Abhijeet L. Wahegaonkar

Anatomical Description of the Dorsal Capsulo-Scapholunate Septum (DCSS)-Arthroscopic Staging of Scapholunate Instability after DCSS Sectioning.

Background The dorsal capsuloligamentous scapholunate septum (DCSS) is a confluence of the dorsal capsule, the dorsal intercarpal ligament (DIC), and the scapholunate interosseous ligament (SLIOL). It appears to play a role in the stability of the scapholunate articulation. The purpose of this study was to describe the anatomical basis for this structure and to investigate its role in scapholunate instability through sectioning of this structure followed by an arthroscopic and fluoroscopic analysis. Material and Methodsu2003In the anatomical part of the study we dissected 3 fresh cadaver wrists to examine the anatomy of the DCSS. In the arthroscopic part of the study we assessed the EWAS grade of SL instability before and after sectioning the DCSS and measured the scapholunate and radiolunate angles fluoroscopically. Resultsu2003Sectioning the DCSS increased the EWAS grade of SL instability but did not affect the scapholunate gap, the scapholunate angle or radiolunate angle. Conclusionu2003We have demonstrated that there is a distinct structure that is separate from the dorsal capsule, which we have labeled the Dorsal Capsuloligamentous Scapholunate Septum. We believe that the DCSS is a previously unreported secondary stabilizer of the SL joint which may have therapeutic and prognostic implications.

Arthroscopic Dorsal Capsulo-Ligamentous Repair in the Treatment of Chronic Scapho-Lunate Ligament Tears

Introductionu2003Scapholunate ligament injuries usually result due to a fall on the outstretched hand leading to scapholunate instability. The natural history of untreated scapholunate instability remains controversial and usually results in late arthritic changes- the so-called SLAC wrist. The advent of wrist arthroscopy helps in early diagnosis and treatment of these serious injuries. In selected cases with reducible scapholunate instability (Garcia-Elias stages 2, 3 and 4) we propose a new all arthroscopic dorsal capsulo- ligamentous repair with the added advantage of early rehabilitation and prevention of post-operative stiffness. Material and Methodsu2003We report the results of our series of 57 consecutive patients suffering from chronic wrist pain refractory to conservative measures. All patients underwent a thorough clinical examination in addition to a standard set of radiographs and MRI exam; and they were treated by an all-arthroscopic dorsal capsulo-ligamentous repair under loco-regional anesthesia on an ambulatory basis. All patients were available for follow-up at regular intervals during the post-operative period. At follow-up, the wrist ROM in all directions, the grip strength, DASH questionnaire and pain relief based on the VAS were recorded for both- the operated and contra-lateral sides. Resultsu2003There were 34 males & 23 females with a mean age of 38.72u2009±u200911.33 years (range 17-63 years). The dominant side was involved in 52 cases. The mean time since injury was 9.42u2009±u20096.33 months (range 3-24 months) and the mean follow-up was 30.74u2009±u20097.05 months (range 18-43 months). The mean range of motion improved in all directions. The mean difference between the post- and pre-operative extension was 14.03° (SEMu2009=u20091.27°; pu2009<u20090.001); while the mean difference between the post-and pre-operative flexion was 11.14° (SEMu2009=u20091.3°; pu2009<u20090.0001) with flexion and radial deviation reaching 84.3% and 95.72% respectively of the unaffected wrist. The mean difference for the VAS score was -5.46 (SEMu2009=u20090.19; pu2009<u20090.0001). The mean post-operative grip strength of the affected side was 38.42u2009±u200910.27u2009kg (range 20-60 kg) as compared with mean pre-operative grip strength of 24.07u2009±u200910.51u2009kg (range 8-40 kg) (pu2009<u20090.0001). The mean post-operative grip strength of the operated side was 93.4% of the unaffected side. The DISI was corrected in all cases on post-operative radiographs. The mean difference between the post-and pre-operative SL angles was -8.95° (SEMu2009=u20091.28°; pu2009<u20090.0001). The mean post-operative DASH score was 8.3u2009±u20097.82 as compared with mean pre-operative DASH score of 46.04u2009±u200916.57 (pu2009<u20090.0001). There was a negative co-relation between the overall DASH score and the post-operative correction of the DISI deformity with a lower DASH score associated with increasing SL angles. Discussionu2003The dorsal portion of the scapholunate ligament is critical for the stability scapholunate articulation, largely due to its attachment to the dorsal capsule. We have recently conducted a multi-centric anatomical study with international collaboration demonstrating the critical importance of this dorsal scapholunate complex. The all arthroscopic capsulo-ligamentous repair technique provides reliable results in addition to avoiding postoperative stiffness. The overall results at a mean follow-up period of more than 2 years in our series of young, active patients appear to be encouraging.

Dorsal Wrist Capsular Tears in Association with Scapholunate Instability: Results of an Arthroscopic Dorsal Capsuloplasty

Purposeu2003The purpose of this study is to report the association of dorsal wrist capsular avulsion with scapholunate ligament instability and to evaluate the results of an arthroscopy-assisted repair. Methodsu2003We retrospectively reviewed 10 patients with a mean age of 39.1 years suffering from chronic dorsal wrist pain. They underwent a wrist arthroscopy with an evaluation of the scapholunate ligament complex from the radiocarpal and midcarpal compartments. An avulsion of the dorsal intercarpal ligament (DICL) from the scapholunate interosseous ligament (SLIL) was visible from the radiocarpal compartment in all cases, while the SLIL was intact. The DICL tear was repaired with an arthroscopy-assisted dorsal capsuloplasty. Patients were assessed preoperatively and postoperatively by the QuickDASH (Disabilities of the Arm, Shoulder, and Hand) questionnaire, by the Visual Analog Scale (VAS) for pain, and by a clinical and radiological examination. Resultsu2003Preoperatively, all patients had reduced flexion and radial deviation of the affected wrist. On the lateral radiograph, 5 of the 10 patients showed an increase of the scapholunate angle (60 to 85°). The scapholunate instability was graded as Messina-European Wrist Arthroscopy Society (EWAS) II in five cases and as grade IIIB in five cases. A tear of the ulnar part of the triangular fibrocartilage complex (TFCC) was found in seven cases. At a mean followup of 16 months, the wrist range of motion (ROM), the grip strength, the QuickDASH, and the VAS of pain improved significatively. The scapholunate angle was normalized in all cases. Discussionu2003Isolated tears of the DICL at its insertion from the dorsal part of the SLIL can be associated with scapholunate instability in the absence of an injury to the SLIL. The diagnosis is made arthroscopically. The arthroscopic dorsal capsuloplasty is a minimally invasive technique that provides short-term satisfactory results. Further studies are needed to determine whether repair of the DICL tear could prevent secondary destabilization of the scapholunate ligament complex. Level of evidenceu2003IV (case series) Diagnosis.

Treatment of Avascular Necrosis of the Proximal Pole of the Scaphoid by Arthroscopic Resection and Prosthetic Semireplacement Arthroplasty Using the Pyrocarbon Adaptive Proximal Scaphoid Implant (APSI): Long-Term Functional Outcomes

Fractures of the proximal pole of the scaphoid with associated avascular necrosis and nonunion are well known to be problematic. Many techniques for fixation and reconstruction of the proximal pole of the scaphoid have been reported, often with poor results. One of the newer modalities of treatment for these difficult cases is excision of the proximal pole and replacement with a pyrocarbon implant. The ovoid shape of the implant acts as a spacer and repositions itself throughout the range of motion of the wrist. The procedure can be performed arthroscopically, thus reducing the morbidity and allowing the procedure to be a day case. Satisfactory results have been reported in elderly patients, but there is a paucity of literature regarding the outcomes in younger patients. This multicenter retrospective study evaluates the clinical, radiologic, and functional outcomes in patients under the age of 65 years with a minimum follow up of 5 years. There were 14 patients with scaphoid nonunion advanced collapse (SNAC) grade I, II, or III wrists, with a mean age of 53 years and mean follow up of 8.7 years. There were improvements in all of the patient related variables including VAS pain scores (7.5 to 0.7), extension (45° to 60°), flexion (32° to 53°), and grip strength (15.8 to 34.6 kg). Complications included volar subluxation of the implant, which was acutely surgically corrected (1), volar subluxation of the implant, with persistent pain that required a four-corner fusion (2), and secondary radial styloidectomy (3). This technique is an attractive, minimally invasive alternative for nonunion and avascular necrosis resulting from fractures of the proximal pole of the scaphoid. The authors provide details of the technique, including technical suggestions for performing the procedure.

Arthroscopic Scapholunate Reconstruction

The treatment of scapholunate ligament injuries has always been a challenge for surgeons. Interventions by open surgery can achieve stability but with a particularly high stiffness in flexion.