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Modified Corella (arthroscopic assisted) scapho-lunate ligament reconstruction with Arthrex Bio-tenodesis screw

    Overview

    Learn the Modified Corella (arthroscopic assisted) scapho-lunate ligament reconstruction with Arthrex Bio-tenodesis screw surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Modified Corella (arthroscopic assisted) scapho-lunate ligament reconstruction with Arthrex Bio-tenodesis screw surgical procedure.
    This is a detailed step by step instruction through a Modified Corella arthroscopic assisted reconstruction of the scapho-lunate interosseous ligament (SLIL).
    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 to the lunate and then dorsal to volar though the lunate and onto the volar radio-scapho-capitate (RSC) ligament. This aims to reconstruct the volar secondary stabiliser of the scapho-trapezial-trapizoid ligament (STT), the dorsal and volar limbs of the SLIL. The operation is performed as a daycase procedure and the patient is placed in cast for 2 weeks following the procedure and then a splint with focussed rehabilitation with a specialist therapist.
    Patients often return to light work at 8 weeks, heavy work at 3 months and continue to improve up to a year post-operation.
    Readers will also find of use the following OrthOracle techniques : Diagnostic Wrist Arthroscopy (using Acumed ARC Tower )
    and Modified Brunelli procedure : Scapho-lunate ligament reconstruction for wrist instability using Biotenodesis screw(Arthrex)
    Compared to the open Modified Brunelli procedure, which is commonly the treatment choice for SLIL reconstruction, the Modified Corella is certainly a more complex procedure and requires arthroscopy skills in addition to wrist surgery skills. There is however little of the procedure which is wholly arthroscopic and therefore it is better termed arthroscopic assisted. The rationale behind this surgery compared with the Modified Brunelli is 2 fold. Firstly, with no large wound in the dorsal wrist capsule, the range of movement in the published series appears to be better post-operatively than with the Modified Brunelli. Secondly the use of the interference screws in the scaphoid and lunate, lock the ligament reconstruction and avoid it slacking off. Having performed both procedures I get the impression that the scaphoid is more firmly pulled and fixed to the lunate with the Corella compared to the modified Brunelli. One note of caution is that the Corella should not be used if there is any instability between the lunate and triquetrum as it is liable to exacerbate this instability by stabilising just the radial side of the proximal carpal row.
    The original description of this operation and report of its originators series is published in Hand Clinics:
    Corella F, Del Cerro M, Ocampos M, Simon de Blas C, Larrainzar-Garijo R. Arthroscopic scapholunate ligament reconstruction, volar and dorsal reconstruction. Hand Clin. 2017 Nov; 33(4):687-707.

    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 middle to 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 occasionally 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 result in a ‘strange feeling’ even with a normal wrist, and more so the injured wrist).
    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 scars from previous surgery 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 active and passive 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 tenses their wrists to prevent the subluxation occurring during the examination.
    The Kleinman shear test and Reagan test for Luno-triquetral instability and Lichtman midcarpal shift testfor midcarpal instability can also be performed but are not related to SLIL injury.
    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, 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 doors-radiocarpal ligement (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 or on a 1.5T scanner). 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 if 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 Modified Brunelli (3LT procedure) 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 (excluding radial styloid as noted).
    -Patients with laxity of the LTIL or midcarpal instability in addition to the SLIL tear.

    Setup

    The operation is performed under regional or general anaesthetic a takes 120 mins.
    In addition to standard surgical instruments, equipment required will be an Esmarch bandage, sterile tourniquet, arthroscopy set-up with camera, stack and tower, ArthrexTM small tendon shuttle, two ArthrexTM 3x8mm biotenodesis screws, 3 mm cannulated drill including appropriate wire, a 0.8x40mm cerclage wire, an image intensifier and a plaster cast.

    Operation – 1

    The wrist is set up in the traction tower as per standard arthroscopy.
    The patient is supine with their arm on an arm board, a sterile tourniquet and arm in traction tower with finger traps on the index and middle fingers.
    The stack and screen are at the patients feet and the scope and power tools are in a mobile basin on the opposite side of the operating table from the surgeon.
    NB – This procedure directly follows on from the ‘Diagnostic wrist arthroscopy’ and is the same patient therefore the set up, initial portal and findings will not be repeated in this operation. Additionally a examination under anaesthetic with fluoroscopic review is advised before draping the patient.
    Portals made were 3-4, 4-5 and 6R radio carpal (RC) and ulnar (UMC) and radial (RMC) mid-carpal portals.

    Skin markings are drawn on the wrist and the 3-4 RC and 6R portals are created.The set up of the wrist arthroscopy is shown in the diagnostic arthroscopy operation procedure.
    Shown on the image is the surface markings of the distal radius and ulna, the Extensor carpi ulnaris (ECU) tendon, Lister’s tubercle and the arthroscopy portals – 6R, 3-4 RC, 4-5 RC, RMC and UMC.
    All surface markings should only be drawn when the wrist is in the arthroscopy tower under the desired distraction.
    Portal are made with sharp dissection to skin and blunt to extensor retinaculum and the joint as per the diagnostic arthroscopy operation description.

    A routine diagnostic wrist arthroscopy is performed to confirm the diagnosis. Once the diagnosis of scapho-lunate interosseous ligament (SLIL) tear is confirmed with no other abnormalities which may change the operative procedure i.e. degenerative changes, luno-triquetral interosseous ligament (LTIL) injury, the procedure can begin.

    A grade 4 drive through sign is seen at the Scaphoid-lunate junction. The metal probe seen in the bottom of the image has been inserted through 3-4 RC portal and the camera is in the RMC portal pushing between the scaphoid (Sc) and lunate (L).

    The lung-triquetral ligament is stable as assessed by a probe. This is essential in order to continue with the modified Corella technique. If the Luno-triquetral ligament is also lax or torn then an alternative operative technique should be used.

    This video is shot with the probe through the UMC and camera through the RMC portals.
    Initially the lunate is below and the capitate above with the Triquetrum to the right and the probe is testing a stable Luno-Triquetral ligament/joint.
    The camera then moves radially and drops down between the Scaphoid and Lunate to show a Grade 4 tear with ‘drive through’ sign, the distal radius cartilage is visible at the bottom of the picture.
    The camera is then lifted back onto the lunate and the ‘drive through’ sign repeated.

    The 4-5 RC portal is created.The 4-5 RC portal is located at the level of the radio-carpal joint just to the ulnar aspect of the mass of extensor tendons of the 4th compartment (extensor digitorum communis and extensor indices). This portal is made as other portals with sharp dissection to the skin and blunt straight artery clip through the extensor retinaculum (ER) and joint capsule.
    The arthroscopy trochar is inserted into the joint to secure a smooth tract and then removed. The camera does not need to be inserted at this point.

    With the dorsal portals created the Flexor carpi radialis (FCR) graft is 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 in the image 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 and should be preserved
    The FCR tendon sheath is opened – this should only be opened in a small area to make sure the wire used in the next step stays within the tendon sheath.

    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 its harvest.

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

    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 tipThis will be found overlying the FCR tendon in the tendon sheath.
    Occasionally it may slip down one side and can be found once the tendon is mobilised.

    The whole FCR tendon is lifted out of the wound and the tenotomy scissors placed beneath.The wire is also pulled out of the wound taking care that it exits the same defect created in the forearm and muscle fascia as the tendon.

    A artery clip can be used to split the FCR tendon in half. The ulnar half is elevated and the radial half dropped back into the wound.Once the tendon is split, the scissors are passed beneath one half of the tendon and the other is allowed to drop back into the wound.
    The ulnar half of the tendon is used as this spirals distally to become the radial side of the tendon when it reaches the scaphoid. If the radial half of the tendon is used this may create a bulkier and tendon solar scar.
    Just note that the wire has exited on the side of the tendon which is being harvested or on top of the tendon centrally as in this case.

    Half the FCR is cut and passed upwards through the wire loop.Once passed through the loop the tendon end is grasped firmly with a artery clip.

    While the cut FCR tendon end is held tightly with an artery clip the wire is pulled distally in an oscillating/sawing motion.During this, counter traction is applied by the artery clip.
    When the wire loop is almost at the wrist the cut end can be released and the tendon will pop out of the wound.

    The distal splitting can be performed with simple traction to create the tendon division.The harvested tendon length is seen.

    The tendon division needs to extend just distal to the scaphoid tubercle.
    This is best achieved with traction and tenotomy scissors. If the tendon is not split distal to the scaphoid the line of pull of the reconstruction with not be correct. Using a blade can lead to tendon division which will ruin the graft.
    In preparation fo the lunate drill hole further dissection is required at this point to view the volar wrist capsule. With the FCR graft prepared the deep forearm fascia and very distal edge of carpal tunnel is incised to reveal the flexor tendons and median nerve. At this point a small Langenbeck retractor is placed beneath the flexors and nerve distal to the pronator quadrates to ensure a view of the volar wrist capsule is possible.

    The 3-4 RC portal is slightly extended to view the scaphoid.The standard portal is incised to 1.5x the normal size which allows 2 small Ragnell retractors to reveal the scaphoid.

    Packed for disposable for 3×8 tenodesis screw set.

    Contents for disposable for 3×8 tenodesis screw set.
    From top to bottom.
    2 x 2/0 Fibrewire with needle
    2 x red tubes which contain the wires now removed and are cut down to act as wire guides in the procedure.
    1 x Wire with loop – suture passer
    1 x Wire with sharp tip and wire loop – for the Tightrope procedure not used here but can act as spare wire if small one bends.
    1 x short K-wire which passes through cannulated drills
    3 x cannulated drills – 2.5mm, 3.0mm, 3.5mm

    Bio-tenodesis screw 3x8mm and packaging.

    Small Quick pass tendon shuttle and packaging.

    A k-wire is placed through the 3-4 RC portal onto the dorsal ridge of the scaphoid.The wire is the size which will run through the cannulated drill being used. In this case the Arthrex bio-tenodesis screw insertion set comes with a 2.5, 3.0 and 3.5mm cannulated drill, k-wires and suture passer. The wires come inside red tubes which are ideal to cut down to size and use as tissue guide when inserting the k-wires into the scaphoid and lunate.

    Operation – 2

    The red wire protector is cut down to 3cm and placed over the wire as a tissue protector.

    The wire is driven from dorsal ulnar to palmer radial in the scaphoid and checked on radiographs.With the red tube tissue guide in place the wire is placed just radial to the insertion of the SLIL on the scaphoid and aim radially and slightly distally. With a finger on the scaphoid tubercle to aid with aiming the wire is driven from the dorsal ridge to exit just proximal to the scaphoid tubercle centrally or just radial of centre.
    NB – If the wrist is held in slight ulnar deviation during this the dorsal ridge is easier to find through the 3-4RC portal at the distal edge of the RC joint where the joint capsule attaches.
    Lateral radiograph with wire in situ is shown.

    PA radiograph of the wire placement in the scaphoid.
    The wire often ends up just radial of centre on the palmar side as to aim centrally often takes the wire too close to the scapho-capitate joint, especially when the larger hole of the drill is made.
    NB – Make sure to take radiographs in a number of positions to check placement especially to avoid breaching the mid carpal joint however do not excessively extend the wrist during this as it may bend the wire.

    The scaphoid tubercle and distal waist is exposed.To allow for easy passing of the FCR graft from volar to dorsal the volar exit point of the k-wire must be easily visualised.
    This often requires further dissection volarly and either retraction of partial division of the radio-scapho-capitate (RSC) ligament which travels over the waist of the scaphoid just proximal to the tubercle. This ligament is variably attached to the scaphoid volar wait.
    The cannulated drill should not be used until the exit location of the k-wire is clearly visible.

    A 3.0mm cannulated drill is used over the k-wire in the scaphoid.It is important to retract the soft tissue to safety or use a drill sleeve during this step to avoid tendon injury.

    The Arthrex small tendon shuttle is passed through the scaphoid.The shuttle is passed volar to dorsal. the pointed tip of the shuttle is easily blunted and therefore is excess soft tissue overlies the drill hole it may make passing the shuttle or even finding the drill hole difficult.

    To receive the shuttle dorsally the extended 3-4RC portal needs to be mobilised with retractors to line the portal up with the bone tunnel. Ulna deviation of the wrist can also assist in this step.

    The FCR graft is fed into the tendon shuttle and passed through the scaphoid.The shuttle is easy to use with the correct technique.
    Invert the shuttle as in this picture so the mesh is slide back over the black plastic stem.

    Grip the tendon and the shuttle with toothed forceps (A). The forceps (A) grip the shuttle at the junction of the mesh and the black stem.
    The mesh is the slid over the forceps (A) and the tendon.
    A second set of forceps (B) the grips the tendon from outside the mesh and the first set of forceps (A) can be removed and the mesh slide to its full length over the tendon graft.

    The shuttle is slowly pulley from dorsally until the tendon starts to enter the drill hole at which point the shuttle can be pulled more firmly – this often requires some saline for lubrication and an artery clip, as shown in the picture, to grip onto the shuttle.
    NB – if the tendon will not pass it may be too big and can be removed from the tendon shuttle and a third of its fibres stripped and the process repeated.
    It is best to have 2-3 small tendon shuttles as this process can damage them making them of little use for the second pass of the tendon through the lunate.

    The 3x8mm biotenodesis screw is inserted volar to dorsal in the scaphoid.During insertion the graft must be pulled to tighten the reconstruction between the 2nd metacarpal base and the scaphoid substituting for the stretched scapho-trapezi0-trapezoid ligament.
    The screw can stick on the end of the handle therefore it is best to remove and replace the screw onto the handle before attempting insertion. The metal driver inside the screw is also liable to snap if angulated and therefore care must be taken to direct the screw down the correct hole orientation (the wire can be placed back into the hole by hand to remind the surgeon of its direction before screw insertion and then removed).
    During insertion the screw needs firm longitudinal pressure as the threads are blunt to protect the tendon and therefore do not progress initially without this longitudinal force to engage the bone tunnel.

    The wire is passed across the lunate through the 4-5RC portal.When passing the wire the same red tube can be used as a drill guide. the wire is aims mid way proximal to distal on the lunate and inserted on the dorsal on the junction between the ulna 3rd and radial 2/3rds and exits on the volar radial corner of the lunate (the volar SLIL insertion).

    The wire is driven to the volar cortex of the lunate.As the volar wrist structures (median nerve etc) are at risk the k-wire is driven to the volar cortex initially.
    The lateral fluoroscopy image can be seen.

    The PA fluoroscopy image is shown.

    The flexors and median nerve are retracted and a wire is inserted and over-drilled with a 3.0mm drill.Take care not to bend the wire at this point.
    The next step can be performed up in traction or on the arm board.
    The k-wire is slowly driven through the volar cortex of the lunate and out the wrist capsule until the wire can be seen. The flexors and nerve must remain retracted with a small Langenbeck retractor for protection at this point. Once the wire is safely passed 5mm through the capsule as second piece of the red tubing 4-5cm long is placed over the wire tip and the wire is then safely drive out past the skin incision.
    With a drill guide dorsally and the red tube palmar over the wire the 3.0mm cannulated drill is passed through the volar cortex and capsule and then the drill is safely withdrawn. The red tube remains over the wire protecting the volar structure throughout.
    The drill must come through the volar capsule to create a hole otherwise this can be very difficult to find with the biotenodesis screw later on.

    The tendon shuttle is passed dorsal to volar through the 4-5RC portal and then lunate.Passing a k-wire through the lunate drill hole can make locating this hole easier and the shuttle can follow the k-wire. Unfortunately the shuttle is not cannulated and therefore can not be passed over the wire.
    NB- Use fluoroscopy to confirm location of hand held k-wire as it can easily passed through enlarged scapholunate gap rather than the bony tunnel.

    An artery clip is placed on either end of the shuttle to keep it in place.

    Volar view of the shuttle exiting the wrist.
    NB – Remember to keep the tendon graft moist with either intermittent wetting or wrapping in a wet swab.
    The hand is then placed back on the traction tower.

    A suture is passed from the 3-4RC portal through the wrist and out of the 4-5RC portal.The 2/0 fibrewire on the set can be used with the needle cut off for this section.
    IMPORTANT NOTE – During this step the suture must enter the exact portal the tendon graft is currently exiting and must exit the exact portal the tendon shuttle is exiting.
    This point may seem obvious but if a small strand of tissue is between the original and adjacent pseudo-portal then the graft will not sit on the dorsum of the bones or pull through properly. As seen in the picture the portal can be exposed by pulling the tendon graft to one side thus stretching the portal for easier access.

    Arthroscopic image of the suture in the wrist before it is passed out of the portal

    The suture being retrieved though the 4-5RC portal.
    Once retrieved the 2 free ends of the suture are knotted to create a loop and the graft is laid though the suture loop so the loop catches it about half way along its length.

    The suture exiting the 4-5RC portal is pulled delivering the tendon out of the 4-5RC portal.Saline can be used to lubricate the tendon smoothing its passage through the joint.

    The tendon graft is placed into the tendon shuttle.The same technique as before is used.

    The tendon within the shuttle.

    The shuttle and tendon are pulled through the lunate.Saline can be used to lubricate the tendon for its passing.
    NB – The tendon needs to be long enough for the shuttle to pull it though the bone. If the tendon is too short the end of the shuttle will remain within the lunate and it is then a struggle to get it out as it is still clamped onto the tendon within the tight bony tunnel.

    Operation – 3

    This video is shot with the camera in the RMC joint.
    Initially the camera is between the Scaphoid and lunate demonstrating the ‘drive through’ sign and it is then lifted back into the mid carpal joint.
    At this point we can see the Scapho-lunate joint closing and the 2 bones becoming level. This occurs when tension is placed on the tendon graft exiting the volar Lunate. This causes the Scaphoid to squeeze up to the Lunate, extend and supinate.

    The graft is placed on tension and the exit hole through the capsule is exposed.This step is performed off traction.

    The second biotenodesis screw is now inserted volar to dorsal in the lunate.During this insertion the graft must be on traction to pull the scaphoid to the lunate on the dorsal aspect.
    As before, a k-wire can be used to find the entry point and the screw is removed and recited from the driver and then with longitudinal force in the correct direction the screw is inserted.
    The scaphoid screw hole can be seen easily if well prepared however the lunate screw hole will alway have volar capsule in the way and therefore once in place and before the driver is removed a radiograph is taken to check location of the screw and the depth.

    PA radiograph of the screw in situ – only the driver can be seen but its location in the drill hole is clear.

    Lateral radiograph shows the wider part of the driver is on to the lunate volar cortex and therefore showing the screw is fully inserted.
    If the driver snaps in the screw with the screw not fully inserted the original driver from the scaphoid screw can be used to push the broken piece into the lunate and complete the screw insertion.

    The graft is sutured to the volar RSC ligament.The remaining 2/0 firewire from the set is used to complete the volar part of the reconstruction.

    The graft sutured down.

    Dorsal skin wounds are closed with 4/0 vicryl rapide.

    Volar skin wounds are closed with 4/0 vicryl rapide.

    Occlusive dressings are applied.

    After a period of 5mins with the tourniquet down, a wool bandage split at the wrist is applied.The wool is split to allow swelling and some non- circumferential wool is laid over the defect.

    A dorsal plaster and bandage are applied.The bandage is applied loosely to allow for swelling.

    Pre-Operative PA and Lateral radiographs.
    Notice the slight step in between the Lunate and the Scaphoid (A). The was no gross increase in Scapho-lunate gap >3mm or Dorsal intercalated segment instability seen in this patient with Scaphoid-lunate angle around 45 degrees and Capito-lunate angle around 0 degrees. No ring sign can be seen as the Scaphoid is not overly flexed.

    Pre-operative 3T MRI coronal image T2 showing slight gapping of Scaphoid-lunate joint (A).

    Pre-operative 3T MRI axial image T2 showing tear in dorsal SLIL (A) seen as a line of white fluid though the SLIL ligament.

    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 then again at 2 weeks for cast off and splint.
    The wrist splint is made by the therapists who then start a regimen of finger movements and SLIL protective wrist movements – dart throwers movements.
    At 6 weeks the hand therapists starts more standard range of movement exercises and then is expected to start strengthening exercises at 3 months.
    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 heavier jobs can be returned to and the strength is greatly increased by 6 months and plateaus at 2 years.
    No radiographs are taken unless there is concern with the post-operative recovery.

    Recommended Reading

    As for any large wrist surgery there are possible complications of infection, tendon and nerve injury, neuro-vascular injury, fracture or avascular necrosis of the scaphoid or lunate and chronic regional pain syndrome which are all very uncommon.
    More common issues will be that the patient has some level of stiffness or continued pain and decreased strength compared with normal.
    As this is a relatively new procedure there are not many published papers on its outcomes however the creator of the the original procedure publish his series in 2017.
    Corella F, Del Cerro M, Ocampos M, Simon de Blas C, Larrainzar-Garijo R. Arthroscopic scapholunate ligament reconstruction, volar and dorsal reconstruction. Hand Clin. 2017 Nov; 33(4):687-707.
    More common issues will be that the patient has some level of stiffness or continued pain and decreased strength compared with normal.
    As this is a relatively new procedure there are not many published papers on its outcomes however the creator of the the original procedure publish his series in 2017.
    Corella F, Del Cerro M, Ocampos M, Simon de Blas C, Larrainzar-Garijo R. Arthroscopic scapholunate ligament reconstruction, volar and dorsal reconstruction. Hand Clin. 2017 Nov; 33(4):687-707.
    In this series the surgeon describes the results of 27 patients over a 5 year period. All patients had pain, reduced wrist function and were more than 3 months following injury. Around half the patients were grade 3 and half grade 4 on the Geissler classification. At 6 months post surgery the range of movement was the same as pre-operatively. The Visual analogue score, Disabilities of the Arm, Shoulder and Hand score and grip strength were all significantly improved and continued to improve further during the 2 year follow up. The procedure was performed for both static and dynamic instabilities and both the scapho-lunate angle and gap were significantly better post surgery however in static cases some gapping did remain.



    Reference

    • orthoracle.com

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