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Chronic Scapholunate Instability Treated With

Temporary Screw Fixation
Margaret Woon Man Fok, MBChB, Diego L. Fernandez, MD
Purpose To determine the efcacy of scapholunate (SL) temporary screw xation to maintain
the reduction of SL interval after ligament debridement, repair, or reconstruction.
Methods A total of 36 patients who had chronic SL instability were included. Arthroscopic
debridement was performed for dynamic instability, and primary repair or reconstruction of the
SL ligament was performed for static instability. We then used SL screw xation for the protection of the repair or reconstruction. Screws were removed when loosening was noted on x-ray.
Results The average patient age was 43 years. Eleven had dynamic instability, and 25 had
static instability. The average follow-up was 7.9 years. Nearly 95% of the patients had no
more than mild pain. The average ranges of movement of the wrist were 55 extension, 51
exion, 26 ulnar deviation, and 15 radial deviation. Postoperative x-ray revealed an average
SL angle of 56 . The average SL gap was 2.5 mm. Both of these radiographic parameters
were maintained at nal follow-up. Dorsal intercalated segmental instability (DISI) deformity
was not corrected in 2 patients. One patient had avascular changes in the proximal scaphoid
and lunate but remained asymptomatic at 7 years postoperatively. There was no further
intercarpal and radiocarpal degeneration.
Conclusions Temporary SL screw xation together with arthroscopic debridement, ligament
repair, or reconstruction provided a stable closure of the SL interval and satisfactory clinical
and functional results along with a low incidence of complication. (J Hand Surg Am. 2015;(-):-e-. Copyright 2015 by the American Society for Surgery of the Hand. All rights
Type of study/level of evidence Therapeutic IV.
Key words Chronic scapholunate dissociation, scapholunate instability, screw xation.

ligament is
the most commonly injured intrinsic wrist
ligament,1 although the diagnosis is frequently missed acutely.2 As a result, many patients
present late with persistent wrist pain and diminished

From the Department of Orthopaedic Surgery, Lindenhof Hospital, Bern, Switzerland.

Received for publication May 6, 2014; accepted in revised form December 2, 2014.
No benets in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Margaret Woon Man Fok, MBChB, Department of Orthopaedics
and Traumatology, 5/F, Professorial Block, Queen Mary Hospital, Pokfulam Road, Hong
Kong; e-mail: Margaret_fok@yahoo.com.

grip strength. Several procedures for chronic SL ligament instabilities exist, including arthroscopic
debridement and pinning,3e7 direct repair with capsulodesis,8e10 dorsal capsulodesis alone,11e13 ligamentoplasties,14e19 and bone-retinaculum-bone
reconstruction.20,21 Even if a satisfactory clinical
and functional result is obtained, deterioration of the
radiographic ndings are often noted. Even if the
immediate postoperative reduction is satisfactory, it is
not uncommon to see the loss of reduction with
reference to the SL interval and SL angle at long-term
follow-up.3,9,11,17e20,22e24 In nearly all studies, temporary Kirschner wire xation and splinting were
used postoperatively.5,6,8,9,11,13,19,20,25 As it may take
more than 3 to 4 months for either the repair to heal

2015 ASSH

Published by Elsevier, Inc. All rights reserved.


or the reconstruction to incorporate,26 loss of reduction can be seen even when patients are allowed to
mobilize their wrists as early as 8 weeks following
Kirschner wire removal.19,20
The rationale of using SL screw augmentation is to
provide a more favorable mechanical environment for
soft tissue healing after the repair or reconstruction of
the SL ligament. It allows stable closure of the SL
interval (lag-screw effect), which permits early postoperative cast-free movement. Unlike tenodesis that
only corrects rotatory subluxation, realignment of the
scaphoid and lunate restores normal load transfer
across the scaphoid and lunate fossa. Maintenance of
screw xation for at least 4 months also allows for
durable soft-tissue healing.27,28
The purpose of this article was to evaluate the
outcome of patients with SL instability who had undergone a repair or a reconstruction of SL ligament
together with SL screw augmentation.
This was a retrospective study of patients surgically
treated with chronic scapholunate instability by the
senior author at the Lindenhof Hospital, Bern,
Switzerland. Patients included in the study had
chronic instability, determined by persistent or
increasing symptoms and signs at least 3 months after
trauma between 1991 and 2012.4,5,10,11,19,29,30 We
excluded those patients with xed SL mal-alignment
or notable arthritic degeneration in either the radioscaphoid or capitolunate joints.
The diagnosis of SL instability was based on
clinical ndings, including tenderness over the scapholunate junction and a positive Watson test, and
conventional radiographs, including standard neutral
posteroanterior view, standard lateral view and
clenched st anteroposterior (AP) view.4 An increase
of the SL angle of greater than 60 ,4,11,13,19,25,31
an increase of the SL interval greater than 3
mm,4e6,8e11,13,19,25,31 an increase of the SL interval
in clenched st view, and the signet ring sign of the
scaphoid were assessed.4,32,33 Magnetic resonance
imaging had been performed prior to the consultation
in 32 cases.

an episode of trauma prior to the onset the symptoms,

of which 18 were high-velocity accidents (8 cycling, 7
skiing, and 3 motorcycles), 5 had a fall from height, 7
had a simple fall, and 6 had a punch injury. One patient
had undergone a failed Brunelli procedure16 prior to
presentation. At the time of injury, 20 patients were
clerical workers, 12 were manual workers, and 4 were
housewives. The Watson test was positive in all patients.34 The preoperative average range of movement
of the wrist was exion 62 , extension 59 , radial
deviation 20 , and ulnar deviation 26 . The average
grip strength was 55% (range, 25% to 100%)
compared with the unaffected hand. Preoperative
x-rays showed 18 patients with dorsal intercalated
segment instability (DISI) (ie, SL angle < 60 ). The
average SL angle was 75 (range, 55 to 82 ). The
average SL interval was 3.8 mm (range, 3e8 mm).

Thirty-six patients with chronic, reducible scapholunate instability without arthritic changes were reviewed. There were 20 men and 16 women with an
average age of 43 years (range, 21e63 y). Twenty-two
patients had their dominant wrists affected. The
average time from the onset of symptoms to surgery
was 12 months (range, 6e25 mo). All patients recalled

Operative techniques
Wrist arthroscopy was performed for patients with
dynamic instability (ie, SL interval  3 mm, SL angle
of  60 , and the presence of an increased SL interval on clenched st view). In these cases, the
grading of SL instability was based on the Geissler
classication.35 Arthroscopic debridement was performed followed by SL screw augmentation in 11

J Hand Surg Am.

FIGURE 1: A slip of extensor carpi radialis brevis tendon reconstructs the SL ligament. The tendon slip passes through the
scaphoid and lunate tunnels and is tied over the top with maximal
tension using heavy braided nonabsorbable suture.

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FIGURE 2: A X-rays of a dissociative SL tear with a widening of SL interval and an increase in SL angle. B Primary open repair. C Two
mini-bone anchors are xed in the scaphoid and lunate. D Dorsal capsulodesis uses an ulnarly based strip of the dorsal intercarpal
ligament and attaches to the bone with bone anchors. E X-rays showing the anatomical reduction of SL interval and SL angle. A
Kirschner wire was temporarily used to keep the scaphoid in reduced position. F X-rays of a reduced SL interval and SL angle at 2-year
follow-up. The SL screw was removed 6 months postoperatively.

cases with grade 3 tears. For static instability (ie, SL

interval > 3 mm and SL angle > 60 ), reduction of
the SL gap and rotatory subluxation of the scaphoid
was performed rst. It was achieved by using temporary K-wire xation between the distal scaphoid
and the capitate (as joystick) while the SL interval
and the lunate rotation was held with a pointed
reduction clamp. The screw was then inserted from
scaphoid to lunate. A 2.5-cm longitudinal incision in
the anatomical snuffbox was used, taking care not to
damage the radial artery and the supercial radial
nerve branches. The wrist was placed in ulnar deviation to allow for ease of screw insertion and to avoid
radial styloidectomy. A standard (Zimmer) or a cannulated Herbert screw (Martin, Tuttlingen) was
placed in the SL axis of rotation (ie, parallel to the AP
inclination of the radius and in the central position in
the sagittal plane using uoroscopic control).
After the placement of screw, either primary open
repair12 and dorsal capsulodesis or reconstruction of the
SL ligament, depending on the integrity of the residual
SL ligaments, using a dorsal approach, was performed.
For the ligament repair, the Taleisnik technique with
transosseous tunnels, using 2.0 braided suture,36 was
performed. For the ligament reconstruction, depending
on the surgeon preference at the time, techniques varied
from a slip of extensor carpi radialis brevis tendon
(Fig. 1), using a segment bone-retinaculum-bone taken
from the distal radius as described by Weiss,20 to using a
dorsal capsulodesis (Fig. 2).
J Hand Surg Am.

In those patients for whom we felt that the screw

xation offered maximal stability, the temporary
Kirschner wire across the distal scaphoid into the
capitate was removed. In 2 of 36 cases, this Kirschner
wire was maintained for 6 weeks (Fig. 2).
Postoperative protocol
A short arm radial orthosis including the base of
thumb was applied after surgery and was maintained
for 3 weeks when active wrist motion was started.
Gradual strengthening was started at 8 weeks and
heavy lifting was not permitted until at least 4 months
postoperatively. Clinical parameters, including pain,
range of movement, grip strength, and complications,
and radiographic parameters, including SL angle and
SL interval, were all monitored at the outpatient visits
regularly, including but not limited to the postoperative visits at 2 weeks, 6 weeks, 3 months, 6
months, and every year.
Pain was graded as none, mild, moderate, or severe
(as described by the Fernandez grading system37).
Screws were removed when we noted loosening
(localized osteolysis around the screw threads), which
usually occurred 4e7 months after operation.
Data analysis
Statistical analysis of comparing means of preoperative and postoperative radiologic and clinical parametric data of the operated and the unaffected wrist

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FIGURE 3: A X-ray and magnetic resonance images of a dissociative SL tear. No midcarpal or radiocarpal arthritis was noted. B X-ray
showing the reduction of an SL interval and angle after extensor carpi radialis brevis tendon graft reconstruction and SL temporary
screw xation. The reduction was maintained after the removal of screw 4 years postoperatively.

radial deviation 15 , and ulnar deviation 26 . There

was no statistically signicant change in the grip
strength, with the average grip strength being 67%
(range, 50% to 100%) when compared with the unaffected side. Postoperative x-rays showed that the
average SL interval was signicantly improved to 2.5
mm (range, 2e4 mm, P < .02), and the average SL
angle was also signicantly reduced to 56 (range,
40 to 75 , P < .01) (Fig. 3).
Thirty patients returned to their previous occupation at an average of 6 months (range, 4e12 mo)
postoperatively depending on the nature of their
work. Six patients who performed heavy manual labor prior to injury changed to a lighter activity work.
Radiographically, there was no measurable increase
in the SL interval and SL angle at the latest follow-up
as compared with the immediate postoperative x-rays
(Fig. 4). One patient developed avascular changes at
the proximal poles of the scaphoid and lunate, 6 patients showed mild degenerative changes at the radial
styloid, and 1 had mild narrowing of the capitolunate
joint. None had progressed to a more advanced
degenerative pattern (ie, scapholunate advanced collapse stage II or greater) at the last follow-up. For the

was performed by the Student t test. P values were

considered to be signicant at < .05.
There were 11 dynamic and 25 static scapholunate
instabilities. Of the 25 patients with complete tears, 9
patients underwent primary repair of the ligament and
dorsal capsulodesis, and the remaining ones had ligament reconstruction using either a slip of extensor
carpi radialis brevis tendon (7 patients) or use of a
bone-retinaculum-bone graft. The Herbert screws
were removed at an average of 5 months (range, 4e7
mo) uneventfully. Neither screw breakage nor supercial or deep infection was noted postoperatively.
The average follow-up period was 7.9 years (range,
1e10 y). Thirty-four patients had either no or mild
pain. Two patients continued to have severe pain
postoperatively, which we accounted for by a failure
to correct their DISI deformities intraoperatively.
The change in wrist range of movement was not
statistically signicant when compared with the
preoperative status. The average range of motion
measurements included exion 51 , extension 55 ,
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FIGURE 4: A X-rays of a dissociative SL tear. SL interval and SL angle were reduced by ligament reconstruction and SL temporary
screw xation. B X-rays showing maintenance of the reduction of both the SL interval and SL angle 1 and 8 years postoperatively.

overall satisfaction37 (based on pain, range of

movement, and functional outcome): 24 patients were
rated excellent, 10 patients good, and 2 poor (ie, the 2
patients with xed DISI deformities).
For the 2 patients who had xed DISI deformities,
a scapholunocapitate arthrodesis was subsequently
performed at 6 and 9 months postoperatively due to
the presence of severe pain. They experienced pain
relief and resumed work. The patient who developed
avascular changes at the proximal poles of scaphoid
and lunate 1 year postoperatively remained asymptomatic at the recent follow-up of 7 years, therefore
no surgery has been necessary.

midcarpal joint.4,38,39 Over the past 3 decades, authors

have described various treatments based on the anatomy of the SL ligament and the etiology of SL
The general consensus for treatment is that if the
ligament remnant is good, primary repair with or without capsulodesis for augmentation is recommended.
Meanwhile, if ligament is deemed irreparable, reconstruction of the SL ligament is advisable.16,21 There is
currently no consensus on which treatment is the best,
however.39,43 In 2004, Zardakas et al25 identied 21
procedures that were advocated by 468 surgeons. More
have been published since then. Although each treatment suggests its advantages in terms of ease of
execution and satisfactory clinical and radiological
outcomes, it is not uncommon to observe loss of
reduction with reference to the SL interval and SL angle
on x-rays at long-term follow-up.3,9,11,17e20,22e24,32

The aim of treatment of chronic SL instability is to
restore the anatomy prior to the development of
degenerative arthritis of the radiocarpal and later of the
J Hand Surg Am.

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Many causes account for this phenomenon including

severity of injury, time since injury, reducibility of the
SL joint, quality of the SL ligament remnants, and
severity in cartilage damage.39 Based on the knowledge
of ligament repair and reconstruction, most studied in
the knee joint, months may be needed for the ligament to
heal or to incorporate. Even then the quality of the
reconstructed or repaired ligament is still inferior to the
non-injured ligament.26,44 Thus if the immobilization is
8e10 weeks,9,11,15,16,19,20 the repair or the reconstruction may be progressively stretched, leading to the
deterioration of observed radiological outcomes.
Pauchard et al15 reported a deterioration in the radiographical outcomes when compared with the preoperative measurements in all patients with dynamic SL
instabilities and 60% of patients with static instabilities.
Moran et al11 reported a signicant increase in SL interval and SL angle in their patient series. Schweizer
et al9 noted that 23% of their patients developed
degenerative changes in the midcarpal joint in the long
term despite a repair and augmentation.
Herbert described screw reduction of SL instability and reported his results of acute SL ligament
repairs.27,45 He stated that the SL ligament took
months instead of weeks to heal,27,28 and thus internal xation would be helpful for a moderate period
(ie, 6e9 mo for augmentation), producing a stabilized soft tissue restraint or brous tissue remodeling.
We have extended the indications of temporary
screw xation for chronic SL instability and have
used the Herbert technique for the repair of chronic
SL instability since 1991. We believe that it is still
advisable to augment the repair and reconstruction in
chronic SL instability as the tendency for dissociation is greater than that in acute setting due to
the chronicity in stretching the adjacent soft tissues
(eg, the secondary stabilizers). The screw allows
stable closure of the SL interval (lag-screw effect)
that permits early cast-free movement after treatment. Unlike tenodesis that only corrects rotatory
subluxation, realignment of the scaphoid and lunate
restores normal load transfer across the scaphoid and
lunate fossa. With the screw in situ, anatomical
carpal alignment can then be achieved and maintained. This differs from the results of the other
studies3,9,11,17e20,22e24 in which deterioration of the
radiographic parameters were observed over time,
after either repair or reconstruction of the SL ligament, even though their clinical and functional parameters could be maintained.8,9,15,20 One exception
is the report by Garcia-Elias et al,46 where, with the
3-ligament technique, no recurrence of carpal
collapse occurred in 37 of 39 patients.
J Hand Surg Am.

Our technique is different from the reduction and

association of the scaphoid and lunate procedure,31
which attempts a brous union and SL screw xation without either repair or reconstruction.47,48 In our
treatments, the cartilage of both scaphoid and lunate
are preserved. Our results support our approach using
a 4e7 month xation to allow for the healing or
incorporation of SL ligament. We observed good
clinical and radiological results in all except the 2
cases with persistent DISI deformity and with minimal complications. The 2 cases with persistent DISI
deformity postoperatively were mainly caused by the
failure to recognize and correct the DISI deformity
intraoperatively. The patient who developed avascular changes at the proximal poles of scaphoid and
lunate was the one who had previously undergone a
modied Brunelli procedure and then had a boneretinaculum-bone graft in this study. Damage to the
blood supply to the carpal bones was suspected due
to repeated drilling of the scaphoid and lunate. It is
necessary to remove the Herbert screws once loosening can be observed on x-rays. Otherwise, the screw
may pull out or break and cause complications.28,47
Our studys limitations include that it was a single
surgeon series, we included both dynamic and static
SL instabilities with possibly different prognoses, and
we included several treatment techniques depending
on the status of the SL tear. We used a Herbert screw
for temporary xation in all cases followed by early
mobilization of the wrist. This technique may not be
the complete answer for the treatment of SL instability. Nevertheless, temporary screw xation prevents early loss of carpal alignment and maintains a
favorable mechanical environment for soft tissue
regeneration and healing of primary repair or reconstruction of the scapholunate ligament.
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