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All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain.
SYM19: Scapholunate Reconstruction
2020: Addressing the Critical Ligaments
Moderator(s): Scott W. Wolfe, MD
Faculty: Greg Bennett Couzens, MD, Mark Ross, FRACS, Michael J. Sandow, BMBS,
FRACS, FAOrthA, and Abhijeet L. Wahegaonkar, MD
Session Handouts
Saturday, October 03, 2020
75TH VIRTUAL ANNUAL MEETING OF THE ASSH
OCTOBER 1-3, 2020
822 West Washington Blvd
Chicago, IL 60607
Phone: (312) 880-1900
Web: www.assh.org
Email: [email protected]
8/31/2020
1
SYM19: Scapholunate Reconstruction
2020: Addressing the Critical
LigamentsSession Chair: Scott W. Wolfe, MD
Faculty: Abhijeet L. Wahegaonkar, MD, Greg Bennett Couzens, MD, Mark Ross, FRACS and Michael J. Sandow, BMBS, FRACS, FAOrthA
SYM19: Scapholunate Reconstruction 2020: Addressing the Critical Ligaments
www.thehandsurgeryclinics.com
75th Annual Meeting of the ASSH
October 1-3, 2020
Abhijeet L. WahegaonkarAdjunct Professor of Hand Surgery
Distinguished Clinical Tutor of Orthopedic Surgery
Director- Upper Limb, Hand & Microsurgery Fellowship Program
Consultant & Head
Department of Upper Extremity, Hand & Microvascular Reconstructive Surgery
Sancheti Institute for Orthopaedics & Rehabilitation
Jehangir Hospital
Pune, INDIA
A Global Perspective on Outcomes of Scapholunate
Ligament Reconstruction
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COI/ Disclosures
• No disclosures
Scapholunate Dissociation
• Most commonly recognized pattern of carpal instability
Scapholunate Dissociation
• Most commonly recognized pattern of carpal instability
• known predisposition for development of DJD
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Scapholunate Dissociation
• Most commonly recognized pattern of carpal instability
• Known predisposition for development of DJD
• Thorough understanding of anatomy and mechanics is
prerequisite for appropriate management and optimum
outcomes
Treatment
• Depends on classification
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Treatment
Duration
• Acute: Good healing potential
• Subacute: Some healing potential
• Chronic: Little healing potential;
repair/reconstruction needed
• Chronic with DJD:
Reconstruction/salvage
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Treatment
• Depends on classification
• Depends on surgeons preference*
•
• *Zarkadas PC et al. A survey of the surgical management of acute and chronic scapholunate instability. J Hand Surg Am. 2004;29(5):848-857
Treatment
• Depends on classification
• Depends on surgeon’s preference/training/experience*
• Depends on patient needs and expectation
• Treatment of SLD is difficult, not always predictable, and seldom entirely satisfactory.
*Zarkadas PC et al. A survey of the surgical management of acute and chronic scapholunate instability. J Hand Surg Am. 2004;29(5):848-857.
Considerations
• 1) Is the dorsal SLL intact?
• 2) Does the dorsal SLL have sufficient tissue to be repaired?
• 3) Is the scaphoid posture normal?
• 4) Is any carpal malalignment reducible?
• 5) Is the cartilage on the radiocarpal and mid-carpal surfaces normal?
• 6) Does the abnormal SL relationship involve two distinct planes of deformity
(widening and rotatory)?Garcia-Elias M, et al Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and
surgical technique.J Hand Surg Am. 2006 Jan; 31(1):125-34.
• Kitay A, Wolfe SW Scapholunate instability: current concepts in diagnosis and management. J Hand Surg Am.
2012 Oct; 37(10):2175-96.
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Considerations
How does the Classification help in Decision Making?
Garcia-Elias et al. JHS 2006
How does the Classification help in Decision Making?
Garcia-Elias et al. JHS 2006
Dynamic
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How does the Classification help in Decision Making?
Garcia-Elias et al. JHS 2006
Static
Stage 4: Complete SL ligament injury- nonrepairable with
easily reducible rotary subluxation of the scaphoid and
normal cartilage
Stage 4: Complete SL ligament injury- nonrepairable with
easily reducible rotary subluxation of the scaphoid and
normal cartilage
• Tenodesis Procedures
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Stage 4: Complete SL ligament injury- nonrepairable with
easily reducible rotary subluxation of the scaphoid and
normal cartilage
• Tenodesis Procedures
Stage 4: Complete SL ligament injury- nonrepairable with
easily reducible rotary subluxation of the scaphoid and
normal cartilage
• Tenodesis Procedures
Stage 5: Complete SL ligament injury- nonrepairable with
IRReducible rotary subluxation of the scaphoid and normal
cartilage
Options
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Ligament Reconstruction Techniques
Martin Langer MD
Ligament Reconstruction Techniques
Martin Langer MD
Ligament Reconstruction Techniques
Martin Langer MD
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Ligament Reconstruction Techniques
Martin Langer MD
Ligament Reconstruction Techniques
Martin Langer MD
Ligament Reconstruction Techniques
Martin Langer MD
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Ligament Reconstruction Techniques
Martin Langer MD
Ligament Reconstruction Techniques
Martin Langer MD
Ligament Reconstruction Techniques
Modifications:Sanj KakarGabor Szalay
www.Arthrex.com
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Outcomes
Long term – recurrence
(Megerle K, et al. Long-term results of dorsal intercarpal ligament capsulodesis for
the treatment of chronic scapholunate instability. J Bone Joint Surg [Br] 2012;94-
B:1660-1665.)
Loss of arc of motion
Kinematics/ kinetics not restored
Outcomes
Wang P, et al Equivalent Clinical Outcomes Following Favored Treatments of Chronic Scapholunate Ligament Tear. HSS J. 2017;13(2):186-193.
Outcomes
Wang P, et al Equivalent Clinical Outcomes Following Favored Treatments of Chronic Scapholunate Ligament Tear. HSS J. 2017;13(2):186-193.
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Outcomes
Wang P, et al Equivalent Clinical Outcomes Following Favored Treatments of Chronic Scapholunate Ligament Tear. HSS J. 2017;13(2):186-193.
• No significant difference in outcomes from capsulodesis or reconstruction for treatment of chronic scapholunate instability.
• However, the retrospective studies examined were notably heterogeneous in design with high estimates of variance. Further prospective trials are necessary to determine an ideal treatment strategy.
Outcomes
Outcomes
Montgomery SJ, et al: Surgical outcomes of chronic isolated scapholunate interosseous ligament injuries: a systematic review of 805 wrists, 2019 Mar 22]. Can J Surg. 2019;62(3):1-12.
• Analysis of clinical, radiographic and patient-reported outcomes
• Used a fixed effects model weighted by sample size with combined outcomes estimated via least squares means with 95% confidence intervals
• Performed a subgroup analysis of static versus dynamic instability.
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Outcomes
Montgomery SJ, et al: Surgical outcomes of chronic isolated scapholunate interosseous ligament injuries: a systematic review of 805 wrists, 2019 Mar 22]. Can J Surg. 2019;62(3):1-12.
• No statistically significant differences in outcomes between surgical techniques or in subgroup analysis
• Overall, postoperative wrist flexion and pain scores decreased, and grip strength and patient-rated outcomes improved.
Outcomes
Montgomery SJ, et al: Surgical outcomes of chronic isolated scapholunate interosseous ligament injuries: a systematic review of 805 wrists, 2019 Mar 22]. Can J Surg. 2019;62(3):1-12.
Outcomes
Montgomery SJ, et al: Surgical outcomes of chronic isolated scapholunate interosseous ligament injuries: a systematic review of 805 wrists, 2019 Mar 22]. Can J Surg. 2019;62(3):1-12.
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Outcomes
Montgomery SJ, et al: Surgical outcomes of chronic isolated scapholunate interosseous ligament injuries: a systematic review of 805 wrists, 2019 Mar 22]. Can J Surg. 2019;62(3):1-12.
• Based on the current standard of literature, it will be difficult to advance our knowledge on chronic isolated SLIL tears. It is time to stop putting our energy into single surgeon retrospective case series.
• Collaboration in the form of multicentre prospective RCT and consistent reporting using common data elements offer an opportunity to truly understand the problem, learn about the natural history and potentially flesh out optimal treatment strategies.
Dilemma
What is the solution for treating a scapholunate dissociation that has a
static deformity and/or unusable ligament and still maintain the greatest
range of motion, preserve near normal kinematics and last?
Summary
• Proper patient selection and indication
• Multicentre prospective RCT
• Accurate detailed documentation of all patients (non-op and op)
• documentation of diagnostic method
• Stratification of patients by degree of injury
• Standardized outcome measures including patient-reported outcomes
• Long-term follow-up.
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Question
The concept that a scapholunate ligament injury
visualized arthroscopically, without static x-ray
changes, inevitably leads to SLAC wrist is supported
in the literature by what level of evidence?
A. I
B. II
C. III
D. IV
E. None
Preferred response: E
Question
The scaphoid shift test, as described by Watson, requires:
A. Ulnar-directed pressure on the scaphoid
B. Volarly-directed pressure on the scaphoid proximal pole
C. Volarly-directed pressure on the lunate
D. Dorsally-directed pressure on the lunate
E. Dorsally-directed pressure on the scaphoid distal pole
Preferred Response: E
Thank you!
www.thehandsurgeryclinics.com
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Scott W Wolfe, MD
Royalty: Trimed, Extremity Medical, ElsevierConsulting Fees: Extremity MedicalSpeakers Bureau: TriMed
None relevant to this talk
SYM19: Scapholunate Reconstruction 2020:Addressing the Critical Ligaments
SCOTT W. WOLFE, M.D.
Anatomy of the Dorsal Scapholunate Complex:Implications of Injury
Hospital for Special Surgery, New YorkWeill Medical College of Cornell University
Scott W. Wolfe, MD
© Scott W. Wolfe, MD 2020
75th Annual Meeting of the ASSH SYM19: Scapholunate Reconstruction 2020: The Critical Ligaments October 3, 2020
CapitateHamate
Triquetrum Lunate
Scaphoid
dSLT complex
The Dorsal ScapholunotriquetralLigament Complex
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THE DORSAL SLT LIGAMENT COMPLEX LIGAMENT ANATOMY
Richard A. Berger, MD, Ph.D., Hand Clinics 1997
Extension Flexion
Viegas et al., JHS 1999DRC
DIC
Dorsal SLT ligament complex
• 90 cadaveric specimens• DIC is an intrinsic ligament (carpal to carpal) • Both DIC and DRC consistently insert on lunate• DICL hypothesized to be a restraint to DISI• DRC hypothesized to be a restraint to VISI
J.Hand Surg. 1999DIC DRC
99%90%DIC
J.Wrist Surg. 2012
• Dorsal capsulo-ligamentous fold• Attaches to dorsal SLIL• Part of the complex binding DIC to SLIL• Arthroscopic repair described
J.Wrist Surg. 2014
Controversy: Dorsal Ligament Anatomy
Berger, Bishop, Bettinger 1995
Hagert, E. 2008Nagao, S. et al., 2005
Richard A. Berger, MD, Ph.D., 2003
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Controversy: Dorsal Ligament Anatomy
Berger, Bishop, Bettinger 1995
Hagert, E. 2008Nagao, S. et al., 2005
Richard A. Berger, MD, Ph.D., 2003
Labral-like acetabular roof of the dST ligament
Tq
Sc
DIC
Dorsal Scaphotriquetral ligament
DST
D
The 2018 Linscheid-Dobyns Excellence in Wrist Research Award: ASSH
2019
• Isolated SLIL injuries don’t produce DISI
• LRL, STT and DICL are critical lunate stabilizers
• The greatest increase in RLA (DISI) was noted when STT or DICL + DICS were cut
• There is a differential effect of the DICL and DICS
2019
• MRI study: 90 patients with SLIL tear• 2mm or more gap associated with increased
signal in DIC and/or DRC ligament• Reinforces cadaveric studies that show DIC
injury is critical to scapholunate dissociation
JHS 2019
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ARE WE CAUSING DISI?
Berger, RA., Bishop, AT, Bettinger, PC:
Ann Plast.Surg., 1995
**** * * ??
* ** * *
*
IS THE “LIGAMENT SPLITTING APPROACH” LIGAMENT-SPARING? PURPOSE1. Define the anatomy and insertional area
of the DIC, DRC and DST ligaments
2. Establish a novel dorsal surgical “window” approach to the carpus that preserves the dorsal scapholunotriquetral ligament complex
Loisel, F., Wessel, L., Morse, K., et al, JBJS, submitted, 2020
HYPOTHESIS
The “ligament-splitting” approach to the carpus leads to greater kinematic
abnormalities than a “window” approach.
METHODSAnatomy
• 17 FF cadaveric specimens, no prior injury/DJD – 7♂, 10♀ Age: 67.1 (range 48-86)
• DIC and DRC inspected, photographed, measured; then lifted from triquetral insertion
• DST exposed and measured• Scaphoid, lunate and trapezoid insertions
measuredWessel, L., Kim, J., Morse, K. et al, JHS (A), submitted, 2020
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METHODSImaging
• 3 imaged with thin-cut high-res (4T) MR imaging (GE Medical systems) prior to dissection
• Ligaments identified on 0.7-1.0mm serial sections in three planes (axial, coronal, sagittal)
• Bones and ligaments segmented using ITK-SNAP (ver. 3.8.0) [SCI, Univ. Penn]
• 3D interactive carpal model constructed with layered ligaments
• Highest density likely represents most aligned (isometric) ligament fibers
METHODSKinematics
• 24 cadaveric wrist-forearms, no prior injury/DJD• Mounted in a custom frame• 4 phases, each cycled with load
I. IntactII. SLIL cut percutaneouslyIII. Ligament-split vs Window approachIV. Anchor vs “baseball stitch” closure
RESULTSAnatomy
Insertion site MeanArea (mm2)
St. Deviation
Conjoined insertion on the triquetrum 88.5 6.4
DST Insertion on the lunate 59.0 5.0
DST insertion on the scaphoid ridge 23.9 5.4
DRC insertion on the lunate 29.3 27.6
DRC insertion on the radius 66.0 7.9
DIC insertion on the scaphoid ridge 41.4 2.6
DIC Insertion on the trapezoid 46.4 7.7
DIC
DRC
H C S
Anatomy of Dorsal SLT Ligament ComplexOverlying DIC fibers excised for exposure
DSLT
@Lauren Wessel, MD
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Anatomy of Dorsal SLT Ligament Complex
SCH
Overlying DIC fibers excised for exposure
DSLT
@Lauren Wessel, MD Hagert, E. 2008 Wessel/Wolfe modifications, 2020
RESULTSImaging
Hagert, E. 2008 Wessel/Wolfe modifications, 2020
RESULTSImaging
We believe the dorsal scapho(luno)triquetral ligament binds the proximal carpal row, and is the deep anchoring
subcomponent of the DIC. It also represents a dorsal labrum for
the capitate.
The DIC proper overlies the DSLT and attaches
predominantly to the trapezoid & trapezium.
Fiber splitting capsulotomy « Window » approach
APPROACH
RESULTSKinematics
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Fiber splitting capsulotomy Active dorsal scaphoid translation produced
APPROACH
RESULTSKinematics
Fiber splitting capsulotomy « window » approach
CLOSURE
RESULTSKinematics
Mean scapho‐ lunate Gap (mm)
RESULTSKinematics
Mean radio lunate angle (°)
RESULTSKinematics
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CONCLUSIONS• The dorsal SLT ligament complex is
critical to the stability of the proximal row• The DIC, DRC and DST each insert on the lunate• The dorsal scapho(luno)triquetral ligament is the
insertional subcomponent of the DIC• The ligament-splitting approach creates
additional postural and kinematic abnormalities• A window approach enables safe open repair of
the SLIL and DIC/DRC/DST
THANK YOU!!
Lauren Wessel, MDFrancois Loisel, MDAlfonso Perez, MD
Kyle Morse, MDDavid J. Kim, MS
Ubaldo Alaya Gamboa, MD
Matthew Koff, PhDRyan Breighner, PhDKathleen Meyer, MSStephen Doty, PhD
Christian Victoria, MSHollis Potter, MD
© Scott W. Wolfe, MD 2020
The 75th Annual Meeting of the ASSH SYM19: Scapholunate Reconstruction 2020: The Critical Ligaments October 3, 2020
Special thanks to the entire DSLT team:
Funded in part by the American Foundation for Surgery of the Hand, Fast Track Grant #2236
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DISCLOSURES
Greg B. Couzens, MD
Speakers Bureau: Medartis, LMT (Australian
distributor for Trimed, Integra)
Ownership Interests: Shares in Field
Orthopaedics.
Beyond the SLIL:Diagnostic workup of the
critical ligaments of the carpusGreg Couzens, MBBS, FRACS (Orth)
1. Brisbane Hand & Upper Limb Clinic.2. Princess Alexandra Hospital.3. Queensland University of Technology.
ASSH 75
SYM19 – Scapho-lunate Reconstruction 2020: Addressing the Critical Ligaments. 2:30-2:38pm
Extrinsic
ligaments
Dorsal radio-
carpal ligament
Dorsal intercarpal
ligament
Long radio-lunate
ligament
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Xray other side
Courtesy of Mark Ross
RadiusCapitate
Radio-lunate
Luno-capitate
Scapho-lunate
Alignmentof both
sides
Infer ligament injury from plain films
Image critical extrinsic ligaments on MR
Visualise injured structure with arthroscopy
Visualise carpal motion on animated CT
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Infer ligament injury
▪ pattern of static deformity on
plain films
▪ stress films
Image critical extrinsic ligaments on MR
▪ injury to extrinsic ligaments often
identified
▪ Significance varies, needs correlation
with x-rays, clinical findings
Visualise carpal motion on
animated CT
▪ Disruption of normal
smooth pattern of
motion
▪ Excessive motion
Using the method described by Leng et al
2011 & Shore et al 2013
Effective dose: 0.07 mSV per scan
maneuvre equating to <1mSV for entire CT
scan Skin dose: 33mgy / <1mSV
128 slice cardiac CT
4D CT
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Visualise injured
structure with
arthroscopy
▪ Bare area at
site of avulsion
▪ Swollen
ligament
▪ Test integrity of
attachment
Lateral X-Ray
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Lateral X-Ray
99%90%
Viegas, S.
1999
Identify on PDFS sequences
▪ Gradient or T2 weighted for small bony
avulsions
Trace course of ligament in sequential slices
Identify ligament in all three planes
▪ Sagittal sequences will be the most useful
Absence of normal ligament
High signal in ligament
Swelling of ligament
MR Arthrogram only if plain MR unhelpful and
you are convinced of an extrinsic ligament
injury
Magnetic Resonance Imaging
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Attachments of dorsal ligaments
to proximal row
Normal MR
appearance
Dorsal Extrinsic ligaments
▪ Dorsal Radio-carpal
ligament
▪ Dorsal Intercarpal
ligament
DICL
DRCL
Dorsal Extrinsic ligaments▪ Dorsal Radio-carpal
ligament
▪ Dorsal Intercarpal ligament
Normal MR
appearance
Normal triquetral insertion of DIC ligament
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Dorsal Extrinsic ligaments
▪ Dorsal Radio-carpal
ligament
▪ Dorsal Intercarpal ligament
Normal MR
appearance
Dorsal Extrinsic
ligament injury
▪ Dorsal Radio-
carpal ligament
Positive findings
▪ Swollen
▪ High signal
▪ Absent
Intact
attachment
of DICL
Dorsal Extrinsic
ligaments
▪ Dorsal Radio-
carpal
ligament injury
▪ Intact dSLL
▪ Torn vSLL
▪ Disrupted
DRCL towards
insertion
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Dorsal Extrinsic ligaments
▪ Dorsal Radio-carpal
ligament
▪ Dorsal Inter-carpal
Ligament
TFC
disc
Dorsal Extrinsic
ligaments
▪ Avulsion injury
▪ Dorsal Radio-
carpal ligament
▪ Dorsal Inter-
carpal Ligament
DRC ligament
stripped up off
insertion
Dorsal Extrinsic ligaments
▪ Swelling and disruption
▪ Dorsal Radio-carpal ligament
▪ Dorsal Inter-carpal Ligament
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Course▪ Anterior to
proximal pole
of scaphoid▪ No
attachment to scaphoid
▪ Overlaps
vSLLcompletely
▪ May have attachment to triquetrum
Volar extrinsic ligaments
▪ Long Radio-lunate
ligament
▪ Radio-scapho-
capitate ligament
Normal
appearance
RSC ligRSC lig
LoRL lig
Normal
appearance
Volar extrinsic ligaments
▪ Long Radio-lunate
ligament
▪ Radio-scapho-
capitate ligament
RSC lig
LoRL lig
RSC lig
LoRL lig
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Normal
appearance
Volar extrinsic ligaments
▪ Long Radio-lunate
ligament
▪ Radio-scapho-
capitate ligament
RSC ligRSC lig
LoRL lig
LoRL lig
LoRL
LoRL
LoRL
Normal
appearance
PDFS
sequences
RSC
RSC
RSC
Normal
appearance
PDFS
sequences
Long radio-lunate ligament
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Volar extrinsic ligamentsLong radio-lunate ligament
▪ Swollen
▪ High signal
Complete disruption with oedema in lunate
Volar extrinsic ligaments
Long radio-lunate ligament
▪ Swollen
▪ High signal
Torn
LoRLL
21 yo
Normal
LoRLL
Volar extrinsic ligaments
Long radio-lunate ligament
▪ Swollen
▪ High signal
LoRL Lig.
Near
insertion
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Volar extrinsic ligaments
Long radio-lunate ligament
▪ Swollen
▪ High signal
Associated
with non-
displaced
scaphoid
fracture
In plaster
LoRL sprain
LoRL sprain
LoRL sprain
Volar extrinsic ligaments
Intact dSLLTorn vSLL and LoRL lig
Volar extrinsic ligaments
Torn
Scapholunate
ligament with
intact Long
Radio-lunate
ligament
Acute subtotal SLL
tear with intact LoRL lig
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Arthroscopic
Assessment
▪ Bare area at site of avulsion▪ Swollen ligament▪ Test integrity of attachment
In my (limited) experience▪ DRL avulsion best seen from RC
joint
▪ DICL avulsion best seen from MC joint
▪ Use 6R or 1/2 portal for visualising▪ ‘horizon view’
Tq
Lu
View from
MCR portal
Tq
Lu
Tq
Lu
Lu
Tq
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View from 6R portal
DICL separated from lunate
Swollen SLL
Summary▪ Awareness of patterns of injury.
▪ High index of suspicion
▪ XR contralateral side
▪ Identify critical extrinsic ligaments on
MR
Thankyou
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The Lunate Bare Area and the RADICL (Reduction/Augmentation DICL) repair
Mark Ross Professor of Orthopaedic Surgery
University of Queensland Brisbane Hand and Upperlimb Clinic
Brisbane, Australia
Greg Couzens , Francois Loisel , Scott Wolfe
In relation to carpal instability there has been an excessive focus on intrinsic ligaments • Perhaps we should dispense with the term Secondary stabilisers
• Perhaps extrinsic ligaments are the PRIMARY stabilisers
• DRC and DIC insert on almost the entire non articular surface of dorsal lunate
• In many cases of partial and complete intrinsic ligament injury and in CIND-T there is an identifiable loss of insertion of the extrinsic dorsal capsular ligaments to the dorsal lunate (the pathological “Bare Area”)
Diagnosis of Bare Area • MRI
• MRA?
• A/S
Arthroscopic Assessment of Capsular Attachments • Must put scope in :
• 1/2 or 6 R/U
• MC U or R
Arthroscopic treatment • RADICL
• Repair / Augmentation DICL ( DRCL)
G2 / Ewas 3
• Symptomatic after trial of rehab
• Rupture volar band SLIL
• Intact dorsal band SLIL
• Assess for Luante Bare area ( MRA or A/S)
• Reattach – A/S RADICL
Arthroscopic treatment of acute perilunate
• Radicl repair can form part of repair
Implications for Open Treatment
• Avoid “creating” detachment of capsular attachment to dorsal lunate through surgical approach
• Favour window approach
• If lunate Bare Area identified during reconstruction ensure reattachment performed as part of repair
Summary
• PRIMARY Stabilisers
o LRL o vSTTJ , o DICL/DRCL
• Extrinsic ligaments→ primary stabilisers
• Assess and treat in all grades of carpal instability
• Identify dorsal capsular dissociation from lunate – Dorsal Lunate Bare Area
• MRI vs MRA not resolved
• A/S – must use correct portals and look for lesion – easy to miss from 3/4 portal
Summary - Treatment
– Don’t make it worse with approach – capsular windows
– Reattach dorsal ligaments to lunate in A/S and open cases
• A/S -Partial SL – G2/ EWAS 3
• A/S - (?)Dynamic SL – G3/ EWAS 4
• CINDT DISI and VISI
• Open – after reconstruction
• A/S – Perilunate
30-Aug-20
1
Targeting the palmar and dorsal critical
stabilizers: Novel techniques to address
DISI and carpal translation.
Michael J. SANDOW FRACS PhD
Wakefield Orthopaedic Clinic
&
Centre for Orthopaedic and Trauma Research
University of Adelaide
Adelaide
Declaration of InterestI declare that in the past three years I have:
• held shares in: True Life Anatomy (3D Imaging Technology)
Macropace Products
RuBaMAS
• received royalties from: nil
• done consulting work for: nil
• given paid presentations for: nil
• received institutional support from: nil
Signed: Michael JSandow
Developing interactive 3D imaging since 1997.
1998 1999 2001
Disclosure / COI
True Life Anatomy
How do you explain the wrist?
Why has the Wrist been so difficult to sort?
All wrist are different
Current “theories” generally based on attempts to reconcilevoluminous empirical observations
all wrists perform basicallythe same functions and tasks
6
Unifying model of carpal mechanics based on computationally derived
isometric constraints and rules-based motion
– the stable central column theory
M. J. Sandow, T. J. Fisher, C. Q. Howard, S. Papas
May 2014
30-Aug-20
2
The complexities of wrist function are enabled by the presence of the Stable Central Column
>> Radius > lunate > capitate > 2/3rd metacarpal
VOLAR
DORSAL
L-TqLongR-LSc-Tm
Sc-L
3D CT models in: RD / Neutral / UD
➢ ISOMETRIC CONNECTIONS
Each row – proximal / distalOnly moves in a single
FLEXION – EXTENSION axis
Same ISOMETRIC Constraints for RD/UD and Flex/Extend
Moritomo -2006Distal row motion is
uniaxial with the scaphoid
Two single axis cylinders with variable offset
When cylinders in line and moving in same direction
>> Flexion / Extension
When offset and moving in opposite directions
>> Radial / Ulnar deviation Flexion Extension
30-Aug-20
3
Radial Deviation Ulnar Deviation
Carpus - Two linked Rows
The combined binary output of two offset unitary arc joints,
→ two degrees of freedom
Each moves througha single arc of motion
components and they can each vary, but in combination create function
>> Rules Based Motion
1. Bone morphology
2. (Isometric) constraints
3. Surface interaction
4. Load
shape x linkage x friction x force = Wrist function
Four components / rules
16
Unifying model of carpal mechanics based on computationally derived
isometric constraints and rules-based motion
– the stable central column theory
M. J. Sandow, T. J. Fisher, C. Q. Howard, S. Papas
May 2014
- the stable central column theory -
30-Aug-20
4
What controls Lunate Extension
DCSS
LRL
dSLIL
LTq
What controls Lunate Flexion
Ref: C. Mathoulin
“Scapho-lunate” gapOnly measurable in 2D on x-rays and CT
? Radiological gap
? SLIL attachments
? Dorsal displacement of Scaphoid
3mm
17.3mm
Pre-operative
“2D” X-ray Gap
“3D” S-L Gap
7.4mm
3mm
17.3mm
Pre-operative Computer (virtual) reduction
“2D” X-ray Gap
“3D” S-L Gap “3D” S-L length
Ligaments creating oblique external linkage, with translation creating rotationally stable carpus on radius
Adding the short Radio-Lunate ligament prevent distraction
Two Degrees of Freedom➢ Flexion / Extension
➢ Radial Dev / Ulnar Dev
30-Aug-20
5
If we can understand how the wrist works, then can work out how to fix it when it does not!
FCR stripSynthetic tape
(anchor)No K-wires
ANAFAB (for Scapho-lunate dissociation)Anatomical Front and Back Reconstruction
Technique overview:www.woc.com.au/ANAFAB
November 2019
The Stable Central Column Theory explains how the wrist works
and how to fix it.
www.woc.com.au/Wrist_explainedwww.woc.com.au/wrist.pdf