EVIDENCE-BASED MEDICINE Acute Scapholunate Ligament Instability Michael S. Guss, MD,* Wesley H. Bronson, MD,* Michael E. Rettig, MD* THE PATIENT time.2e4 Dorsal intercalated segment instability due to A 31-year-old right-hand-dominant male professional SLIL injury can cause intermittent pain or snapping, dancer felt pain during hyperextension of his right and is associated with the gradual development of SL advanced collapse arthritis, although the natural history wrist attempting to pick up his dance partner 2 weeks Evidence-Based Medicine before presentation. He presents with pain and weak- of radiographic changes, symptoms, and disability is 1 ness in the right wrist. There is obvious swelling and incompletely understood. Operative treatment of acute tenderness dorsally at the scapholunate (SL) interval and subacute injuries is believed to alleviate symptoms 5,6 of the right wrist. His grip strength is measured 20% of and delay or prevent arthrosis. Surgical techniques the uninvolved side using a hand dynamometer. The for acute injuries include closed, arthroscopic-assisted, scaphoid shift test was too painful to perform. A or open reduction, percutaneous or open screw or wire posteroanterior static wrist radiograph demonstrates fixation, and direct repair of the SLIL (with open an SL interval of 4 mm and a cortical ring sign. The treatment) with or without dorsal capsulodesis with no 7 lateral wrist radiograph reveals a radiolunate angle of consensus on the best method. 30 and an SL angle of 95 . THE EVIDENCE THE QUESTION Zarkadas et al surveyed 468 hand surgeons regarding 7 What is the optimal treatment of acute SL ligament the management of acute and chronic SL instability. injury? Soft tissue procedures were favored for acute cases (97%). More than two-thirds preferred direct repair CURRENT OPINION with (44%) or without (33%) a dorsal capsulodesis. There was tremendous variability in the management Garcia-Elias et al proposed 6 stages of SL insuffi- of acute injuries (20 different surgical procedures). ciency. Acute injuries generally fall into stage II: Rohman et al compared 82 SLIL injuries (both “complete disruption with repairable ligament.”1 The partial and complete), with 27 treated acutely within scapholunate interosseous ligament (SLIL) usually 6 weeks of injury. Injuries were divided into isolated avulses off of the scaphoid. These injuries are amenable (7 acute, 43 chronic) and complex (20 acute, 7 to direct repair (using suture anchor or suture through chronic). Complex injuries included any additional bone tunnels) with or without dorsal capsulodesis. ligamentous or bony lesion. Distal radius fractures Scapholunate interosseous ligament injury is usually and triangular fibrocartilage tears were common, and diagnosed months to years after injury, and many pa- a list of each injury was not provided. Surgical pro- tients do not recall an injury. Dorsal intercalated cedures included 16 direct repairs with or without segment instability (DISI) develops after complete capsulodesis in 6 isolated and 10 complex injuries, 7 rupture of the SLIL. It may not be apparent initially, Kirschner wire (K-wire) fixations in complex injuries, perhaps because the scaphotrapezial-trapezoidal and 3 open reductions in complex injuries, and 1 ligament radioscaphocapitate ligaments become more lax with reconstruction in an isolated SLIL injury. Patients treated within 6 weeks were significantly less likely From the *Department of Orthopaedic Surgery, Division of Hand Surgery, NYU Hospital for Joint Diseases, New York, NY. to have a second procedure (4% to 18%) and showed fi Received for publication May 12, 2015; accepted in revised form May 24, 2015. a nonsigni cant trend toward superior radiographic fi outcomes, determined by a narrower SL gap and a No bene ts in any form have been received or will be received related directly or fi indirectly to the subject of this article. lower SL angle, and a nonsigni cant trend to have Corresponding author: Michael S. Guss, MD, Department of Orthopaedic Surgery, lower Quick Disabilities of the Arm, Shoulder, and Division of Hand Surgery, NYU Hospital for Joint Diseases, 301 E 17th Street, 14th Floor, Hand scores compared with patients treated after 6 New York, NY 10003; e-mail: [email protected]. weeks. Forty-three isolated SLIL injuries were 0363-5023/15/4010-0022$36.00/0 chronic and 7 acute. In addition, isolated SLIL in- http://dx.doi.org/10.1016/j.jhsa.2015.05.018 juries were more likely to receive an additional soft Ó 2015 ASSH r Published by Elsevier, Inc. All rights reserved. r 2065 2066 ACUTE SL LIGAMENT INSTABILITY tissue or salvage procedure with late treatment; 9 of K-wire fixation (4 patients), open reduction and K- Evidence-Based Medicine 43 were treated in the chronic period versus zero of 7 wire fixation (5 patients), direct ligament repair (2 treated in the acute period. Several complications patients), and direct ligament repair and K-wire fixa- were listed without much explanation: 2 pin in- tion (7 patients). Both groups regained an average of fections, 3 retained guidewire fragments, 3 early pin more than 80% of range of motion and grip strength removals, and 1 migration of an implant.6 compared with the uninjured side. There was no sig- Bickert et al described 12 patients with complete nificant difference in pain, Mayo scores, Quick Dis- SLIL ruptures who underwent direct SLIL repair us- abilities of the Arm, Shoulder, and Hand scores, SL ing suture anchors within a mean of 40 days of injury.8 angle, or SL-interval between groups.13 There were 4 patients with Mayfield stage IV com- plete perilunate dislocations, 4 with stage III injuries, SHORTCOMINGS OF THE EVIDENCE 2 with stage II injuries, and only 2 with stage I isolated SL ligament ruptures. The results were categorized Relatively few patients are diagnosed with acute based on pain, DASH score, and difference of the grip SLIL injuries, so most of the evidence addressing strength to the uninjured side. An average of 19 direct repair and repair with capsulodesis is in pa- fi months after surgery, 8 patients were rated excellent tients with subacute and chronic SLIL insuf ciency. or good, 2 satisfactory, and 2 poor. One patient Studies of acute injuries are small retrospective case developed lunate osteonecrosis and one patient rated series with limited follow-up that mix partial and excellent had SL dissociation radiographically.8 complete injuries and isolated injuries with injuries Rosati et al performed direct repair using a suture that are part of a more complex pattern. There are no anchor within 21 days of injury for 10 isolated SLIL prospective or long-term studies comparing direct lesions and 8 SLIL lesions with associated injuries, repair and direct repair and capsulodesis or any other including scaphoid fracture (4 patients), perilunate technique. dislocation (3 patients), and ulnotriquetral ligament injury (1 patient). Of the 18 patients, 16 had excellent DIRECTIONS FOR FUTURE RESEARCH or good Mayo functional outcome scores a mean of 5 Randomized prospective trials with long-term follow- 32 months after surgery. up comparing direct repair versus direct repair with Moran et al described 31 patients with problems capsulodesis in the acute setting would determine if fi fi ascribed to SL insuf ciency (18 classi ed as dynamic there are any differences in short- and long-term and 13 as static) treated with either Blatt or Mayo symptoms, disability, and arthrosis. Studies should dorsal capsulodesis evaluated a minimum of 2 years 9 separate isolated SLIL injuries from SLIL injuries after surgery. They found no difference between the with perilunate injury. Partial and complete SLIL 2 treatments: both groups had improved pain and injuries should also be studied separately. A mini- fl 9 decreased exion. mum 10-year follow-up with radiographs will be Minami et al evaluated 12 patients who had SLIL necessary to characterize the natural history of acute repair (3 within 6 weeks of injury) an average of 5 SLIL instability treated nonoperatively or treated with years after surgery and found that the alignment of 10 a surgical repair including changes in the SL interval, the carpus had deteriorated. They later described 17 SL angle, and radiolunate angle, and the development patients treated with ligamentous repair and Blatt of arthrosis. capsulodesis11 (14 treated within 2 months of injury) and documented maintained SL angles and wrist flexion 70% of the uninjured side.11 OUR CURRENT CONCEPTS FOR THIS PATIENT Pomerance et al evaluated 17 patients an average of Patients with SLIL injury have fewer symptoms, less 5 years after SLIL repair and capsulodesis for dynamic disability, more motion, and better radiographic instability an average of 22 weeks after injury.12 Of the alignment when they have operative treatment within 8 patients with strenuous jobs, only 3 resumed their 6 weeks of injury compared with when they are preoperative employment without modification.12 treated later.5,6 Unfortunately, most patients present Gradl et al evaluated 18 patients with operative with subacute or chronic injuries. intra-articular distal radius fractures (DRF) with SLIL Our patient’s history, examination, and radio- injury treated acutely (median 4 d, range 0e30) and graphs are consistent with a complete acute SL compared them with 20 operative DRF patients rupture, likely Garcia-Elias stage II. We offered the without a ligament injury an average of 43 months after patient operative repair to limit wrist pain and snap- surgery.13 The SLIL was repaired using percutaneous ping episodes in the near term and to limit arthrosis in J Hand Surg Am. r Vol. 40, October 2015 ACUTE SL LIGAMENT INSTABILITY 2067 the longer term. Because the patient places substantial 2. Short WH, Werner FW, Green JK, Masaoka S. Biomechanical demands on the wrist, he chose operative treatment. evaluation of the ligamentous stabilizers of the scaphoid and lunate: Part II.