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Modified Brunelli procedure – Scapho-lunate ligament reconstruction for wrist instability using Biotenodesis screw(Arthrex)

    Overview

    Learn the Modified Brunelli procedure : Scapho-lunate ligament reconstruction for wrist instability using Biotenodesis screw(Arthrex) surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Modified Brunelli procedure : Scapho-lunate ligament reconstruction for wrist instability using Biotenodesis screw(Arthrex) surgical procedure.
    This is a detailed step by step instruction through a Modified Brunelli reconstruction of the scapho-lunate interosseous ligament (SLIL) also know as the 3 ligament tenodesis.
    The operation is performed to restore carpal mechanics following a SLIL injury and often subsequent attrition of the secondary stabilisers leading to a dorsal-intercalated segment instability (DISI). SLIL injuries over 4-6 weeks old are often very difficult to repair primarily and may require reconstruction if symptoms persist. If the wrist remains symptomatic despite appropriate rehabilitation, splintage and analgesia therapy, surgery may be required.
    This can be the case in Geissler grade 3 or 4 ligament tears seen arthroscopically and may also be the operation of choice in grade 1 scapho-lunate advanced collapse (SLAC) in conjunction with a radial styloidectomy.
    The operation uses a third to a half of the flexor carpi radialis (FCR) tendon which is passed through the scaphoid, across the dorsal lunate and around the dorso-radiocarpal ligament (DRC). This aims to reconstruct the volar secondary stabiliser of the scapho-trapezial-trapizoid ligament (STT), the dorsal limb of the SLIL and tighten the secondary stabiliser of the DRC. The operation is performed as a daycase procedure and the patient is placed in cast for 4-6 weeks following the procedure to start focussed rehabilitation once casting is complete.
    Patients often return to light work at 8 weeks, heavy work at 3 months and continue to strength and improve up to a year post-operation.
    Author: Mr Mark Brewster FRCS (Tr & Orth)
    Institution: The Royal Orthopaedic Hospital, Birmingham ,UK.

    Indications

    Anatomy.
    The SLIL is made off 3 parts connecting the scaphoid to the lunate. The dorsal section is the strongest followed by the volar and then the weak proximal fibrocartilaginous part which connects the two. There is no distal part to the ligament and therefore is makes a U shaped ligament between the two bones. The proximal part often has degenerative perforations in older age.
    The ligament is densely supplied with proprioceptive fibres which as part of a reflex arc helps the ligament protect itself by firing stabilising muscles if overstretched.
    The ligament prevents gapping, over rotation and volar/dorsal translation between the bones and due to the shape of the scaphoid and its fosse on the radius, over flexion if it occurs is also accompanied by pronation of the scaphoid opening the dorsal SL joint more than the volar.
    Indications.
    This procedure is indicated for wrist pain which is not responding to simple analgesia, splintage or a focussed wrist physiotherapy rehabilitation regimen where the underlying cause is a torn SLIL.
    This can be the case in Geissler grade 3 (partial tear) or 4 (complete tear) ligament tears seen arthroscopically and may also be the operation of choice in grade 1 scapho-lunate advanced collapse (SLAC) in conjunction with a radial styloidectomy.
    Symptoms.
    A SLIL tear which remains symptomatic often produces dorsal central and radial wrist pain. This is worse on loading and radial deviation. Patients particularly find loading on an extended wrist such as pushing open a door or the press-up position painful due to dorsal synovitis and instability of the proximal scaphoid in the scaphoid fossa of the radius.
    Patients may also complain of a clunking or clicking wrist which gives way due to pain. They may complain of a weakened grip and occasional with long standing injuries the patient may have some shoulder or elbow compensatory pains.
    A decreased range of movement or associated dorsal central wrist ganglion is also common in these patients.
    Examination.
    When assessing for wrist instability and ligament injuries the contra-lateral wrist must examined initially for two reasons. One to discover what is normal for the patient as laxity, clicks and clunks can be normal if asymptomatic. Secondly as some of the examination tests stress the wrist in unusual ways, the patient is then aware what to expect and what is normal (some tests such as Lichtman mid-carpal shift test can be uncomfortable or a ‘strange feeling’ on a normal wrist – especially if there is a positive finding).
    The examination of a wrist with an underlying scapho-lunate ligament injury may reveal forearm muscle wasting due to disuse on inspection. Swellings such as dorsal ganglia, deformities and previous scars should also be noted.
    The wrist is then palpated systematically usually starting away from the most painful site and progressing around the wrist generally over the radio-carpal, mid-carpal and distal radio-ulna joint lines but also more specifically over bony prominences such as the scaphoid tubercle, pisiform and hook of hamate. Palpation may also yield more information with different wrist positioning i.e. in flexion more of the scapho-lunate ligament is exposed to palpation and in ulnar deviation more of the waist of the scaphoid is palpable beyond the radial styloid. On the ulna side of the wrist tenderness over the Extensor carpi ulnaris (ECU) may actually be deeper pain within the TFCC and can be differentiated by palpation in supination where the tendon lies more dorsally and pronation where it lies more ulnarly.
    Following palpation the range of movement is assessed – flexion (75), extension (70), supination (85), pronation (70) and radial (20) and ulnar deviation (35) – normal ranges in degrees provided in brackets.
    A torn SLIL often is represented by pain on palpation dorsal and central in the wrist just distal to Lister’s tubercle which may be worse with slight flexion of the wrist as this exposes more of the ligament injury to palpation.
    Specific to a SLIL injury, with increase levels of instability there may be a more generalised dorsal central and radial wrist pain with mild swelling due to a more wide spread synovitis created by the proximal pole of the scaphoid translating dorsally within the scaphoid fosse of the radius.
    In the acute setting the whole wrist may be painful including over the radial styloid if an associated styloid fracture was present.
    Movement may be normal but is often restricted particularly in wrist extension.
    Special tests to be performed include :
    The Kirk-Watson test for SLIL instability
    The thumb is placed over the scaphoid tubercle and the index finger over the SLIL just distal to Lister’s tubercle. The wrist is take from ulnar to radial deviation with pressure applied to the tubercle. In a competent ligament the thumb is pushed away by the tubercle. In a incompetent ligament the volar tubercle pressure resists the scaphoid flexion and the proximal pole of the scaphoid dorsally subluxes off the scaphoid fosse of the distal radius with a clunk. When the wrist is take back into ulnar deviation another clunk is felt as the scaphoid proximal pole relocates.
    It is very common in SLIL injuries that this test is negative however is painful and creates a painful click. This will be the case in partial ligament ruptures, the presence of intact secondary stabilisers or patient who tense their wrists to prevent the subluxation occurring during the examination.
    The Kleinman shear test and Reagan test for Luno-triquetral instability
    The Lichtman midcarpal shift test for midcarpal instability.
    Grip strength should also be tested with a Jaymar dynamometer. It may be difficult to elicit a positive result in some of these tests especially in the acute setting if pain is a major issue and the patient’s wrist is not relaxed during the examination. Differential diagnoses such as STT arthritis, De Quervain’s tenosynovitis and Luno-triquetral ligament tear and mid-carpal instability need to be exclude with palpation and special tests and imaging.
    STT arthritis
    Focal volar STT joint pain. A painful Kirk Watson test with more pain in radial deviation and on the more palmar rather than dorsal as seen in SLIL tears.
    De Quervains tenosynovitis
    Eichhoff test, Finklestein test and WHAT test (Wrist Hyperflexion and Abduction of thumb test)
    Investigations.
    Plain X-rays
    Investigations for suspected SLIL tear include plain PA and lateral radiographs of the wrist with the addition of a clenched fist view to reveal the presence of a dynamic instability not revealed on the static films. On these radiograph I am looking for:
    Arthritis – in particularly stages of Scapho-lunate advanced collapse (SLAC) of the wrist are described by Watson starting with radial styloid arthritis (stage 1) scaphoid fossa arthritis (stage 2) and then then Capito-lunate arthritis (stage 3).
    Fracture – associated distal radius or scaphoid fracture or bony avulsion from the dorsal of the wrist such as the DRC avulsed off the triquetrum.
    Ligament injuries – identified with increase interosseous gaps on the PA (>3mm for SLIL) and clenched fist views and altered scapho-lunate angles of >60 degrees and capito-lunate angles >20 degrees on the lateral view (revealing a dorsal intercalated segment instability -DISI).
    MRI scan
    An MRI scan (preferable 3T) is the next investigation for many patients as this can identify occult fractures and identify ligament injuries and other soft tissue abnormalities such as synovitis and ganglia.
    An experienced radiologist can identify SLIL injuries with a high sensitivity and specificity (results are much poorer when trying to identify luno-triquetral ligament (LTIL) injuries). The MRI can also be used to more clear define the DISI deformity if present on appropriate slices.
    CT scan
    If an MRI in contra-indicated due to patient co-morbidities or claustrophobia then a CT scan or SPECT scan (single-photon emission computed tomography) is useful for identifying pathology.
    The gold standard diagnostic investigation for a SLIL and LTIL injury is a diagnostic arthroscopy however this is clearly more invasive than the MRI scan.
    Non operative treatments.
    There is a progressive instability and development of arthritis in a predictable pattern with an untreated SLIL tear however we do not know what percentage of patient progress to this stage and when arthritis is present, what percentage are symptomatic enough to require intervention.
    That said an incidental finding of a chronic SLIL should not be treated with surgery.
    If a symptomatic chronic SLIL tear is seen then initial treatment is a focused physiotherapy regimen to strengthen the wrist and improve wrist stability. This treatment is essential even if surgical treatment is planned in order to maximise the preoperative strength and range of movement of the wrist.
    With partial ligament injuries the therapy regimen is often the only treatment required.
    Other non surgical treatments include analgesia and intermittent splinting for symptoms relief in specific tasks.
    Alternative operative treatments.
    Alternative surgical treatment can be performed to reduce pain such as a Posterior and Anterior interosseous nerve neurectomy which may further damage the proprioception to the ligaments however is more major reconstructive surgery was not wanted by the patient a denervation is an option.
    There are also alternative methods to reconstruct the SLIL. The arthroscopic assisted Corella method, the Scapho-lunate Axis method(SLAM) or a dynamic partial ECRB transfer to distal scaphoid.
    Patients where there is additional complexities of other ligament tears or mid carpal instability may even be better treated with partial or complete wrist fusions in rare cases.
    Contra-indications.
    Absolute
    -A patient who cannot undergo a 2 hour operation or will not complete with post operative rehabilitation
    -Patients with radio-carpal or mid carpal arthritis
    Relative
    -Patients with laxity of the LTIL or midcarpal instability in addition to the SLIL tear.

    Setup

    The operative is performed under regional or general anaesthetic a take 90-120 mins.
    In addition to standard surgical instruments, equipment required will be an Esmarch bandage, Arthrex small tendon shuttle and mini corkscrew anchor, 3 mm cannulated drill including appropriate wire, a 3x8mm Arthex biotenodesis screw, a 0.8x40mm cerclage wire, an image intensifier and a plaster cast.

    Operation – 1

    Skin marking: the CMCJs, capitate and volarly palpated scaphoid tubercle, distal radius and ulna and DRUJ along with a small circle over Lister’s tubercle are marked.
    With the arm resting on the arm board the surface anatomy is marked. Shown here the level of the CMCJs and outline of the capitate is marked. A dotted line level with the volarly palpated scaphoid tubercle is also marked. The distal radius and ulna and DRUJ are marked along with a small circle over Lister’s tubercle.
    The incision is just ulnar to Lister’s tubercle extending from just distal to the mid carpal joint and 1cm proximal to Lister’s tubercle.

    Skin incision ulnar to Lister’s tubercle extending from just distal to the mid carpal joint and 1cm proximal to Lister’s tubercle.As the procedure can take around 2 hours the arm is exsanguinated with an Esmarch bandage and tourniquet inflated after prepping, draping and skin marking to minimise the tourniquet time.
    The skin is incised as marked.

    Once through the skin, the superficial veins are diathermised and the fat divided to expose the extensor retinaculum.The location of the incision is usually between superficial nerves and which are often not seen in this dissection. Perforators are seen passing through the retinaculum and are divided.

    3rd extensor compartment is opened, referencing Listers tubercle.Lister’s tubercle is palpated and then using a blade cut directly onto the bone lifting the retinaculum and periosteum from the ulnar side to expose the extensor pollicis longus tendon. Beware here as the tendon can easily be injured if cutting too distally where is turns radially around the tubercle.
    The scissors can be seen pointing to Lister’s tubercle.

    The EPL must be identified and avoided.EPL can be seen beneath the retinaculum at the tip of the skin hook.

    The tenotomy scissors are used to open the 3rd extensor compartment proximally.

    The EPL is now exposed once the retinaculum is open.

    The same technique is then used to open the third compartment distally.

    4th Extensor compartment seenThe EPL is now completely mobile. Proximally, as indicated by the scissors tips, the muscles of the 4th extensor compartment can be seen.

    The 4th extensor compartment is opened The scissors are used to divide the vertical septum between the 3rd and 4th extensor compartments and then the 4th compartment is released distally.

    The EPL is retracted and the tendons of the 4th compartment are seen.

    The EPL is elevated and the septum between it and the second extensor compartment is released.

    ECRB is seen in the second compartment.The tendons of the second extensor compartment are seen beneath the EPL which is being elevated with a Ragnell retractor.

    The posterior interosseous nerve and artery need to be identified.The posterior interosseous nerve and artery (PIN and PIA) are seen at the tip of the forceps in the base of the 4th extensor compartment.

    The posterior interosseous nerve and artery are mobilised.The PIN and PIA are mobilised and here shown tented over the Ragnell retractor.

    Diathermy is used to remove a 1cm section of the PIN and PIA.

    Reveal the dorsal wrist capsule beneath the 4th extensor compartment.The West self retainer is sited underneath the ECRL/B radially and the EDC ulnarward to reveal the dorsal wrist capsule beneath the 4th extensor compartment.
    The k-wire is being held parallel to the fibres of the dorso-radial carpal (DRC) ligament which can just be seen in the picture. The DRC extends from the radius around the level of Lister’s tubercle to the dorsum of the Triquetrum. Splitting between its fibres represents the proximal limb of the Berger approach into the wrist joint.

    The extent of the dorso-radial carpal (DRC) ligament is identified.The k-wire is showing the level of the mid carpal joint and the blade is seen sitting in the centre of the DRC with half distal and half proximal to its location.

    Incise the dorso-radial carpal (DRC) ligament The k-wire is now on the very distal lip of the distal radius. Comparing this and the previous picture the width of the DRC between the 2 locations of the k-wire can be seen.

    Opening the dorso-radial carpal (DRC) ligament After the blade has made a small cut between the fibres, scissors are used to bluntly split along the fibres thus staying in line with the fibres and protecting and deep structures from injury.

    The dorso-radial carpal (DRC) ligament is splitOn opening the scissor the line off the DRC fibres can now clearly be identified.

    Opening the radial side of the jointNow the DRC is split, the ECRL and ECRB are elevated and the blade is used to cut the wrist capsule off the radius from the styloid down to the split in the DRC.
    Note – care must be take to avoid injury to the tendons of the 1st extensor compartment which are at risk during this radial dissection.

    Once the 2 incisions are joined the wrist capsule can be mobilised. The skin hook is holding the apex of the flap.

    With the capsular flap retracted the scaphoid (Sc) and lunate (L) can be seen.

    The scapholunate ligament is identified and inspectedThe forceps point to the defect in the scapholunate ligament which on the previous image looked intact, however was easily probed apart as only connected with thin none structural scar tissue.

    Operation – 2

    With the dorsum prepared the Flexor carpi radialis (FCR) graft can be harvested.
    Around 10cm is harvested via 2 palmar incisions. One transverse 2cm incision 10cm proximal to the scaphoid tubercle and a small hockey stick incision over the tubercle and FCR tendon at the wrist crease.
    A circle has been drawn around the scaphoid tubercle at the distal incision site.

    The first step of the harvest is the distal incision is opened to reveal the FCR tendon sheath.
    The volar branch of the radial artery is often seen at the distal extent of this incision.

    The FCR sheath is longitudinally opened.

    A 0.8mmx 40mm cerclage wire is used to harvest the FCR.
    The author finds this technique more reliable and quicker than using a suture or tendon passer as the wire will never snap or ‘let go’ of the tendon during it harvest.

    The cerclage wire is bent double using an artery clip and the tip bent up

    The looped end of the wire is passed into the sheath. The curved tip facing upwards and is slid up the sheath until it can be palpated at the level of the 10cm mark previously drawn.

    Once palpated, a 2 cm transverse incision is made to retrieve the bent wire tip This will be found overlying the FCR tendon in the tendon sheath.

    The whole FCR tendon is lifted out of the wound and the tenotomy scissors placed beneath.

    The tendon is the split by using a Ragnell retractor or artery clip.This separates the radial and ulnar halves of the tendon.

    The radial half of the tendon is allowed to drop back into the forearm and the wire is retrieved out of the woundTake care that it has been retrieved between the 2 tendon halves and not ulnar to the ulnar half of the tendon which will create difficulty when the tendon is harvested.

    The radial half of the FCR tendon is cut at its proximal extent. This does not need to be held onto as it will not retract into the forearm as long as the surgeon or assistant does not extend the wrist before completing the retrieval.

    The loop of wire is then widened using an artery clip and the cut tendon end passed up through the looped wireWhen the wire is pulled distally it will strip between the fibres of the FCR to divide it longitudinally.
    Take care that there is not tendon sheath or other tissues caught between the cut FCR and wire to prevent a smooth harvest.

    While the cut FCR tendon end is held tightly with an artery clip the wire is pulled distally in an oscillating/sawing type movementDuring this counter traction applied by the artery clip.

    The final distal splitting can be performed with simple traction to create the tendon division When the wire loop is almost at the wrist the the cut end can be released and the tendon will pop out of the wound.
    The tendon division needs to extend just distal to the scaphoid tubercle.

    It is important to clear the scaphoid tubercle of any soft tissues to clearly identify it The wire is being used to point out the scaphoid tubercle which can be palpated or identified on X-rays.
    It is key to ensure no tissues obstruct the passing of the tendon from volar to dorsal once the scaphoid hole is drilled.

    A guide wire is drilled from dorsal to volar at the proximal edge of the scaphoid tubercleThe 1.1mm k-wire from the cannulated drill set which will be over drilled with a 3mm drill (2.5 in smaller hands) is inserted.
    The wire is drilled from dorsal to volar as the dorsal exit location of the tendon is far more crucial to the mechanics of the reconstruction than the volar entry point.
    The volar entry point just needs to be at the proximal edge or just proximal to the tubercle whereas the dorsal exit of the tendon should be a couple of mm from the scapho-lunate joint and just proximal to the insertion of the mid carpal capsule on the dorsal ridge of the scaphoid.
    This dorsal exit location allows the tendon to exert an extensor force on the scaphoid when it is then passed across the lunate and thought the proximal DRC.
    You will also notice that the wire axis is much more horizontal and shorted in length than the standard axis for screw insertion for scaphoid fractures.

    The final scaphoid wire placement can be seen dorsal to volar in the wrist.

    The scaphoid wire position should be checked on Image intensifier.Scaphoid wire placement on PA Xray almost directly across the waist of the scaphoid.

    Scaphoid wire placement on lateral Xray seen entering the dorsal ridge and exiting just proximal to the scaphoid tubercle.

    The scaphoid giude-wire is over-drilled.A 3mm cannulated drill is used to overdrive the wire from the palmar or dorsal side depending on preference.

    A small Arthrex tendon shuttle is used to pass the FCR tendon .To pass the FCR through the scaphoid I use a small tendon shuttle made by Arthrex which incorporates a mini finger trap which can be threaded through the drill hole with the tendon held inside and grips more tightly on the tendon as it is pulled through the bone.
    This allows a large tendon to be passed through the bone as at no point is a double thickness of tendon being squeezed into the tight bony tunnel.

    To use the shuttle, first evert it and slide it back over itself as the photograph as shown.

    The tendon tip is then held with toothed forceps as they also hold the everted tip of the shuttle (not the pointy black end).
    The forceps must be in line with the shuttle as shown.

    The shuttle meshed end is then slid over the forceps and a second pair of forceps hold the tendon and the meshed shuttle from the outside as shown.

    The inner forceps are then removed and still holding the tendon and shuttle with the second set of forceps the everted shuttle is slide back into its normal position with the tendon now contained within it – as shown.

    Operation – 3

    The shuttle with the tendon now inserted is passed through the bone tunnelAs the shuttle is not cannulated the k wire may be passed dorsal to volar to show the location of the bone tunnel but the shuttle needs to be passed down the tunnel alone. Its passage can be lubricated by saline.
    Two tips when passing the tendon:
    1. If it doesn’t go easily using the shuttle the tendon is likely to thick and will need thinning down.
    2. Before passing the FCR strip through the bone, carefully check that the tendon comes straight from its anchor on the 2nd metacarpal, over the STT joint and tubercle and into the bone and hasn’t caught any soft tissues or the other half of the FCR in its path.

    As the tendon graft was too large it was split into 2 grafts as see in the image and the larger graft was passed palmar to dorsal through the scaphoid using the tendon shuttle.

    The 3 x 8 mm Athrex biotenodesis screw used to fix the graft in the scaphoid bone tunnel.
    The screw is made from Polyetheretherketone (PEEK) and is radiolucent and cannulated. The tip is relatively blunt and therefore need constant pressure during a slow controlled insertion technique to avoid snapping the screwdriver within the screw. The 3mm diameter screw is used for a 3mm diameter bone tunnel with a graft inside.

    The tendon transfer is placed under appropriate tension and fixed using a biotenodesis screwThe screw is easiest to insert from dorsal to palmar with the tendon graft under tendon. Once the screw is inserted, the reconstruction of the STT ligament is fixed. As most ligament reconstructions stretch a little over time, I insert the screw with the wrist in slight ulnar deviation to extend the scaphoid and shorten the STT ligament reconstruction distance.

    For the next step of the procedure an anchor is sited in the dorsal lunate. The anchor shown here is the Arthrex mini corkscrew which is self tapping and inserted to the black line on the anchor and comes with 2 needle and 2/0 fibre-wire attached.

    The mini anchor is placed half way from proximal to distal and radial to ulnar in the lunate.This is best assessed before insertion on the X-ray as it is easy to insert the anchor too distally and breech the mid carpal joint if the surgeon incorrectly angles the anchor distally or forgets the amount of lunate which is hidden behind the dorsal lip of the radius and therefore sites it too distally.

    Location of lunate anchor on lateral X-ray

    Location of lunate anchor on PA X-ray

    The lunate anchor can be seen in situ with the FCR at the top of the picture ready to pass across the lunate and around the DRC.

    An artery clip is used to puncture a hole where the DRC is still attached to the dorsal lip of the distal radiusThe clip is then passed beneath this part of the DRC and is used to pull the FCR graft from inside the joint to outside the joint.

    The FCR tendon is passed through DRCWhen the tendon graft is pulled through it is important to have one suture from the anchor distal to it and one proximal to is as shown in the picture. This then allows thew suture attached to the anchor to be tied over the tendon graft as traction is applied to snug the tendon down to the dorsal of the lunate.

    The Lunate anchor suture is tied over the graft Anchor suture tied over for graft. The sutures are not cut at this point as they are required again in a later step.

    This picture is to demonstrate that although 5cm of the tendon graft may be wasted it does not mean 5 rather than 10cm should be harvested as the discarded tendon length is essential when passing the tendon through the bony tunnel and hold to create tension during the procedure.

    Once tied to the lunate the graft is then sutured back onto itself over the SLIL region with the same suture still attached to the graft.
    Firstly tied the suture over the tendon as was carried out for the initial pass and then once secure, pass the suture with the needle through both thicknesses of tendon and tie therefore tying through as well as around the tendon substance.
    The excess tendon is then removed with a 15 blade which is also used to cut the sutures (Fiberwire suture is best cut with a blade, not suture scissors).

    The capsule is then repaired with 3/0 vicryl.

    The appearance of the capsule once repaired.

    The extensor retinaculum is repaired.The self retainer is removed and the EPL, EI and EDC are allowed to sit back in their compartments. This picture shows the 4th extensor compartment repaired with 3/0 vicryl and the EPL dropped back into position.

    Skin is closed with an absorbable suture – in this case 4.0 vicryl rapide

    The palmar wounds are close with 4/0 Vicryl rapide direct to skin.

    Occlusive dressings are applied to the wounds.

    Occlusive dressings are applied to the wounds.

    Prior to the plaster cast the tourniquet is deflated and the hand allowed to swell for 5 mins to reduce the risk of increased post operative pain from a tight plaster cast.
    The hand and forearm are then wrapped in wool however a length of around 10cm from the radial styloid proximally is cut down to skin to avoid circumferential wool at this point which does not stretch, again to reduce cast tightness.

    The remaining wool is then laid over the split forward and backward to pad over it only 1/2 the circumference of the wrist as shown.

    A dorsal slab is then applied wrapped in a crepe bandage and held with Elastoplast tape.

    Pre-op PA wrist X-ray showing a widened scapholunate interval (>3mm) and a signet ring sign which marks the flexed posture of the scaphoid.
    In addition this patient had an bone cyst in the lunate possibly related to avulsed SLIL.

    Operation – 4

    Pre-op lateral wrist X-ray again showing the lunate cyst but no clear DISI deformity one may expect.

    Pre-op coronal MRI T2 showing STT joint effusion, wide scapholunate interval and bone oedema and a cyst in the radial aspect of the lunate.

    Pre-op sagittal MRI T2 Pre-op sagittal MRI T2 showing the lunate bone cyst and a borderline DISI deformity with a capitolunate angle of almost 20 degrees.

    Post Operative

    The patient is operated on as a daycase and due to the size of the operation is sent home with a Bradford sling, oral morphine, codeine, paracetamol, an anti-emetic and a laxative.
    They are also warned that this is a ‘painful’ operation and advised to start taking analgesia as soon as they feel their hand, not when they are in pain which may then be too late to load the analgesia in time.
    The patient is then seen in 1 week for a wound check and cast change and if too swollen another cast change at 2 weeks. When the swelling is reduced a full cast is applied to allow a total cast time of 6 weeks.
    At 6 weeks the cast is removed and intense physiotherapy is started. During this 6 week cast period if the patient is not moving their fingers well enough the physiotherapy for finger mobilisation is commenced earlier.
    It is expected that at 8 weeks a patient may go to work in a light job and drive, possibly with the support of a splint. At 3 months heavy jobs can be returned to and the strength is greatly increased by 6 months and plateaus at a year.
    No radiographs are taken unless there is concern with the post-operative recovery.

    Recommended Reading

    Complication of the SLIL reconstruction include infection, scar pain (particularly the volatile wrist scar), stiffness, continued pain, chronic regional pain syndrome, FCR rupture.
    Here is some further reading which will be useful to provide a more complete overview of this condition and its treatment>

    Talwalkar SC1, Edwards AT, Hayton MJ, Stilwell JH, Trail IA, Stanley JK. Results of tri-ligament tenodesis: a modified Brunelli procedure in the management of scapholunate instability.J Hand Surg Br. 2006 Feb;31(1):110-7.
    This team from Wrightington, UK, treated 162 patients with the 3LT and 117 completed a questionnaire and 55 were reviewed with 1-8 year follow up. 72 patients had a dynamic and 45 a static instability pre-operation which had no bearing on post operative range of motion. Around 60% of patients had mild or no pain. A mean loss of around 30% flexion and 20% extension was lost. Over three quarters were satisfied with their surgery (good to excellent).

    Thomsen NOB, Besjakov J, Björkman A.Accuracy of Pre- and Postcontrast, 3 T Indirect MR Arthrography Compared with Wrist Arthroscopy in the Diagnosis of Wrist Ligament Injuries. J Wrist Surg. 2018 Nov;7(5):382-388.
    In relation to SLIL tears this team used a 3 Tesla MRI with or without arthrography. The used intra-operative arrthoscopic ligament assessment as the gold standard to bench mark to.
    Of 53 patients, 30% had Geissler 2 and 3 partial tears and around 10% had complete grade 4 tears. Accuracy was higher for two observers using postcontrast indirect MR arthrography than for pre-contrast MR imaging in partial tears. No difference was found for patients with total SLIL ruptures.
    In relation to SLIL tears this team used a 3 Tesla MRI with or without arthrography. The used intra-operative arrthoscopic ligament assessment as the gold standard to bench mark to.
    Of 53 patients, 30% had Geissler 2 and 3 partial tears and around 10% had complete grade 4 tears. Accuracy was higher for two observers using postcontrast indirect MR arthrography than for pre-contrast MR imaging in partial tears. No difference was found for patients with total SLIL ruptures.

    Reference

    • orthoracle.com

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