Aims. 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. Methods. 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. Results. 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). Conclusion. 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. Cite this article: Bone Joint J 2023;105-B(3):307–314

Introduction and Objective. Scapholunate instability is the most common cause of carpal instability. When this instability is left untreated, the mechanical relationship between the carpal bones is permanently disrupted, resulting in progressive degenerative changes in the radiocarpal and midcarpal joints. Different tenodesis methods are used in the treatment of acute or early chronic reducible scapholunate instability, where arthritis has not developed yet and the scapholunate ligament cannot be repaired. Although it has been reported that pain is reduced in the early follow up in clinical studies with these methods, radiological results differ between studies. The deterioration of these radiological parameters is associated with wrist osteoarthritis as previously stated. Therefore, more studies are needed to determine the tenodesis method that will improve the wrist biomechanics better and will last longer. In our study, two new tenodesis methods, spiral antipronation tenodesis, and anatomic front and back reconstruction (ANAFAB) were radiologically compared with triple ligament tenodesis (TLT), in the cadaver wrists. Materials and Methods. The study was carried out on a total of 16 fresh frozen cadaver wrists. Samples were randomly allocated to the groups treated with 3 different scapholunate instability treatment methods. These are TLT (n: 6), spiral antipronation tenodesis (n: 5) and ANAFAB tenodesis (n: 5) groups. In all samples SLIL, DCSS, STT, DIC, RSC and LRL ligaments were cut in the same way to create scapholunate instability. Wrist CT scans were taken on the samples in 4 different states, in intact, after the ligaments were cut, after the reconstruction and after the movement cycle. In all of these 4 states, wrist CTs were taken in 6 different wrist positions. For every state and every position through tomography images; Scapholunate (SL) distance, Scapholunate (SL) angle, Radioscaphoid (RS) angle, Radiolunate (RL) angle, Capitolunate (CL) angle, Dorsal scaphoid translation (Dt) measurements were made. Results. Scapholunate distances means were different between intact and cut states only in neutral and clenched fist positions for all groups (p values <0.001). Mean differences were similar between the groups (p > 0.100). In neutral position, for SL center distance, mean difference between cut and reconstruction states were not different between the groups (p=0.497) but it was noted that only TLT group could not restore to the intact state. In neutral position, for SL angle, compared with the cut state, TLT and ANAFAB significantly reduced the angle (TLT: 20° (p=0.005), ANAFAB: 28° (p<0.001)) whereas antipronation tenodesis could not (13°, p=0.080). In clenched fist position, for SL angle, compared with the intact state, only ANAFAB group restored the angle, TLT and antipronation groups were significantly worse than the intact state (TLT: p<0.001, antipronation: p=0.001). In clenched fist position, for RL angle, compared with the intact state, ANAFAB and TLT groups restored the angle but antipronation group was significantly worse than the intact state (p<0.001). In neutral position, for RS angle, compared with the cut state, only ANAFAB significantly reduced the angle (11°, p<0.001) whereas TLT and antipronation groups could not (TLT: 6° (p=0.567), antipronasyon: 4° (p=0.128). Conclusions. In the presence of severe scapholunate instability in which a several number of secondary stabilizers are injured, the ANAFAB tenodesis method may be preferred to the classical method, TLT tenodesis. The results of spiral antipronation tenodesis were not better than the TLT

The pattern of injury to the carpal ligaments following wrist trauma is unclear. Different imaging techniques often prove inconclusive rendering the diagnosis difficult and hence the treatment controversial. This study aimed to observe and evaluate the differences in scapholunate kinematics before and after sectioning the scapholunate interosseous ligament (SLIL) and radioscaphocapitate ligament (RSC). Twenty two embalmed cadaveric wrists were used. There were four males and seven females with an average age of 84 years. Their medical records confirmed the absence of previous history of wrist diseases or injuries. The extensor and flexors tendons of the wrist were removed leaving the capsule intact. Two drill bits (1.5 mm) were used to make a hole each in scaphoid and lunate, one centimeter apart. The drill bits were left in the bones to act as metal wires for calibration. Each wrist was moved through a set of motions and each movement was performed thrice; first one with the ligaments intact, second with SLIL sectioned and the last one with RSC excised. Digital photographs were taken and angles measured with MB Ruler software. Analysis of variance was done using SPSS 12. There was no angle between the metal pointers when the ligaments were intact. There was movement and change in angle detected when SLIL and RSC were sectioned. The sectioning of the SLIL lead to a significant increase in the angle between the pointers in all the movements recorded (p value < 0.001). Subsequent sectioning of the RSC further increased this angle but this increase was much smaller compared to that after sectioning SLIL. On completion of the measurements the wrist capsule was opened to reveal that both the ligaments had been successfully sectioned and there were no degenerative changes in the bones or ligaments in any wrist. This first cadaveric evaluation of alterations in scapholunate motion with sectioning of SLIL and RSC revealed that SLIL has a significant influence on the scapholunate kinematics, where as sectioning of the RSC has little additional effect. This in-vivo finding might have implications of importance of preserving SLIL during wrist surgeries and its role in management of carpal instabilities

Aims. The purpose was to evaluate early clinical, patient-reported, and radiological outcomes of the scapholunate ligament 360° tenodesis (SL 360) technique for treatment of scapholunate (SL) instability. Methods. We studied the results of nine patients (eight males and one female with a mean age of 44.7 years (26 to 55)) who underwent the SL 360 procedure for reducible SL instability between January 2016 and June 2019, and who were identified from retrospective review of electronic medical records. Final follow-up of any kind was a mean of 33.7 months (12.0 to 51.3). Clinical, radiological, and patient-reported outcome data included visual analogue scale (VAS) for pain, Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), Mayo Wrist Score (MWS), and Patient-Rated Wrist Examination (PRWE). Means were analyzed using paired t-test. Results. Before surgery, patients with SL instability were significantly impaired with respect to wrist flexion, extension, and grip strength (mean flexion, 51° (20° to 85°) vs 73° (45° to 90°); mean extension, 46° (15° to 70°) vs 66° (45° to 80°); mean grip strength, 25 kg (20 to 31) vs 50 kg (35 to 68) compared to the unaffected side). The mean SL gap (4.9 mm (2.3 to 7.3) vs 2.1 mm (1.6 to 2.9)) and mean SL angle (71° (59° to 105°) vs 50° (38° to 64°) were also significantly greater in the affected wrist. At final follow-up, there was mean improvement regarding clinical, radiological, and functional outcomes comparing preoperative to final postoperative values for the VAS for pain scale, QuickDASH, MWS, PRWE, and SL gap and SL angle. Conclusion. In our small series, the SL 360 procedure for reducible SL instability has favourable early clinical, patient-reported, and radiological outcomes at a mean of 33.7 months (12.0 to 51.3). The suture tape and tendon construct confers robust stability, permitting earlier mobilization without the inherent disadvantages of Kirschner wire stabilization. Cite this article: Bone Joint J 2021;103-B(5):939–945

There is currently no commercially available and clinically successful treatment for scapholunate interosseous ligament rupture, the latter leading to the development of hand-wrist osteoarthritis. We have created a novel biodegradable implant which fixed the dissociated scaphoid and lunate bones and encourages regeneration of the ruptured native ligament. To determine if scaphoid and lunate kinematics in cadaveric specimens were maintained during robotic manipulation, when comparing the native wrist with intact ligament and when the implant was installed. Ten cadaveric experiments were performed with identical conditions, except for implant geometry that was personalised to the anatomy of each cadaveric specimen. Each cadaveric arm was mounted upright in a six degrees of freedom robot using k-wires drilled through the radius, ulna, and metacarpals. Infrared markers were attached to scaphoid, lunate, radius, and 3rd metacarpal. Cadaveric specimens were robotically manipulated through flexion-extension and ulnar-radial deviation by ±40° and ±30°, respectively. The cadaveric scaphoid and lunate kinematics were examined with 1) intact native ligament, 2) severed ligament, 3) and installed implant. Digital wrist models were generated from computed tomography scans and included implant geometry, orientation, and location. Motion data were filtered and aligned relative to neutral wrist in the digital models of each specimen using anatomical landmarks. Implant insertion points in the scaphoid and lunate over time were then calculated using digital models, marker data, and inverse kinematics. Root mean squared distance was compared between severed and implant configurations, relative to intact. Preliminary data from five cadaveric specimens indicate that the implant reduced distance between scaphoid and lunate compared to severed configuration for all but three trials. Preliminary results indicate our novel implant reduced scapho-lunate gap caused by ligament transection. Future analysis will reveal if the implant can achieve wrist kinematics similar to the native intact wrist

Aims: To evaluate the role of Blatt’s capsulodesis and scapholunate ligament repair in patients with chronic scapholunate instability. Methods: Nineteen (15 males, 4 females) patients with chronic scapholunate instability underwent surgical repair and dorsal capsulodesis. At a mean follow-up of 28 months, all patients were assessed to identify any improvement in analogue pain scores, grip strength, range of movement of wrist and overall result of surgery. Results: Pre-operative arthroscopic findings revealed a scapholunate gap of > 2mm and ease at visualising the capitate by passing the scope through the scapholunate interval confirming the diagnosis. Surgery consisted of repair of torn ligament and supplementary dorsal capsulodesis (Blatt’s technique). 12 patients (63%) had returned to normal working activities at pre-injury level. There was a marked improvement in level of pain (mean pain level= 8.7 pre-operative vs. 2.3 postoperative, p=0.003). Seventeen patients (89.5%) would recommend this operation to others with similar problems. Only one patient (5%) rated the results as worse off following surgical intervention. Statistically significant pain improvement and grip strength were noted. ROM of wrist did not improve in most patients. Conclusion: Treatment of the chronic scapholunate instability remains contentious. It is suggested early surgical intervention will benefit majority of the patients. Our result concluded that Blatt’s capsulodesis has a role in chronic scapholunate instability

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

Chauffeur fractures or isolated radial styloid fractures (IRSF) are known to be associated with scapholunate ligament (SL) injuries. Diagnosis without arthroscopic confirmation is difficult in acute fractures. Acute management of this injury with early repair may prevent the need for more complex reconstructive procedures for chronic injuries. We investigated if all IRSF should be assessed arthroscopically for concomitant SL injuries. We performed a prospective cohort study on patients above the age of 16, presenting to the Gold Coast University Hospital with an IRSF, over 2 years. Plain radiographs and computerized tomography (CT) scans were performed. All patients had a diagnostic wrist arthroscopy performed in addition to an internal fixation of the IRSF. Patients were followed up for at least 3 months post operatively. SL repair was performed for all Geissler Grade 3/4 injuries. 10 consecutive patients were included in the study. There was no radiographic evidence of SL injuries in all patients. SL injuries were identified arthroscopically in 60% of patients and one third of these required surgical stabilisation. There were no post operative complications associated with wrist arthroscopy. We found that SL injuries occurred in 60% of IRSF and 20% of patients require surgical stabilisation. This finding is in line with the literature where SL injuries are reported in up to 40-80% of patients. Radiographic investigations were not reliable in predicting possible SL injuries in IRSF. However, no SL injuries were identified in undisplaced IRSF. In addition to identifying SL injuries, arthroscopy also aids in assisting and confirming the reduction of these intra-articular fractures. In conclusion, we should have a high index of suspicion of SL injury in IRSF. Arthroscopic assisted fixation should be considered in all displaced IRSF. This is a safe additional procedure which may prevent missed SL injuries and their potential sequelae

Aim. To evaluate the correlation between the clinical Kirk Watson test and arthroscopic Geissler classification in scapholunate instability. Methods. All patients undergoing wrist arthroscopy between April 2006 and April 2010 were evaluated. Patients were included in the study if they had a Kirk Watson test and a wrist arthroscopy with an assessment of the stability of the scapholunate joint using the Geissler classification. Patients who had a Kirk Watson test performed with subsequent normal scapholunate joint at arthroscopy were included as a control group. Geissler grades 1 and 2 and grades 3 and 4 were grouped for further analysis into low and high grade instability groups respectively. Results. 76 patients were included in the study. 62 had scapholunate pathology and 14 had normal arthroscopic examinations of the stability of the joint. A positive test was found in 30% (3) of patients with grade 1 instability, 29% (4) with grade 2, 60% (12) with grade 3 and 78% (14) with grade 4 instability demonstrated at arthroscopy. The test was positive more commonly in those with grade IV instability compared with others (78% vs. 43%; p=0.015). There was a higher number with a negative test in the low grade instability group (71% vs. 32%; p=0.01) and a higher number with a positive test in the high grade instability group (68% vs. 29%; p=0.006). The test was most sensitive (78%) and most specific (57%) for those classified with Geissler grade IV instability and sensitivity and specificity were also high for those with high grade instability (68% and 66% respectively). Conclusions. The Kirk Watson test is a sensitive and specific test for diagnosis of higher grade instability of the scapholunate joint. We found a positive correlation between increasing scapholunate instability when assessed using the Geissler classification and positivity of the test. This confirms that the Kirk Watson test can be a useful test in the assessment of those with symptomatic instability of the joint and may reflect damage not only to the scapholunate ligament but to the secondary stabilisers of the joint as well

Aim: To evaluate the functional and radiographic results of dorsal capsulodesis in predynamic and dynamic scapholunate instability. Methods: Nineteen patients underwent a scapholunate interosseous ligament repair combined with a dorsal capsulodesis as described by Blatt, in as many wrists for scapholunate instability between 1994 and 1999. The diagnosis was based on a clinical, radiographic and arthroscopic assessment. Mean follow up was 22 months (8 months – 5 years). 15 patients were available for follow up. Most (13 of 15) of the patients presented with predynamic or dynamic instability. Results were analysed clinically and radiologically. Results: Thirteen patients showed a good or excellent clinical result. There was a statistically significant improvement in pain relief (VAS scores) and grip strength (58% of the opposite side). Mean extension and ulnar deviation was significantly better (62% and 53% of the opposite side respectively) and there was a significant reduction in wrist flexion (49% of the opposite side). 13 patients returned to their original level of activity. There was no significant change in the mean SL gap and angle after surgery. Thirteen patients would recommend this operation. Conclusions: We thus believe that this procedure can produce encouraging results in cases of pre dynamic and dynamic instability in a patient population with low demand wrists. Larger case loads and more complete follow ups would be desirable to derive strong evidence based conclusions

A consecutive series of 100 cases of wrist injury, other than those referred with a radial fracture, have been reviewed to determine the incidence of acute scapholunate instability; a "clenched fist" radiograph was used in addition to the routine scaphoid views. Of 19 patients with an increase in the scapholunate gap, five were eventually considered to have significant scapholunate instability, two in association with Colles' fractures. Injuries producing significant ligamentous damage and carpal instability may be as common as scaphoid fractures. They require special consideration in diagnosis and management

Purpose. Although multiple surgical options exist for chronic static scapholunate dissociation, no single procedure has been found to be superior clinically or kinematically. We hypothesize that the reduction and association of the scaphoid and lunate (RASL procedure) is a safe and effective procedure that improves function and alleviates pain in the injured wrist. The purpose of this study is to report long-term follow-up of patients undergoing the RASL procedure over a 20-year period. Method. Between December 1991 and September 2008, the senior author performed 36 RASL procedures for chronic static scapholunate dissociation. This reconstruction involves reduction of the rotational deformity and diastasis between the scaphoid and lunate through a dorsal approach to the wrist. Maintenance of reduction is accomplished with a cannulated, headless, smooth-shafted compression screw directed from the scaphoid to the lunate along the anatomic axis of rotation between the two bones. For the purposes of this study, patients were evaluated by visual analog pain scale (VAS), Disability of the Arm, Shoulder and Hand questionnaire (DASH), SF-36 health survey, physical examination and radiographs. Results. Thirty-two of 36 patients were available for questionnaires and 23 available for questionnaires and physical examination, with an average time to final follow-up of 6.2 years post-operatively. The mean DASH score was 16.6, and other patient-based outcomes showed similarly favorable results. Range of motion was well preserved with 80% of the contralateral flexion-extension arc being maintained in those available for physical examination. Grip strength was well preserved at 90% of the contralateral side. X-rays showed significant decreases in scapholunate gap (p < 0.001) and scapholunate angle (p < 0.001) as compared to preoperative films. In the 32 patients followed, there were 2 treatment failures going on to have salvage procedures for progression to scapholunate advanced collapse deformities. These patients were included in the final analysis. Conclusion. The RASL procedure is a safe and effective treatment for chronic static scapholunate dissociation. It re-aligns the scaphoid and lunate, restores function, reduces pain, and appears to be robust over time

INTRODUCTION. Scapholunate instability is a common form of carpal instability and Brunelli procedure has been advocated as a surgical intervention for this difficult problem. MATERIALS AND METHODS. Twenty five patients with clinical and radiological diagnosis of scapholunate dissociation were included in the study. Mean age of the patients was 37 years. All the patients were treated by modified Brunelli procedure, with the flexor carpi radialis tendon being passed through a drill hole in scaphoid and sutured to radiotriquetral ligament. All patients had a wrist arthroscopy prior to the index procedure and associated injuries recorded. The average postoperative follow up for the patients was 60 months. RESULTS. Patient rated wrist evaluation score improved from an average of preoperative score of 108 to a postoperative score of 33.8. The hand grip strength improved in 22 out of 25 patients. 21 (84%) patients were satisfied with the procedure and would undergo the operation again if required. CONCLUSION. This case series reaffirms the current literature regarding efficacy of modified Brunelli procedure in scapholunate instability. Early and midterm results suggest this procedure to be a useful option in carefully selected patients group

Purpose: The mechanical behavior of human scapholunate ligaments is not described well in the literature regarding torsion. Presently, intact scapholunate specimens were mechanically tested in torsion to determine if any tensile forces were generated as a result. Method: Scapholunate specimens (n=19) were harvested and inspected visually. Scaphoid and lunate bones were potted in square chambers using epoxy cement. The interposing ligaments remained exposed. Specimens were mounted in a specially designed test jig and remained at a fixed axial length during testing. Using angular displacement control, ligaments were subjected to a torsional motion regime that included cyclic preconditioning (25 cycles, 1 Hz, triangular wave, 5 deg max), ramp-up to 15 deg at 180 deg/min, stress relaxation for 120 sec duration, ramp-down to 0 angulation at 180 deg/min, rest period for 5–10 minutes, and torsion-to-failure at 180 deg/min. Torque and axial tension were monitored simultaneously. Results: Tests showed a coupled linear relationship between applied torsion and the resultant tensile forces generated for the ligament during ramp-up (Torsion/Tension Ratio = 38.86 +/− 29.00 mm, Linearity Coefficient R-squared = 0.89 +/− 0.15, n=19), stress relaxation (Ratio = 23.43 +/− 15.84 mm, R-squared = 0.90 +/− 0.09, n=16), and failure tests (Ratio = 38.81 +/− 26.39 mm, R-squared = 0.77 +/− 0.20, n=16). No statistically significant differences were detected between the Torsion/Tension ratios (p=0.13) or between the linearity (R-squared) of the best-fit lines (p> 0.085). Conclusion: A strong linear relationship between applied torsion and resulting tensile forces for the ligament was exhibited during all testing phases. This may suggest that there is interplay between torsion and tension in both the stabilization of the scapholunate ligament during normal physiological motion and during resistance to injury processes. This is the first report in the literature of the coupling of torsion with tension for the scapholunate ligament

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 treatment of scapholunate (SL) ligament injuries is addressed by surgical procedures to stabilize the carpal joint. Open techniques include bone-ligament-bone transfers, tenodesis, partial fusions and carpectomies. Innovative procedures using wrist arthroscopy, offer minimally invasive fixation without full exposure of carpal bones; however, the success of the technique and its impact on the reduction on the range of carpal movement is as yet not well known. In this work, the performance of Corella tenodesis technique to repair the SL ligament is evaluated for a wrist type II by numerical methods. Human wrist can be classified based on the lunate morphology: type I for lunate that articulates with radius, scaphoid, capitate and triquetrum, and type II which has an extra surface to articulate with the hamate. A finite element model was constructed from CT-scan images, the model includes cortical and trabecular bones, articular cartilage and ligaments. Three scenarios were simulated representing healthy wrist, SL ligament sectioning and the Corella technique. The performance of the technique was assessed by measure the SL gap in dorsal and volar side as well as the SL angle to be compared to cadaveric studies. In intact position, the SL gap and the SL angle predicted by the numerical model is 2.8 mm and 44.8º, these values are consistent to the standard values reported in cadaveric experiments (2.0 ± 0.8 mm for SL gap and 45.8 ± 9.7 for SL angle). Virtual surgeries may help to understand and evaluate the performance of the techniques at clinical application

We present an anatomical study and the description of a new surgical technique for the arthroscopic treatment of scapholunate ligament injuries. Materials and Methods: 5 specimens were used to perform the new arthroscopic technique and prove with confidence it’s reproducibility. After arthroscopic surgery, anatomic dissection had been performed to measure the distances to the critical wrist structures such as the posterior interosseous nerve, the radial artery and the distance of the portals to the extensor compartments. Surgical Technique: Ligamentoplasty was performed with the flexor carpi radialis to reconstruct the dorsal scapholunate ligament. First, a standard wrist arthroscopy was performed, and two bone tunnels were made. One across the scaphoid, through the 3/4 portal from its dorsal face to the tubercle, and another through the 4/5 portal to the lunate, perpendicular to its axis. The plasty of the FCR was obtained by a volar approach, and it was passed through the tunnel of the scaphoid. Subsequently, the plasty was passed from the 3/4 portal to 4/5, through a small 3-cm arthrotomy on this site. Finally, we introduced the plasty in the lunate tunnel with a biotenodesis screw. At this manner the tenodesis Bone (insertion of FRC) - Tendon (FRC) - Tenodesis (FRC in lunate) was completed. Results: Tenodesis were obtained in all 5 cases with no mayor damage to the structures described. The average of distance to IP nerve was 12 mm; to radial artery 17 mm and to superficial radial artery 9 mm. The average of distances from the portals to different extensor compartments are 3/4 portal to the second 2,8 mm, to the third 3,2 mm and to the forth 5,2 mm. 4/5 portal to the fourth 1,8 mm and to the fifth 7,2 mm. Radial midcarpal portal to the second 2mm and to the fourth 5,6 mm. Cubital midcarpal portal to the fourth 2,2 mm and to the fifth 7,4 mm. Discussion: This is a revolutionary wrist arthroscopic technique, because usual reconstruction techniques of the scapholunate damage are done openly. With this arthroscopic technique three objectives are achieved. First, it reduces soft tissue damage, scar tissue and the section of secondary stabilizers of the wrist. Secondly, it ensures that, without doing and arthrotomy, the injured of IP nerve is avoided maintaining proprioception of the wrist and the properly function of the dynamic stabilizers. And finally the use of a stronger implant will shorten the time of immobilization. Conclusion: We have developed a new surgical technique for arthroscopic reconstruction of the scapholunate ligament that will improve the outcomes of standard open techniques, as long as it will gain mobility and maintain the proprioception of the wrist. However clinical trials in patients are needed to confirm with scientific rigor the new technique described

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

One hundred and sixty-two patients with a diagnosis of scapholunate instability underwent a modified Brunelli procedure over a 7 year period. One hundred and seventeen were assessed with the help of a questionnaire and, of these, 55 patients attended for clinical evaluation. The mean follow-up was 4 (1-8) years. There were 72 patients with dynamic scapholunate instability and 45 patients with static instability. The average age was 38 years. There were 50 males and 67 females. 77 (62%) patients had no to mild pain with a mean visual analogue score of 3.67 (SD=2.5)). The loss in the arc of flexion-extension was due to a reduced range of flexion (mean 31% loss), while 80% of extension was maintained, compared with the contralateral side. The grip strength on the operated side was reduced by 20% of the non-operated side. There was no statistically significant difference (p>0.05) in the range of movement or the grip strength between the static and dynamic group or the claims and non-claims group. Ninety (79%) patients were satisfied with the result of the surgery (good to excellent) and 88% of the patients felt that they would have the same surgery again. We feel that these results compare favourably with the early results published from this unit and recommend this procedure for dynamic and static scapholunate instability

Abstract. Objectives. The scapholunate interosseous ligament (SLIL) has a unique C-shape following the arc of the scaphoid and lunate surfaces from distal dorsal around to distal volar. This ligament comprises of three subregions: dorsal, proximal and volar. The SLIL enthesis, a specialized region where this ligament attaches to the scaphoid and lunate, has not previously been studied despite its important mechanical function in the biomechanics of the wrist joint. This study therefore aims to compare the histomorphological differences between the SLIL subregions, including at their entheses. This study will examine the qualitative and quantitative differences between the three subregions, as well as between the scaphoid and lunate attachments. Methods. Twelve fresh-frozen human cadaveric wrists were dissected and the gross dimensions of each SLIL subregion measured. Subregions were then histologically processed for qualitative and quantitative morphological and compositional analyses, including quantification of enthesis calcified fibrocartilage (CF) area. Results. From the gross measurements taken, the dorsal subregion was the thickest. There were no significant differences in lengths and widths between the three subregions. Qualitatively, the dorsal and volar subregions had fibrocartilaginous entheses while the proximal subregion inserted into cortical bone via articular cartilage. Quantitatively, the dorsal subregion had significantly more CF than the volar subregion. There was no significant difference in the enthesis CF between scaphoid and lunate attachments in the three subregions. Conclusions. There are significant histomorphological differences between the SLIL subregions. The dorsal subregion has the largest amount of CF, which is consistent with the greater biomechanical force subjected to this subregion compared to the other subregions. This result confirms that the dorsal subregion is the strongest of the three subregions. The similar histomorphology of the ligament at the scaphoid and lunate entheses suggests that similar biomechanical forces are applied to both attachments. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest