Arthroscopic Lunotriquetral Ligamentoplasty, from the Cadaver Lab to the Clinical Practice

Introduction There has been an increase in the diagnosis of injuries to the intrinsic ligaments of the wrist due to the more widespread use of arthroscopy in the treatment of patients with musculoskeletal wrist pain, and arthroscopy is particularly very helpful to determine the etiology of these lesions at the ulnar level. The treatment of lunotriquetral ligament injuries encompasses different techniques with results that are little reproducible. Ligament reconstruction through tendon grafting has shown favorable results, but it involves extensive open approaches that lead to a slower recovery a lower range of joint motion due to the excess of scar tissue. The objective of the present study is to describe the performance, in a cadaver, of a minimally-invasive lunotriquetral and secondary-stabilizer ligamentoplasty and its application in a representative clinical case. Material and Methods A preliminary study of six specimens in which a lunotriquetral and secondary-stabilizer ligamentoplasty was performed consecutively through a free tendon graft with arthroscopic assistance. We proceeded to recreate the complete ligament injury, and to perform an assessment of lunotriquetral instability according to the Geissler classification and an arthroscopic ballottement test. We describe the surgical technique, ligament stability after the ligamentoplasty, and the subsequent anatomical dissection, assessing the anatomical structures susceptible to iatrogenic injury. We also describe the application of the technique in one case, comparing the clinical parameters before and after the procedure: range of motion of the joint, strength, pain and the shortened version of the Disabilities of the Arm, Hand, and Shoulder (QuickDASH) questionnaire. Results The ligamentoplasties performed showed recovery of the stability of the lunotriquetral interval assessed according to the Geissler classification and the arthroscopic ballottement test. In the dissection of the specimens, no iatrogenic lesions were found in the tendons or the surfaces of the mediocarpal and radiocarpal joints. The average distances between the nearest bone tunnels and nerves were of 7.3 mm for the sensory branch of the ulnar nerve, of 3.6 mm for the posterior interosseous nerve, and of 4.5 mm for the ulnar neurovascular bundle. No fractures were observed in the tunnelled bones. In the clinical case herein presented, six months after the intervention, there was an improvement in strength and preoperative pain, with a slight decrease in the joint range of motion (15% compared to the contralateral joint). Conclusions The lunotriquetral ligamentoplasty herein described could contribute to the biomechanical restoration of the carpus and be an option for recosntruction in selected cases. Its performance through minimally-invasive techniques, and the use of a free tendon graft together with specific rehabilitation should be considered to optimize the outcomes.

Outcomes Following Surgical Treatment of Hamate Arthrosis Lunotriquetral Ligament Injuries

Background: An institutional review board–approved study of the functional outcomes of patients after surgical treatment of hamate arthrosis lunotriquetral ligament tear (HALT) lesions was conducted. Methods: In all, 21 wrists in 19 patients underwent arthroscopic, open, or combined treatment of HALT lesions. Seven patients underwent isolated hamate debridement and 14 had concomitant procedures to address lunotriquetral pathology. Nineteen wrists underwent procedures to address additional pathology, including triangular fibrocartilage complex, ulnotriquetral ligament split, and scapholunate ligament injuries. Results: Mayo wrist scores increased from 54 to 71. Sixteen patients had no or mild pain postoperatively, compared with none preoperatively. When stratified by lunotriquetral interosseous ligament management, 75% of the limited treatment group (none or debridement) and 78% of the additional treatment group reported improved pain. Three patients underwent additional surgeries for persistent pain. Conclusion: Resection of the proximal pole of the hamate can improve pain and function for patients with ulnar-sided wrist pain secondary to a HALT lesion. Concomitant wrist pathologies should be considered when determining treatment plans.

Visualization of wrist ligaments with 3D and 2D magnetic resonance imaging at 3 Tesla

Background Wrist ligaments are challenging to visualize using magnetic resonance imaging (MRI). Injuries involving the scapholunate ligament (SLL), the lunotriquetral ligament (LTL), and the triangular fibrocartilage complex (TFCC) are common and difficult to diagnose, often requiring diagnostic arthroscopy. Purpose To compare the visualization of wrist ligaments on a three-dimensional (3D) sequence with two-dimensional (2D) sequences on 3-T MRI. Material and Methods Eighteen healthy volunteers were examined with a 3D SPACE (sampling perfection with application optimized contrasts using different flip angle evolution) sequence and 2D coronal, axial, and sagittal proton density-weighted (PD) sequences. Four musculoskeletal radiologists graded the anatomical visibility of the SLL, LTL, TFCC, and the image quality, using five grades in a visual grading characteristics (VGC) evaluation. After Bonferroni correction, a P value ≤0.005 was considered statistically significant. Results The 3D images were graded significantly better than the 2D images in the visualization of the dorsal and palmar parts of the SLL and the LTL. Regarding the TFCC, the 3D images were graded significantly better for visualization of the foveal attachment. 2D imaging was not found significantly superior to 3D imaging in any aspect. Conclusion The 3D SPACE sequence was scored as superior to the 2D sequences at 3 T in the assessment of the SLL, the LTL, and the foveal attachment of the TFCC. Thus, 3D SPACE can replace 2D PD sequences when these ligaments need to be assessed.

Arthroscopic dorsal capsulodesis for isolated lunotriquetral interosseous ligament injuries

We assessed the outcomes of isolated lunotriquetral ligament injuries in ten patients who underwent arthroscopic dorsal capsulodesis. Data from patient records, radiologic images and arthroscopic video records were evaluated. The patients were evaluated for ulnar-sided wrist pain with history and physical examination. Preoperative radiographs and MRIs for pain aetiology were assessed. The patients underwent arthroscopic dorsal capsulodesis and were evaluated 29 months (range 19–45) after surgery. Nine patients returned to their original jobs. In one patient pain was aggravated with heavy activities. Mean scapholunate angle was 44°. There were significant improvements postoperatively in pinch and grip strength and MAYO wrist, patient-reported wrist evaluation and pain scores. The wrist flexion–extension and the radial ulnar deviation were significantly improved compared with the contralateral hand. We conclude that arthroscopic dorsal capsulodesis offers effective management for isolated lunotriquetral interosseous ligament injuries. Level of evidence: IV

Perilunate instability: A rare variant

Perilunate dislocations and perilunate fracture dislocations are rare injuries that occur as a result of high energy trauma. We describe a case of a volar fracture dislocation of the proximal pole of the scaphoid with an associated scapholunate and lunotriquetral ligament disruption as well as a lunate fossa fracture of the distal radius. These injuries are serious injuries that require a high degree of clinical acumen and radiographic scrutiny to allow for prompt treatment in order to avoid the sequelae of long-term complications that can arise. This case serves as a reminder of the complexity of these injuries and their associated mechanics.

Role of Wrist Arthroscopy in the Management of Established Scaphoid Nonunion

Introduction Patients with scaphoid nonunion and wrist pain may have a wide spectrum of potential concomitant pathologies that may be diagnosed and potentially managed arthroscopically. The aim of this study is to assess the usefulness of wrist arthroscopy in the assessment and treatment of scaphoid nonunion and any associated injuries. Materials and Methods We retrospectively reviewed 34 consecutive patients with established scaphoid nonunion between January 2006 and December 2012 who had undergone arthroscopic assessment. The average age of the patients was 40 years (range: 25–64), and all the patients had arthroscopic assessment of the wrist joint before definitive surgery. The patients with associated intra-articular problems, which could be addressed along with the scaphoid open reduction internal fixation (ORIF) and bone grafting (BG), had definite procedure in the same sitting. However, if the patients had major intra-articular pathology that needed change in the management plan, they had staged definitive treatment after discussing with them about the arthroscopic findings. Results Arthroscopic assessment of the 34 joints showed varying degrees of arthritis affecting radioscaphoid joint (41%) followed by injuries to the triangular fibrocartilage complex (TFCC) (35%), lunotriquetral ligament (LTL) tears (32%), and scapholunate ligament (SLL) injuries (26%). Concomitant procedures performed during the wrist arthroscopy included debridement of synovitis (62%), TFCC debridement (32%), loose body removal (17%), and DRUJ stabilization and TFCC repair (3%). Twenty-nine patients had arthroscopy and definitive procedure in the same sitting, and the remaining had staged or delayed definitive treatment. Conclusion Our study highlights the usefulness of wrist arthroscopy in assessment and management of the scaphoid nonunion and associated pathologies. Besides in 18% of our patients, the initial management plan changed after arthroscopy. Level of Evidence This is a Level IV study.

Wrist Arthrography

Chapter 100 describes the indications, the technique, and the imaging findings of wrist arthrography. Wrist arthrography is selectively performed in routine clinical practice for MR arthrography (MRA), typically in younger patients. The main indications include evaluation of the intrinsic interosseous wrist ligaments (scapholunate and lunotriquetral) and triangular fibrocartilage complex (TFCC) injuries. Contrast should easily inject and disperse throughout the radiocarpal joint space. Complications from contrast injection are rare and include infection and bleeding. Full-thickness tearing of any of the 3 components of the scapholunate and/or lunotriquetral ligament allows abnormal communication with the midcarpal joint. Central tearing of the triangular fibrocartilage disc allows abnormal communication with the distal radioulnar joint.