The traditionally accepted etiology of Scapholunate Advanced Collapse (SLAC) requires traumatic rupture of the scapholunate (SL) ligament which leads to abnormal wrist kinematics and thereafter severe localised degenerative arthritis of the wrist. The purpose of this prospective blinded kinematic analysis was to demonstrate that SLAC wrist also exists in the absence of trauma, and that abnormal carpal bone kinematics (specifically, decreased lunate flexion) is the initiating factor. Patients with SLAC and no history of upper extremity trauma were compared with an age matched control group. All patients completed a questionnaire, personal interview, and a physical examination. A specialised flexion / extension radiographic jig was designed to control for the magnitude of force and position of the wrist in all planes. A total of thirty-five subjects (sixty-nine wrists) were retained for the study, including thirty-three non-traumatic SLAC wrists and thirty-six control wrists. The non-traumatic SLAC group had significantly different radiographic kinematic analysis compared to the control group: increased Watson Stage (2 v 0), SL gap (3.4 v 1.8mm), revised carpal height ratio (rCHR) (77 v 68), SL angle in flexion (forty-one v twenty-eight degrees), and decreased radiolunate (RL) joint flexion (nine v twenty-seven degrees). Most importantly flexion of the asymptomatic non-degenerative wrist of the non-traumatic SLAC group was distributed 70% through the lunocapitate (LC) joint and only 30% through the RL joint (p< 0.05). Conversely, flexion was more evenly distributed in the control group (48% LC and 52% RL). Non-traumatic or developmental SLAC does exist. SLAC can thus be classified into non-traumatic (developmental) and traumatic types. Non-traumatic SLAC begins with abnormal wrist kinematics. Over time restricted lunate flexion and normal scaphoid flexion leads to increased SL angles and eventual attrition of the SL ligament and predisposes patients to SLAC despite having no history of trauma

Purpose: To review a clinical series of patients who have had the SLAC (scapho-lunate advanced collapse) procedure. Method: 50 patients with degenerative disorders of the wrist managed by a single surgeon using a single technique. The technique involved excision of the scaphoid and radial styloidectomy. Midcarpal arthrodesis was performed, and was stabilised with staples. The patients were prospectively followed for two years. Results: The majority of patients were satisfied with their outcome and their pain had decreased. Pre-operative flexion/extension was 39 degrees/38 degrees and post-operatively was 32 degrees/35 degrees. The average grip strength did not change. Conclusion: The SLAC wrist procedure is a useful technique for patients who have localised degenerative arthritis of the wrist

Surgical results following proximal row carpectomy modified with proximal capitate resection and dorsal capsule interposition are presented. A consecutive cohort of thirteen patients was operated upon, and outcomes measured by radiograph, physical examination and DASH questionnaire. AROM values of 50° to 105° for the flexion/extension arc, restoration of grip strength to 72% of the contralateral extremity, and an improved functional outcome can be expected; and patients’ perceptions of functional outcome, as measured by the DASH, are significantly improved as early as six weeks. The results of PRC with interposition for stages II and III SLAC wrist were uniformly favorable. Eaton has described two modifications to the proximal row carpectomy (PRC) procedure: partial capitate resection and dorsal capsular interpositional arthroplasty. The objective is to enlarge the radiocarpal interface to form a broad mobile pseudoarthrosis that would disperse compressive forces across the wrist more effectively. We present the first consecutive cohort of patients (n=13) who have undergone this procedure,. We extend the indications for PRC in this series to include those wrists with stage III SLAC deformity; approximately 67% of wrists had capitolunate arthritis. AROM values of 50° to 105° for the flexion/extension arc, restoration of grip strength to 72% of the contralateral extremity, and an improved functional outcome can be expected from PRC with dorsal capsular interpositional arthroplasty. Patients’ perceptions of functional outcome, as measured by the DASH, are significantly improved as early as six weeks following the procedure. Mean flexion/extension arc achieved was 86° (range, 50° to 105°). Radial deviation averaged 13° (range, 10° to 20°), and ulnar deviation averaged 21° (range, 15° to 25°). Grip strength averaged 72% of the contralateral extremity. The mean decline in the revised carpal height ratio was 24%. The mean DASH score was 20.8 (range, 10 to 29). Visual analog pain improved from 9.25 to 2.67 on average, with one patient reporting no pain with heavy exertion. Patients were evaluated by active range of motion ; grip and pinch strength; radiographs; subjective analog pain; and DASH questionnaire

The purpose of this study was to assess the clinical and radiological outcomes of dorsal intercarpal ligament capsulodesis for the treatment of static scapholunate instability at a minimum follow-up of four years. A total of 59 patients who underwent capsulodesis for this condition were included in a retrospective analysis after a mean of 8.25 years (4.3 to 12). A total of eight patients underwent a salvage procedure at a mean of 2.33 years (0.67 to 7.6) and were excluded. The mean range of extension/flexion was 88° (15° to 135°) and of ulnar/radial deviation was 38° (0° to 75°) at final follow-up. The mean Disabilities of the Arm Shoulder and Hand (DASH) score and Mayo wrist scores were 28 (0 to 85) and 61 (0 to 90), respectively. After significant improvement immediately post-operatively (p < 0.001 and p = 0.001, respectively), the mean scapholunate and radiolunate angles deteriorated to 70° (40° to 90°) and 8° (-15° to 25°), respectively, at final follow-up, which were not significantly different from their pre-operative values (p = 0.6 and p = 0.4, respectively). The mean carpal height index decreased significantly from 1.53 (1.38 to 1.65) to 1.48 (1.29 to 1.65) indicating progressive carpal collapse (p < 0.001); 40 patients (78%) had radiological evidence of degenerative arthritis.

Capsulodesis did not maintain carpal reduction over time. Although the consequent ongoing scapholunate instability resulted in early arthritic degeneration, most patients had acceptable long-term function of the wrist.

The Motec cementless modular metal-on-metal ball-and-socket wrist arthroplasty was implanted in 16 wrists with scaphoid nonunion advanced collapse (SNAC; grades 3 or 4) and 14 wrists with scapholunate advanced collapse (SLAC) in 30 patients (20 men) with severe (grades 3 or 4) post-traumatic osteoarthritis of the wrist. The mean age of the patients was 52 years (31 to 71). All prostheses integrated well radiologically. At a mean follow-up of 3.2 years (1.1 to 6.1) no luxation or implant breakage occurred. Two wrists were converted to an arthrodesis for persistent pain. Loosening occurred in one further wrist at five years post-operatively. The remainder demonstrated close bone–implant contact. The clinical results were good, with markedly decreased Disabilities of the Arm Shoulder and Hand (DASH) and pain scores, and increased movement and grip strength. No patient used analgesics and most had returned to work.

Good short-term function was achieved using this wrist arthroplasty in a high-demand group of patients with post-traumatic osteoarthritis.

The August 2024 Wrist & Hand Roundup. 360. looks at: Methotrexate shows potential in reducing pain for hand osteoarthritis with synovitis; Circumferential casting versus plaster splinting in adult distal radius fractures: the CAST study findings; Surgery shows superior long-term success for Dupuytren contracture compared to needle fasciotomy and collagenase injection; Evolving trends in surgical management of wrist arthritis: a decade-long national analysis; Mid-term outcomes of three commonly used surgical reconstructions for scapholunate instability; SLAC and SNAC: what is the evidence for treatment?; Steroids for trapeziometacarpal osteoarthritis?; When is it safe to return to driving after distal radius fracture fixation? A prospective study

The August 2023 Wrist & Hand Roundup360 looks at: Complications and patient-reported outcomes after trapeziectomy with a Weilby sling: a cohort study; Swelling, stiffness, and dysfunction following proximal interphalangeal joint sprains; Utility of preoperative MRI for assessing proximal fragment vascularity in scaphoid nonunion; Complications and outcomes of operative treatment for acute perilunate injuries: a systematic review; The position of the median nerve in relation to the palmaris longus tendon at the wrist: a study of 784 MR images; Basal fractures of the ulnar styloid? A randomized controlled trial; Proximal row carpectomy versus four-corner arthrodesis in SLAC and SNAC wrist; Managing cold intolerance after hand injury: a systematic review

The June 2024 Wrist & Hand Roundup. 360. looks at: One-year outcomes of the anatomical front and back reconstruction for scapholunate dissociation; Limited intercarpal fusion versus proximal row carpectomy in the treatment of SLAC or SNAC wrist: results after 3.5 years; Prognostic factors for clinical outcomes after arthroscopic treatment of traumatic central tears of the triangular fibrocartilage complex; The rate of nonunion in the MRI-detected occult scaphoid fracture: a multicentre cohort study; Does correction of carpal malalignment influence the union rate of scaphoid nonunion surgery?; Provision of a home-based video-assisted therapy programme in thumb carpometacarpal arthroplasty; Is replantation associated with better hand function after traumatic hand amputation than after revision amputation?; Diagnostic performance of artificial intelligence for detection of scaphoid and distal radius fractures: a systematic review

Proximal Row Carpectomy (PRO has been used as an alternative treatment for advanced radiocarpal arthrosis and carpal collapse. Its use has been recommended for Kienbock’s disease, chronic scaphoid nonunion and scapholunate advanced collapse (SLAC) deformity. Materials – Methods: Twenty-three patients were divided into two groups: group 1, consisting of patients with Kienbock’s disease (10 patients), and group 2, consisting of patients with scapholunate advanced collapse (13 patients). The average age was 51 years (range 27–69) for group 1, and 45 years (range 29–57) for group 2. The average follow-up was 30 months for Kienbock’s disease (range, 23–49 months) and 31 months for SLAC deformity of the wrist (range, 24–51 months). Pre-operative staging was performed on all patients utilizing Lichtmann’s (Lichtmann and Degnan, 1993) classification for Kienbock’s disease and Watson’s (Watson and Ballet, 1984) classification for scapholunate advanced collapse. The procedure was performed as described by Jorgansen (1969) utilizing a dorsal midline approach between the third and fourth dorsal compartments. Styloidectomy, preserving the radiocapitate ligament was performed in 7 out of the 23 patients (5 Kienbock’s and 2 SLAC wrist’s patients). Posterior Interosseous Nerve neurectomy was performed in 2 out of the 10 patients with Kienbock’s disease. Results: Statistically significant differences were noted between the Kienbock’s disease group and the SLAC wrist group (p=0.0023). Of the patients who underwent PRC for Kienbock’s disease 9 of 10 patients reported moderate to severe pain at the final follow-up visits. In the scapholunate advanced collapse group, 2 out of 13 patients demonstrated moderate or severe pain. It was noted that the patients in the SLAC wrist group lost less motion overall than those in the Kienbock’s dis ease group (p=0.00l 5). It was noted in the Kienbock’s disease group that at final follow-up the operated hand was weaker than preoperative (p=0.022). In the scapholunate advanced collapse group there was improvement of postoperative grip strength. Conclusion: We currently recommend the use of wrist arthroscopy as an adjunct to determine the status of the lunate articular surface in Kienbock’s disease, before performing a proximal row carpectomy. Our results indicate that despite only minor chondromalacia of the capitate articular surface and lunate facet of the radius, the use of PRC in Kienbock’s has not been rewarding

The February 2015 Wrist & Hand Roundup360 looks at: Toes, feet, hands and transfers… FCR Tendonitis after Trapeziectomy and suspension, Motion sparing surgery for SLAC/SNAC wrists under the spotlight, Instability following distal radius fractures, Bilateral wrist arthrodesis a good idea?, Sodium Hyaluronate improves hand recovery following flexor tendon repair, Ultrasound treatments for de Quervain’s, Strategies for treating metacarpal neck fractures

The natural history of scapholunate ligament injury is unknown. In fact, as far as we can tell, there has been no study examining the long-term natural history of this condition. It has, however, been assumed that the long-term progression of this injury leads to secondary osteoarthritis – scapholunate advanced collapse (the so-called SLAC wrist). In this study, we evaluated the clinical condition of 11 patients with proven scapholunate ligament injuries that had declined further treatment in an attempt to quantify any long-term disability. Whilst there was on-going pain and functional limitation in the injured wrist, there was no rapid progression of the osteoarthritis or SLAC wrist deformity

We have examined whether the rotatory subluxation of the scaphoid which is seen in patients with advanced Kienböck’s disease is associated with scapholunate advanced collapse (SLAC) wrist. We studied 16 patients (11 men, 5 women) who had stage-IV Kienböck’s disease with chronic subluxation of the scaphoid. All had received conservative treatment. The mean period of affection with Kienböck’s disease was 30 years (14 to 49). No wrist had SLAC. In eight patients, 24 years or more after the onset of the disease, the articular surface of the radius had been remodelled by the subluxed scaphoid with maintenance of the joint space. The wrists of six patients were considered to be excellent, nine good, and one fair according to the clinical criteria of Dornan. Our findings have shown that rotatory subluxation of the scaphoid in Kienböck’s disease is not a cause of SLAC wrist and therefore that scaphotrapezio-trapezoid arthrodesis is not required for the management of these patients

Although articular chondrocalcinosis is a frequently seen disorder, the broad clinical variations of forms affecting the wrist are more recently and more rarely described. Chondrocalcinosis of the wrist is an evolutionary disorder, which can initially be well treated medically. Further in the natural evolution, scaphoradial joint destruction occurs followed by midcarpal wear. Until now one form of chondrocalcinosis, developing scapholunate dissociation and tending towards a SLAC (Scapho-Lunate Advanced Collapse) wrist, has been well documented. We state that there exists a pathway which does not lead to any scapholunate gap and is less often associated with a ST (Scapho-Trapezium) osteoarthritis. This isolated form of chondrocalcinosis of the wrist has been mistaken for SLAC or SNAC (Scaphoid Non-union Advanced Collapse) wrists, because its clinical and radiological resemblance. We propose to call this form the SCAC (Scaphoid Chondrocalcinosis Advanced Collapse) wrist. It is seen in elderly patients. There is a long evolution for several years, and most patients have an extensive medical history before the correct diagnosis is being made. We describe the typical clinical and radiological evolution on five patients. According to the amount and pattern of cartilage destruction we propose a radiological classification in four grades. The five cases presented were all seen in grade III. Two of them underwent previous surgery; a styloidectomy in one and a scaphoid replacement by a titanium prosthesis in the other. Three patients had previous carpal tunnel release. All five have been treated by a hamatoluno-capitate arthrodesis, with resection of the scaphoid and triquetrum (according to Delattre’s technique). Results are described and discussed

Longstanding un-united scaphoid fractures or scapholunate insufficiency can progress to degenerative wrist osteoarthritis (termed scaphoid non-union advanced collapse (SNAC) or scapho-lunate advanced collapse (SLAC) respectively). Scaphoid excision and partial wrist fusion is a well-established procedure for the surgical treatment of this condition. In this study we present a novel technique and mid-term results, where fusion is reserved for the luno-capitate and triquetro-hamate joints, commonly referred to as bicolumnar fusion. The purpose of this study was to report functional and radiological outcomes in a series of patients who underwent this surgical technique. This was a prospective study of 23 consecutive patients (25 wrists) who underwent a bicolumnar carpal fusion from January 2014 to January 2017 due to a stage 2 or 3 SNAC/SLAC wrist, with a minimum follow-up of one year. In all cases two retrograde cannulated headless compression screws were used for inter-carpal fixation. The clinical assessment consisted of range of motion, grip and pinch strength that were compared with the unaffected contralateral side where possible. Patient-reported outcome measures, including the DASH and PRWE scores were analysed. The radiographic assessment parameters consisted of fusion state and the appearance of the radio-lunate joint space. We also examined the relationship between the capito-lunate fusion angle and wrist range of motion, comparing wrists fused with a capito-lunate angle greater than 20° of extension with wrists fused in a neutral position. The average follow-up was 2.9 years. The mean wrist extension was 41°, flexion 36° and radial-ulnar deviation arc was 43° (70%, 52% and 63% of contralateral side respectively). Grip strength was 40 kg and pinch strength was 8.9 kg, both 93% of contralateral side. Residual pain for activities of daily living was 1.4 (VAS). The mean DASH and PRWE scores were 19±16 and 29±18 respectively. There were three cases of non-union (fusion rate of 88%). Two wrists were converted to total wrist arthroplasty and one partial fusion was revised and healed successfully. Patients with an extended capito-lunate fusion angle trended toward more wrist extension but this did not reach statistical significance (P= 0.07). Wrist flexion did not differ between groups. Radio-lunate joint space narrowing progressed in 2 patients but did not affect their functional outcome. After bicolumnar carpal fusion using retrograde headless screws, patients in this series maintained a functional flexion-extension arc of motion, with grip-pinch strength that was close to normal. These functional outcomes and fusion rates were comparable with standard 4-corner fusion technique. A capito-lunate fusion angle greater than 20° may provide more wrist extension but further investigation is required to establish this effect. This technique has the advantage that compression screws are placed in a retrograde fashion, which does not violate the proximal articular surface of the lunate, preserving the residual load-bearing articulation. Moreover, the hardware is completely contained, with no revision surgery for hardware removal required in this series

The February 2023 Wrist & Hand Roundup³⁶⁰ looks at: ‘Self-care’ protocol for minimally displaced distal radius fractures; Treatment strategies for acute Seymour fractures in children and adolescents: including crushed open fractures; Routinely collected outcomes of proximal row carpectomy; Moving minor hand surgeries in the office-based procedure room: a population-based trend analysis; A comparison between robotic-assisted scaphoid screw fixation and a freehand technique for acute scaphoid fracture: a randomized, controlled trial; Factors associated with conversion to surgical release after a steroid injection in patients with a trigger finger; Two modern total wrist arthroplasties: a randomized comparison; Triangular fibrocartilage complex suture repair reliable even in ulnar styloid nonunion.

The April 2024 Wrist & Hand Roundup³⁶⁰ looks at: Lunocapitate versus four-corner fusion in scapholunate or scaphoid nonunion advanced collapse: a randomized controlled trial; Postoperative scaphoid alignment, smoking, and avascular necrosis determine outcomes; Grip strength signals broader health concerns in females with distal radius fractures; Clearing the smoke: how smoking status influences recovery from open carpal tunnel release surgery; Age matters: assessing the likelihood of corrective surgery after distal radius fractures; Is pronator quadratus muscle repair required after anterior plate fixation for distal radius fractures?; Efficacy of total wrist arthroplasty: a comparative analysis of inflammatory and non-inflammatory arthritis outcomes; A comprehensive review of the one-bone forearm as a salvage technique.

Aims

To analyze the short-term outcome of two types of total wrist arthroplasty (TWA) in terms of wrist function, migration, and periprosthetic bone behaviour.

The December 2022 Wrist & Hand Roundup³⁶⁰ looks at: Anti-tumour necrosis factor therapy for early-stage Dupuytren’s disease; Patient experiences of scaphoid waist fractures and their treatment; Postoperative complications following open a1 pulley release for a trigger finger or thumb; How certain are findings in distal radius fractures: a systematic review of randomized controlled trials; Partial wrist denervation in wrist osteoarthritis: patient-reported outcomes and objective function; Dorsal bridge plating versus bridging external fixation for management of complex distal radius fractures; How is reduction lost in distal radius fractures in females aged 50 years and older; The HAND-Q: psychometrics of a new patient-reported outcome measure for clinical and research applications.

Complex carpal injuries can be difficult to assess and manage. They usually occur following high energy injuries to the wrist. Imaging in the form of traction views and a CT scan can help understand the detail of the fracture dislocation pattern. Perilunate dislocations and perilunate fracture dislocations are commonly managed with a dorsal approach to provide an anatomic reduction. A volar approach can be used is median nerve entrapment and allows a surgical repair of the volar aspect of the lunotriquetral ligament. Perilunate dislocations are often classified into greater and lesser arc injuries. The greater arc injuries include fractures which go through the radial styloid, scaphoid, capitate or triquetrum. Lesser arc injuries are through the scapholunate ligament and lunotriquetral ligament. It is common for there to be a combination of greater and lesser arc injuries. We have also identified a complex injury which is a lunate intra-arc injury. This is a fracture through the lunate. With this translunate perilunate dislocation it is important to stabilise the lunate prior to stabilising the remainder of the carpus. The authors have reviewed a series of complex injuries and developed a classification system based on the above findings. In complex cases where reconstruction is difficult then salvage procedures can be performed. SLAC wrist procedure, proximal row carpectomy and full wrist fusion can be performed particularly in highly comminuted cases or cases with a delayed presentation

Introduction. Isolated midcarpal motion during radioulnar deviation could be approximated to be a rotation in a plane of a radiodorsal/ulnopalmar rotation of the wrist, which may coincide with a motion plane of one of the most essential human wrist motions, known as the dart-throwing motion. This has been studied before in normal volunteers using Magnetic Resonance Imaging to study in vivo kinematics of the midcarpal joint in the wrists of normal volunteers. We present the early results of use of biaxial flexible electrogoniometer to study the range of motion in patients with four-corner fusion. Methods. Ten patients with four-corner fusion for SLAC/SNAC wrist were assessed to study flexion-extension, radial-ulnar deviation, and circumduction motions using flexible electrogoniometers. Opposite unaffected wrist was studied to provide normal data. Angle-angle curves (Lissajous's figures) were generated to study the area under the curve and comparison with the normal wrists and also to study the deviation from the neutral axis. Five normal volunteers were also studied to calculate the area under the curve and the axis of deviation during circumduction of the wrist. Results. The coupling action of mid-carpal motion was revealed as obliquity of the axis of motion with extension combined with radial deviation in normal wrists. This was lost in patients with four-corner fusion as revealed with decrease of obliquity in Lissajous's figures from 19 degrees to 5 degrees. There was 80% reduction in the area in the curve of the figures in comparison to normal wrists (4000 to 960 degree-degrees). Discussion. Electrogoniometer and Lissajous's figures provide a useful method of assessment of range of motion in patients with four-corner fusion. They could be used in future for comparison with patients undergoing limited wrist fusion to study the disability experienced and for counselling regarding the postoperative limitation in activities of daily living experienced by these patients