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IC63-R: Scapholunate Ligament Injuries

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IC63-R: Scapholunate Ligament Injuries IC63-R: Scapholunate Ligament Injuries - Repair or Despair? Moderator(s): Ruby Grewal, MD, MSc, FRCS(C) Faculty: Andrea HW Chan, MD, Shrikant Chinchalkar, BScOT,OTR, CHT, Abhijeet L. Wahegaonkar, MD, and Jeffrey Yao, MD Session Handouts 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] 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. 8/10/2020 IC63-R Scapholunate Ligament Injuries: Repair or Despair? Faculty: Moderator: Andrea HW Chan, MD Ruby Grewal, MD Ruby Grewal, MD Jeffrey Yao, MD Abhijeet L. Wahegaonkar, MD Shrikant Chinchalkar, CHT 1 Scapholunate Ligament Injuries: Repair or Despair? Anatomy & Biomechanics Andrea H.W. Chan, MD FRCSC Assistant Professor Divisions of Orthopaedic and Plastic & Reconstructive Surgery Toronto Western Hospital Hand Program University of Toronto 2 Disclosures • None 3 1 8/10/2020 4 40M, 1-year following FOOSH Can the altered wrist anatomy & biomechanics be adequately restored with a reconstruction of the scapholunate ligament (complex)? 5 Concept of Stability • Ligamentous structures Scapholunate Stability • Geometry • Sensorimotor • Symptomatic Carpal • Unable to bear loads Instability1 • Abnormal kinematics 1. Garcia‐Elias, Berger, Horii et al., JHS 1999 6 2 8/10/2020 Ligamentous Constraints 1. Scapholunate Interosseous Ligament (SLIL) • Dorsal, volar, membranous 2. Secondary ligamentous stabilizers • STT Berger, 1997 • RSC • LRL • Dorsal capsular ligaments (DIC, DRC, (DCSS)) 7 Scapholunate Interosseous Ligament (SLIL) Primary stabilizer of the SL joint Dorsal SLIL – 206N • Distraction, torsion, translation Volar SLIL – 118N • Rotation Berger, 1997 Membranous/proximal SLIL – 63N Berger 1996; Berger et al. 1999 8 Biomechanical Properties of the SLIL Static wrist strain (△ Length/Length): • Neutral: very low strain • Extended: high strain (volar & membranous) Lee et al. JHS 2010 In vitro maximum SLIL tensile force: • Greatest in extension Dimitris et al. JHS 2015 9 3 8/10/2020 SL Secondary Stabilizers Stabilizing role, cannot replace SLIL • STT – resists excessive scaphoid flexion & pronation • RSC – resists distal row pronation, ulnar translocation • LRL – resists lunate ulnar translocation, scaphoid pronation, lunate extension • DIC & DRC – “screw-clamp”3 mechanism; locks scaphoid, lunate & Tq around capitate as they tighten Garcia‐Elias, 1997 1. Garcia‐Elias, 1997; 2. Kamal et al., 2016; 3. MacConaill, J Anat, 1941 10 Capsular Attachments • Dorsal capsuloscapholunate septum (DCSS)1,2 • Dorsal wrist capsule SLIL • Sectioning – no static changes, but increase in arthroscopic SL instability staging1 Van OverStraeten et al., 2013 1. Van OverStraeten et al., J Wrist Surg, 2013 11 Evolution of Carpal Biomechanics 12 4 8/10/2020 Biomechanics • Kinematics motion • Kinetics effect of force/torque 13 Evolution of Carpal Biomechanics Navarro (1921), Taleisnik modification (1976) Column Theory • Central – Stable (flexion & extension) • Radial – Mobile (load transfer) • Ulnar – Mobile (deviation & rotation) “Intercalated” Segment Scaphoid is the stabilizing Oval Ring link Theory Lichtman et al., JHS, 1981 14 Evolution of Carpal Biomechanics Gilford (1943) Column Theory • “Link” joints (R-L, L-C) Linscheid (1972) • Intercalated segment: L & Tq “Intercalated” • “Slider crank mechanism” Segment Landsmeer (1960), Fisk (1970) • “Concertina” effect • Scaphoid prevents “zig-zag” Oval Ring Theory deformity Lichtman et al., JHS, 1981 15 5 8/10/2020 Evolution of Biomechanics Lichtman (1981) Column Theory • Reciprocal motion occurs between the proximal and distal rows “Intercalated” Bone/Segment Oval Ring Theory Lichtman et al., JHS, 1981 16 Stable Central Column Theory (Sandow) • Computational analysis • Defines isometric connections between paired carpal bones: Aligns with important ligaments Sandow et al., 2014 • Stable central column (C,H,T,T) resists lunate extension • 2-gear 4-bar-linkage 17 Intact Wrist : Motion Intact wrist planar FEM1,2,3 • Scaphoid & lunate rotate in the same primary direction as the wrist • Motion: Scaphoid > lunate Garcia‐Elias, 1997 1. Short et al., JHS Am, 2002; 2. Wolfe, J Am Soc Surg, 2001; 3. Garcia‐Elias, 2013 18 6 8/10/2020 Wrist Kinetics: Effect of Force Axial compression • Scaphoid flexes • Distal row pronates • Lunate follows the slope of the distal radius • Tq extends/flexes Axial traction • Scaphoid extends • Distal row supinates • Triquetrum flexes Garcia‐Elias et al., 2017 1. Garcia‐Elias et al., Hand Clin, 2017 19 Intact Wrist: Contact Area & Pressure Area and pressure change with motion & load Scaphoid 1.5x greater contact area than lunate1 Tang and Chen, JHS, 2012 Hyperextension with radial deviation2 • Scaphoid contact area shifts radial and dorsal Push-up: Intact & SLIL sectioned • Greater peak pressure in radioscaphoid fossa, not radiolunate fossa3 Neutral Extension Daly et al, JHS, 2017 1. Viegas et al. JHS Am, 1987; 2. Tang and Chen, JHS, 2012; 3. Daly et al., 2017 20 How is carpal collapse prevented in the intact wrist when loaded?? https://www.voanews.com/americas/former‐iranian‐world‐champ‐helps‐coach‐us‐weightlifters‐olympics 21 7 8/10/2020 SL Stability: Self-Stabilizing Mechanism • 2 major groups of oblique ligaments: • Helical anti-pronation ligaments • Scapholunate stability • Helical anti-supination ligaments • Midcarpal stability Garcia‐Elias et al., 2017 Garcia‐Elias et al., 2017 22 Helical Anti-Pronation Ligaments (HAPLs) Intrinsic: SL LTq Extrinsic: LRL RSC SC DIC Garcia‐Elias et al., 2017 23 Kinetic Theory of Carpal Stability Self-stabilizing mechanism1,2,3,4 • Posture of the lunate is maintained by the scaphoid flexion moment & opposite Tq extension moment Garcia‐Elias, 2013 1.Kauer, 2.Weber, 3.Garcia‐Elias, 2013; 4. Garcia‐Elias et al., 2017 24 8 8/10/2020 How do kinematics change with a SLIL disruption? Scaphoid Shift Test Scaphoid 25 SL Dissociation (SLD) • SLIL disruption + disruption/attenuation of ≥1 critical secondary stabilizer 1,2,3,4,5,6 1. SL diastasis: ≥ 3mm 2. Scaphoid rotatory instability: S-L angle ≥ 70° (independent scaphoid flexion & pronation) 3. Lunate extension: R-L angle ≥ 15° 4. Dorsal scaphoid translation 1. Linscheid et al., 1972; 2. Short et al., JHS, 2005; 3. Short et al., JHS, 2007; 4. Perez et al, JBJS Am, 2019; 5. Padmore et al., 6. Short et al., 2015 26 Selective Sectioning: In Vitro Studies • Complete sectioning of SLIL alone Dynamic, not static changes1 • ↑ Scaphoid flexion & pronation • ↑ Lunate extension • Sectioning of secondary stabilizers alone Do not effect SL kinematics2,3,4 • Sectioning of SLIL + 2° stabilizers + cyclic motion Static changes2,3,4,5 1. Short et al, 1995; 2. Short et al., 2002; 3. Short et al., 2005; 4. Short et al., 2007; 5. Perez et al., 2019 27 9 8/10/2020 Differential SL Gapping Complete sectioning of the SLIL • Dorsal > volar diastasis in the neutral to flexed wrist position (unpublished data)1 Chan AHW, Padmore C et al., unpublished data 28 Dorsal Scaphoid Translation (DST) Dorsal Positive scaphoid shift test • Significant improvement in patient satisfaction if resolution with reconstruction2 Static DST – late finding1 • Required sectioning of SLIL, DIC, STT, LRL Concentric Circles / Dorsal Tangential Line3 • Concentric circles: 2.9mm vs. 0.9mm Volar • DTL: 2.5mm vs. 0.6mm Wolfe, 2001 1. Perez et al., 2019; 2. Wintman et al., 1995; 3. Chan et al., 2019 29 Stages of SL Instability Occult Dynamic SL Dissociation DISI SLAC I II III IV V Injured Partial Complete SLIL Complete SLIL Complete SLIL Same at DISI Ligaments SLIL Partial 2° volar Complete 2° Attritional wear to extrinsics volar or dorsal 2° extrinsics extrinsics Wolfe, X-rays NNSL gap ≥ 3mm SL angle ≥ 70° DJD 2001 +/- SL gap ≥ 3 mm SL angle ≥ 70° RL angle ≥ 15° CL angle ≤ -15° Stress x- N Abnormal Grossly Unnecessary Unnecessary rays Abnormal 30 10 8/10/2020 Reconstruction: Evolving or Resolving? SL diastasis (dorsal & volar) Scaphoid rotatory subluxation (flexion & pronation) Dorsal & Volar SLIL Lunate extension Secondary stabilizers (ST, RSC, LRL, DIC, DRC) Dorsal scaphoid translation Contact pressure/area restoration 31 Repair or Despair?! • We still search for a unifying kinetic model of carpal stability. • Do we have a surgical technique(s) that can restore the anatomy, geometry and biomechanics of the wrist in the setting of a SLIL disruption? • Do we have a surgical technique(s) that stands the test of time? 32 References Berger (1996) The gross and histologic anatomy of the scapholunate interosseous ligament. J Hand Surg Am. 21(2):170e178. Berger (1997) The ligaments of the wrist: a current overview of anatomy with considerations of their potential functions. Hand Clin. 13:63– 82. Berger et al. (1999) Constraint and material properties of the subregions of the scapholunate interosseous ligament. J Hand Surg [Am]. 24A:953-962. Chan K, Vutescu ES, Carlson MG, Wolfe SW, Lee SK. Plain radiographs detect dorsal scaphoid translation in scapholunate dissociation. J Hand Surg Am. 2017 Sep;42(9):S36-7. Crisco JJ et al. (2005) In vivo radiocarpal kinematics and the dart thrower’s motion. J Bone Joint Surg; 87A:2729 –2740. Daly et al. (2017) Effect of Push-Up Position on Wrist Joint Pressures in the Intact Wrist and Following Scapholunate Interosseous Ligament Sectioning. J Hand Surg Am. Dimitris et al. (2015) Force in the Scapholunate Interosseous Ligament During Active Wrist Motion. J Hand Surg Am. 40(8):1525e1533. Garcia‐Elias M, Berger RA, Horii E, et al. (1999) Definition of carpal instability. J Hand Surg [Am];24A:866‐867. Garcia-Elias (2013) Understanding Wrist Mechanics: A Long and Winding Road. J Wrist Surg. 2:5–12. Garcia-Elias et al. (2017) Carpal Ligaments: A Functional Classification. Hand Clin.33: 511-520. Kamal et al. (2016) Carpal Kinematics and Kinetics. J Hand Surg Am. 41(10):1011e1018. Lee et al. (2010) Differential Strain of the Axially Loaded Scapholunate Interosseus Ligament. J Hand Surg. 35A:245–251. Lichtman et al. (1981) Ulnar midcarpal instability — clinical and laboratory analysis. J. Hand Surg., 6: 522.
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