side. The flexion-extension range of motion was 105°. Radiologically, there was a reduction of the diastasis and scapholunate angle. Osteolysis areas around the anchors were described in 47% of patients. The mean QuickDASH was 29.2/100, PRWE 24/100 and Mayo wrist score 67.8/100. Eighty-one percent of patients were satisfied. Seventeen patients had returned to work 5.2 months postoperatively. In the case of work-related injury, the functional scores were poorer, with a delayed return to work. This technique provides encouraging results in the short term. Most patients were improved compared to preoperative state. The work-related injury appears to be a poor prognostic factor. A longer-term study is imperative to confirm the maintenance over time of the correction of carpal malalignment and the evolution of the osteolysis areas.Level of evidence: Level IV Retrospective study.

Surgical management and functional outcomes of perilunate dislocations and fracture dislocations through the dorsal approach.

BACKGROUND: Perilunate dislocations and perilunate fracture dislocations (PLD/PLFDs) are rare injuries of the wrist, with surgical management leading to acceptable functional results. PURPOSE: The purpose of this study was to assess the functional outcomes of the patients of our department who were treated with surgical management of PLDs/PLFDs through dorsal approach, as well as to report any complications on their follow-up. PATIENTS AND METHODS: In this retrospective study, 52 patients with PLD/PLFD, fulfilling the inclusion and exclusion criteria of the study, underwent surgical management of their injury. All patients were followed up at 6 weeks, 12 weeks, 6 months, 1 year postoperatively with radiographic imaging as well as functional scores measured with the modified mayo wrist score and the QuickDASH questionnaire. RESULTS: The mean postoperative modified Mayo score was 76.8 ± 8.8 and the mean QuickDASH score was 1.52 ± 2.18. Of the 52 cases, 20% had excellent results, 42% had good results, 29% had fair results and 9% had poor results as per the modified Mayo wrist score. No patient signed any symptoms of median nerve neuropathy. CONCLUSION: In conclusion, open reduction and internal fixation through dorsal approach is a reliable technique to manage perilunate injuries in spite of radiological evidence of wrist arthritis, as it also provides consistently good results in terms of functional outcomes. LEVEL OF EVIDENCE IV: Retrospective case series study.

Outcomes after radioscapholunate arthrodesis for intra-articular malunion of distal radius fractures.

PURPOSE: To study the clinical, radiological, and functional outcomes after of radioscapholunate (RSL) fusion for intra-articular malunion of the distal radius. METHODS: This retrospective study included 26 patients (17 males and 9 females) with intra-articular malunion of distal radius fractures who underwent RSL arthrodesis using locked miniplates (without distal scaphoid excision) between 2012 and 2020. Their mean age was 43 years (range, 32-56). Patients were assessed radiographically for union and clinically for range of motion, grip strength, and pain (assessed by Visual Analogue Scale (VAS) for pain). Functional evaluation was performed by using the Mayo modified wrist score (MMWS) and the Disabilities for the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS: All patients showed complete healing at the fusion site after a mean of 8.7 weeks (range, 8-12). The mean follow-up period was 72 months (range, 60-84). The pinch strength improved from a mean of 6.2 kg (range, 3-12) to a mean of 9.8 kg (range, 5-18) which represents 80% of the contralateral side. The mean pinch strength was 7 kg (range, 5-18) which presents 80% of the other side. VAS for pain showed a mean improvement of 72.6%. The DASH score improved to a mean of 19.2 (range, 14-24). The MMWS improved to a mean of 68 (range, 45-86). At the final follow-up period, no degenerative changes were detected in the midcarpal joint. CONCLUSION: RSL arthrodesis (using locked miniplates without distal scaphoid excision) is a reliable surgical procedure to manage cases of radiocarpal OA after intra-articular malunion of distal radius fractures with good clinical and radiological outcomes. LEVEL OF EVIDENCE: Level IV- therapeutic.

Scapholunate Instability: Diagnosis and Management - Classification and Treatment Considerations - Part 2.

Intervention for scapholunate instability is aimed at halting the degenerative process by restoring ligament integrity and normalizing carpal kinematics. Part 1 of this Current Concepts article reviewed the anatomy, kinematics, and biomechanical properties of the scapholunate ligament as well as its critical stabilizers. In this section, we provide a foundation for understanding the spectrum of scapholunate ligament instability and incorporate meaningful new anatomical insights that influence treatment considerations. These updates clarify the importance of the critical stabilizers of the scapholunate interval, ligament-specific considerations in scapholunate ligament reconstruction, and the risks of ligament disinsertion when surgically exposing the dorsal wrist. We propose a ligament-based treatment algorithm based on the stage of injury, degree and nature of ligament damage, and presence of arthritic changes.

Correlation Between Dynamic 4-Dimensional Computed Tomography Data and Arthroscopic Testing of Scapholunate Instability: A Preliminary Study.

PURPOSE: The aim of this study was to test the validity and reliability of the assessments of scapholunate (SL) instability status on 4-dimensional (4D) computed tomography (CT) using wrist arthroscopy as a reference standard. METHODS: Thirty-three patients (16 men, 17 women; mean age, 48 ± 13 years) with suspected SL instability were evaluated prospectively with 4D-CT and wrist arthroscopy. Based on the arthroscopic testing of SL joint, 2 groups were defined: group 1 (n = 8) consisted of patients who had no, or slight, SL malalignment in the midcarpal space and group 2 (n = 25) consisted of patients who had moderate or severe SL malalignment. Two independent readers, who did not know the arthroscopic findings, used 4D-CT to evaluate the SL gap, lunocapitate angle (LCA), and radioscaphoid angle (mean and range values) during radioulnar deviation. RESULTS: The interobserver reliability was deemed good or excellent for most of the 4D-CT variables, except for the LCA range (moderate) and SL gap range (poor). For both readers, the SL gap mean, maximum, and minimum values were significantly higher (+67%, +78%, and +39%, respectively) and the LCA mean was significantly lower (-17%) in group 2 than in group 1. The radioscaphoid angle range values were lower (-34%) and the radioscaphoid angle mean values slightly higher (+4%) in group 2, but there was no significant difference between the 2 groups. The SL gap range values were also higher (+86% for R1 and +40% for R2) and the LCA range values also lower (-50% for R1 and -31% for R2) in group 2. CONCLUSIONS: Quantitative 4D-CT data corresponded well with the arthroscopic dynamic analysis of the SL joint in patients with suspected chronic SL instability. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Facet Inclinations and Interfacet Angle of the Distal Radius on Posteroanterior Radiographs: Clinical Associations With 3 Carpal Pathologies.

PURPOSE: The radiographic interfacet angle (IFA), scaphoid facet inclination (SFI), and lunate facet inclination (LFI) of the distal radius were measured in patients with 3 distinct wrist pathologies to determine whether there is an association between these radiographic measurements and these conditions. METHODS: Posteroanterior wrist radiographs were compiled from patients with 3 types of common wrist pathologies (scaphoid waist fracture [n = 54], scapholunate [SL] dissociation [n = 23], and dorsal ganglion [n = 51]). The patients were all Caucasians aged 20 to 45 years who met strict radiographic criteria. The IFA, SFI, and LFI values of these patients were compared with those obtained from 400 normal wrist radiographs of subjects who met the same selection criteria. RESULTS: In men with a scaphoid waist fracture, the IFA and SFI were significantly greater than in normal men, whereas the LFI was significantly lower. In the SL dissociation group, for all patients and for subgroups stratified according to sex, the IFA and SFI were significantly lower than in the normal matched groups. In the dorsal ganglion group, differences were found in the IFA and SFI for women, but not for men. CONCLUSIONS: The facet orientations of the distal radius in patients with scaphoid fracture, SL dissociation, and dorsal ganglion differed from those in the normal population. The IFA alone is most likely to be associated with all 3 pathologies. The SFI and LFI are less likely to be associated with patients with carpal pathologies. CLINICAL RELEVANCE: Patients with a greater IFA may be susceptible to scaphoid fractures when they fall on an overstretched hand. Patients with a smaller IFA may be susceptible to SL dissociation when they fall on an overstretched hand.

Scapholunate Instability: Diagnosis and Management - Anatomy, Kinematics, and Clinical Assessment - Part I.

Injuries to the scapholunate joint are the most frequent cause of carpal instability. The sequelae of these injuries account for considerable morbidity, and if left untreated, may lead to scapholunate advanced collapse and progressive deterioration of the carpus. Rupture of the scapholunate interosseous ligament and its critical stabilizers causes dyssynchronous motion between the scaphoid and lunate. Additional ligament injury or attenuation leads to rotary subluxation of the scaphoid and increased scapholunate gap. Intervention for scapholunate instability is aimed at halting the degenerative process by restoring ligament integrity and normalizing carpal kinematics. In the first section of this review, we discuss the anatomy, kinematics, and biomechanical properties of the scapholunate ligament as well as its critical ligament stabilizers. We provide a foundation for understanding the spectrum of scapholunate ligament instability and incorporate meaningful new anatomical insights that influence treatment considerations. The purpose is to provide an update regarding the anatomy of the scapholunate ligament complex, importance of the critical ligament stabilizers of the proximal carpal row, introduction of safe technique to surgically expose the scaphoid and lunate, as well as pathoanatomy as it pertains to the treatment of scapholunate dissociation. In the second section of this review, we propose a novel ligament-based treatment algorithm based on the stage of injury, degree and nature of ligament damage, and presence of arthritic changes.

Evaluation of a newly designed deep learning-based algorithm for automated assessment of scapholunate distance in wrist radiography as a surrogate parameter for scapholunate ligament rupture and the correlation with arthroscopy.

PURPOSE: Not diagnosed or mistreated scapholunate ligament (SL) tears represent a frequent cause of degenerative wrist arthritis. A newly developed deep learning (DL)-based automated assessment of the SL distance on radiographs may support clinicians in initial image interpretation. MATERIALS AND METHODS: A pre-trained DL algorithm was specifically fine-tuned on static and dynamic dorsopalmar wrist radiography (training data set n = 201) for the automated assessment of the SL distance. Afterwards the DL algorithm was evaluated (evaluation data set n = 364 patients with n = 1604 radiographs) and correlated with results of an experienced human reader and with arthroscopic findings. RESULTS: The evaluation data set comprised arthroscopically diagnosed SL insufficiency according to Geissler's stages 0-4 (56.5%, 2.5%, 5.5%, 7.5%, 28.0%). Diagnostic accuracy of the DL algorithm on dorsopalmar radiography regarding SL integrity was close to that of the human reader (e.g. differentiation of Geissler's stages ≤ 2 versus > 2 with a sensitivity of 74% and a specificity of 78% compared to 77% and 80%) with a correlation coefficient of 0.81 (P < 0.01). CONCLUSION: A DL algorithm like this might become a valuable tool supporting clinicians' initial decision making on radiography regarding SL integrity and consequential triage for further patient management.

A novel classification of Kienbock's disease based on magnetic resonance imaging.

PURPOSE: We devised a classification system for Kienbock's disease using magnetic resonance imaging (MRI). Moreover, we compared it with the modified Lichtman classification and evaluated the inter-observer reliability. METHODS: Eighty-eight patients diagnosed with Kienbock's disease were included. All patients were classified using the modified Lichtman and MRI classifications. MRI staging was based on factors including partial marrow oedema, cortical integrity of the lunate, and dorsal subluxation of the scaphoid. The inter-observer reliability was evaluated. We also evaluated the presence of a displaced coronal fracture of the lunate and investigated its association with the presence of a dorsal subluxation of the scaphoid. RESULTS: Seven patients were categorized into stage I, 13 into II, 33 into IIIA, 33 into IIIB, and two into IV using the modified Lichtman classification. Six patients were categorized into stage I, 12 into II, 56 into IIIA, ten into IIIB, and four into IV using the MRI classification. The greatest shift between the stages was observed in stages IIIA and IIIB when the results of the two classification systems were compared. The inter-observer reliability of the MRI classification was greater than that of the modified Lichtman classification. Fifteen cases with a displaced coronal fracture of the lunate were identified, and a dorsal subluxation of the scaphoid was significantly more present in these patients. CONCLUSION: The MRI classification system is more reliable than is the modified Lichtman classification. MRI classification reflects carpal misalignment with higher fidelity and is more appropriate for classification into stages IIIA and IIIB.

The tangential view described by Moneim to demonstrate scapholunate dissociation: an update.

PURPOSE: Scapholunate dissociation is a common and significant injury to the wrist. Radiographs are important in the diagnosis of this injury and in the planning of treatment. The tangential radiograph view was described almost 40 years ago as a method for accurately measuring scapholunate gaps. The hand is positioned on a 20° foam rubber block and the thumb on the cassette, which positions the scaphoid and lunate articular surfaces parallel, without patient discomfort or effort. The goal of this study was to review this method with more recent data and in a larger group of patients. METHODS: Radiographs of 31 patients who had scapholunate interosseous ligament tears and surgical repair over a 9 year period were retrospectively evaluated. Each of the four authors independently measured scapholunate gaps for posteroanterior and tangential views. RESULTS: The tangential view gaps were significantly greater than the posteroanterior gaps overall. Similar results were found for borderline cases where the posteroanterior gap was less than 3 mm. Every tangential view gap measurement was greater than its respective posteroanterior gap with good inter-rater reliability. CONCLUSION: The tangential view is a reliable radiographic method to identify scapholunate gaps. It should be obtained when there is clinical concern for scapholunate dissociation, especially in patients with borderline posteroanterior gaps.

Review of surgical treatment for chronic scapholunate ligament reconstruction: a long-term study.

PURPOSE: Scapholunate dissociation (SLD) is a common entity encountered by hand surgeons. While multiple methods for surgical treatment exist, there is little agreement on the best surgical techniques to treat chronic, static SLD. Our study's goal was to assess the long-term (greater than five years), clinical and radiologic outcomes of the currently recommended treatment options for chronic, static SLD. METHODS: We performed a review of the literature to assess outcomes after surgical treatment of chronic, static SLD with long-term follow-up of greater than five years. RESULTS: We found only six studies that encompassed the modified Brunelli tenodesis, capsulodesis, scapholunate arthrodesis, and bone-ligament-bone graft using the modified Cuenod procedure. All were level of evidence IV. Many patients went back to some form of work. Tenodesis showed less development of arthritis and greater improvement in scapholunate gap, while capsulodesis showed greater postoperative flexion and extension. Of note, study size varied with 67 combined patients in the capsulodesis studies and 30 patients in the tenodesis studies. CONCLUSION: There was no clear superiority of one procedure over the others. More long-term data are needed to identify the best surgical treatment of chronic, static SLD.

Scapholunate ligament injuries: an instructional review for the FRCS examination.

An instructional review of the anatomy, investigation, and management of scapholunate ligament injuries. Aimed at the knowledge level required for the trauma and orthopaedic FRCS examination.