An instructional review of the anatomy, investigation, and management of scapholunate ligament injuries. Aimed at the knowledge level required for the trauma and orthopaedic FRCS examination.

The objective of this study was to review current data on the contribution of wrist arthroscopy to the management of intra-articular distal radius fractures (IADRFs). The literature published over the last 10 years was reviewed by searching databases with the key indexing terms \'distal radius fracture\', \'articular\', and \'wrist arthroscopy\'. The information in the 21 articles thus retrieved was used to answer the following questions: (i) Can arthroscopy improve the reduction of IADRFs? (ii) How does arthroscopy contribute to the diagnosis and treatment of concomitant ligament injuries? and (iii) Does arthroscopy help to improve the functional scores? The contribution of arthroscopy to IADRF reduction remains controversial. Follow-ups were limited (15 months on average) and some of the studies provided only level IV evidence. The data do not consistently suggest that arthroscopically assisted surgery may improve the quality of reduction. In contrast, they highlight the usefulness of arthroscopy in allowing the same-stage management of carpal ligament injuries. In the 12 studies providing data on this point, scapholunate inter-osseous ligament injuries were present in 41% of cases; one-fourth of these injuries were full-thickness tears that were successfully repaired by arthroscopy. The triangular fibrocartilage complex was injured in 48% of cases, and 30% of these injuries were peripheral ulnar detachments that were successfully repaired by arthroscopy. At present, arthroscopy does not allow the repair of all diagnosed ligament injuries. Comparative studies with longer follow-ups will shed light on the ability of arthroscopy to improve functional scores. LEVEL OF EVIDENCE: IV.

There have been numerous studies on surgery of wrist ligament injuries, but a quick assessment reveals few with a high level of evidence (LoE). The primary aim of this study was to categorize the study type and LoE of studies on repair and reconstruction of the scapholunate ligament, the lunotriquetral ligament and the triangular fibrocartilage complex by applying the LoE rating system proposed by the Oxford Centre for Evidence-Based Medicine. The secondary aims were to evaluate the journal- and geographic- distribution of the included studies.An electronic literature search of articles published 1985-2016, in PubMed, Embase, and Cochrane Library was carried out in May 2016 and updated in April 2017. Therapeutic studies written in English were included. The PRISMA checklist guided the extraction and reporting of data.A total of 1889 studies were analyzed, of which 362 were included. Three journals represented 40% of the included studies and American authors dominated.Most studies (97%) had low LoE (IV-V). No studies of LoE I-II were found. There is insufficient evidence to recommend one technique over the other in terms of wrist ligament surgery in clinical practice. There is an immense lack of comparison studies with high level of evidence in the area of wrist ligament repair and reconstruction.

Background: The purpose of this study was to identify factors associated with unplanned reoperation after surgery for scapholunate interosseous ligament (SLIL) insufficiency. Methods: Using Current Procedural Terminology (CPT) codes from 3 hand surgery centers across 2 metropolitan areas, we identified 316 patients undergoing surgery for SLIL insufficiency from 2000 to 2014. Medical records were manually reviewed to collect data on factors that might be associated with unplanned reoperation, including age, sex, tobacco use, occupation, acuity of treatment, and reconstruction method. Results: Thirty-eight patients (12%) had an unplanned reoperation; most of them (65%) were a secondary reconstruction or salvage procedure (eg, 6 proximal row carpectomies, 9 revision reconstruction, and 10 partial carpal arthrodeses), while 5 (13%) were for unplanned screw removal. The median time between the index and second surgery was 16 months (range, 2-97 months). The type of index procedure was not associated with reoperation. The only factor associated with reoperation was cigarette smoking, and this association persisted when looking specifically at reoperations for revision or salvage. Conclusions: Patients should be counseled that smoking is associated with reoperation after SLIL surgery. Smoking cessation or decreasing nicotine usage may be beneficial prior to surgery. With the numbers available, there was no association between surgical technique and reoperation.

Scapholunate (SL) instability is the most common dissociative carpal instability condition. It is the most frequent cause of wrist osteoarthritis, defined as scapholunate advanced collapse or SLAC wrist. Familiarity with the SL ligament complex is required to understand the various features of SL instability. Damage to the SL interosseous ligament is the main prerequisite for SL instability; however the extrinsic, palmar and dorsal ligaments of the carpus also come into play. When more than 6 weeks has passed since the initial injury event, SL instability is considered chronic because ligament healing is no longer possible. Before osteoarthritis sets in and when the SL instability is still reducible (scaphoid can be reverticalized), ligament reconstruction surgery is indicated. Since the end of the 1970s, various ligament reconstruction or tenodesis techniques have been described. These techniques are used in cases of chronic, dynamic or static reducible SL instability, when no repairable ligament stump and no chondral lesions are present. The aim is to correct the SL instability using a free or pedicled tendon graft to reduce pain while limiting the loss of mobility and protecting against osteoarthritis-related collapse in the long-term. We will perform a systematic review of the various tenodesis techniques available in the literature.

A systematic review was conducted to identify the best management for chronic scapholunate dissociation. EMBASE, MEDLINE, and CENTRAL were searched from 1965-2016. A narrative synthesis was performed. One thousand, one hundred and ninety-one citations were identified, of which 17 had final analysis. In all interventions, the pain score at 2 years reduced from 6.0 to 2.8 with similar effect from capsulodesis and tenodesis techniques. Overall there was an 18% loss of flexion arc. Radial to ulnar arc improved in capsulodesis (+19%; n = 45) and worsened in tenodesis (-6%; n = 45). Grip strength was better in capsulodesis (+31%; n = 64 versus + 11%; n = 56). There was insufficient evidence to link radiological outcome with clinical outcome. Rates of complications (20%) and CRPS (3.8%) were high, with implications for patient consent. Due to heterogeneity in data collection, the lack of comparative studies and short-term follow-up, no conclusion regarding the superiority of a single technique was possible. Longer term comparative studies are required, as are natural history studies. A minimum data set has been advised.
METHODS: II.

Injuries to the scapholunate ligament are common, especially among young active individuals. Surgeons are faced with a difficult problem because of imperfect surgical outcomes and the high demands of this patient population. Here, we review the current concepts and newest literature on scapholunate ligament injuries as well as the classification and treatment options for each stage of scapholunate instability. Emphasis is on stages in which reconstructive rather than salvage procedures can be performed. The natural history is poorly understood; it is unknown which and how many scapholunate injuries lead to wrist arthritis (SLAC wrist). Partial injuries are rare and in small studies did well with arthroscopic treatment. Complete injuries are graded based on the acuity of the injury, the presence and reducibility of scapholunate malalignment, and, finally, cartilage status. In acute injuries, anatomic repair usually leads to satisfactory results, and many authors augment the repair with a capsulodesis technique. In chronic injuries, the presence of static malalignment usually leads to inferior outcomes. Various techniques have been devised and improved over the years. These techniques appear to provide a more anatomic reconstruction, with less loss of motion; motion is 60-80 % of the contralateral side and grip strength averages 65-90 %. Once there is cartilage loss, the surgeon only has salvage procedures to choose from, tailored to the degree of arthritis.