The scapholunate complex: a new concept

The volar midcarpal instability results from the post-traumatic distension (or rupture) of the palmar strap of the extrinsic ligaments. The second row of the bones of the carp will gradually slip on the first which will find itself subluxed back. Arthroscopic suture of extrinsic volar ligaments can be performed to restore the normal anatomy of the carpal bones.

Osteoarthritis of the first carpometacarpal joint is frequent and painful. The use of a ligamentoplasty following trapeziectomy is a simple technique, using only a single dorsal approach. The “hammock” ligamentoplasty using the abductor pollicis longus tendon slips allows to maintain the distance between the scaphoid and the base of the first metacarpal bone while preserving the flexor carpi radialis tendon and weakening the force dislocating the abductor pollicis longus.

In this key lecture, Dr. Rizzo presents wrist arthroscopy indications and complications.

An anatomical and biomechanical study has recently shown that detachment of the scapholunate (SL) ligament from the dorsal capsuloligamentous scapholunate septum (DCSS) and dorsal intercarpal ligament (DIC) worsens scapholunate dissociation. This knowledge has revolutionized the treatment of scapholunate dissociation and formed the basis of the arthroscopic repair of the scapholunate ligament complex. SL ligament repair per se is not adequate; it has to be reattached to the dorsal capsule. This is enabled with an arthroscopic technique, which preserves the dorsal capsule. In some large dissociation, we can use a trick, catching a largest part of the dorsal capsule, proximally and distally, in order to help scapholunate reduction when the knot is tightened.

There are numerous cases of patients with chronic wrist pain. Lesions of the scapholunate ligament and/or TFCC are the most common causes of chronic lesions which account for wrist pain. In some cases, it is a rare isolated lesion with detachment of dorsal intercarpal ligament from the dorsal part of the scapholunate ligament. The diagnosis can be made easier with a new MRI sign, but must be confirmed by wrist arthroscopy. The new technique of arthroscopic dorsal capsuloligamentous repair in these lesions is presented in this lecture with interesting results.

Treatment of 1st CMC arthritis is controversial. Many techniques have been described, and indications are related to the stage of osteoarthritis. When the only trapeziometacarpal joint is involved with preserved axes, we can propose to put a pyrocarbon implant arthroscopically.

Scapholunate advanced collapse (SLAC) is a form of degenerative arthritis of the wrist which is commonly a sequela of scapholunate instability. SLAC follows a typical pattern which begins with arthritis of the radial styloid (stage 1). Stage 2 is marked by the involvement of the entire scaphoid fossa and the scaphoid while arthritic changes involve the midcarpal joint in stage 3. Stage 2 SLAC is typically managed with proximal row carpectomy (PRC), which preserves some degree of wrist flexion-extension arc and reduces pain. However, major drawbacks of this procedure are as follows: incongruence between lunate fossa and capitate, subsequent arthritic changes, and reduced grip strength originating from reduced carpal height. This video shows a recently described salvage procedure, namely arthroscopic interposition tendon arthroplasty (AITA), which attempts to preserve wrist motion and carpal height simultaneously restoring radiocarpal joint space and reducing pain, by interpositioning tendon graft in the radiocarpal joint.

In this key lecture, Dr. Liverneaux highlights robotic assisted wrist arthroscopy.

The first case of arthroscopic radial styloidectomy was reported by Ruch in 1998.
Indications of radial styloidectomy are relative to radioscaphoidal impingement without alteration of the mid-carpal joint by degenerative arthritis (SNAC and SLAC stage 1 and 2). Pseudarthrosis of the radial styloid is another rare indication of radial styloidectomy.
The quantity of radius to remove was evaluated in different studies between 3 and 4mm. Removing more than 4mm of radius may lead to a destabilization of the wrist due to the insertion of ligaments on the anterior marginal part of the radius. No case of carpal destabilization after radial styloidectomy was reported in the literature.
The design of osteotomy may be different depending on the origin of the conflict. SNAC and SLAC lead to different kinds of arthritis and impingement.
Arthrocopy is a very useful tool to carry out radial styloidectomy; it is a minimally invasive procedure with the possibility of early rehabilitation. In case of poor results, there is still a place for open surgery.
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In this key lecture, Dr. Luchetti outlines the arthroscopic Sauve Kapandji (SV) technique.