Jessica B. Hawken MD1 and Aviram M. Giladi MD MS2 1 Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, MD, USA 2 Hand Surgery and Plastic Surgery, The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD, USA Carpal instability is difficult to diagnose. Physical examination is practitioner‐dependent and there are few, if any, objective measurements of wrist stability. Radiographs may appear normal after a ligament tear because secondary ligamentous stabilizers delay static carpal changes, prompting a need for advanced imaging or direct visualization. Static and dynamic radiographs and advanced imaging studies such as arthrograms, ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) can fail to visualize ligament tears in the wrist. Arthroscopic evaluation remains the gold standard as it allows the ligaments to be directly visualized. The tears can then be described with a reproducible classification system (grade I–IV) defined by Geissler.1 The role of arthroscopy is to determine whether a ligament is partially or completely torn and how this likely affects wrist kinematics. The use of arthroscopy in diagnosis of carpal ligament tears has been investigated for almost 30 years, mostly for scapholunate and lunotriquetral ligament injuries. Most recently it has been compared to advances in MRI and CT modalities, including 3.0 Tesla (3T) MRI, and still found to be superior. Arthroscopic repair techniques are described in mostly level IV and V evidence, but do provide the added benefit of combining diagnostic and treatment modalities. Radiography is noninvasive and can demonstrate static, chronic scapholunate instability.2 Stress radiographs may demonstrate abnormalities not visualized on static films; however, “normal” films do not rule out pathology and may be technician‐dependent. Advances with 3T MRI systems allow for 3D sequences and multiplanar reconstructive options to visualize thin intercarpal ligaments during their oblique or curved courses.3,4 In comparison to arthroscopy for the diagnosis of ligamentous injury, Ochman et al. found the sensitivity and specificity were 75 and 100%, respectively, for pathology seen on MRI and confirmed with arthroscopy.5 Hafezi‐Nejad reported magnetic resonance arthrogram (MRA) had the highest sensitivity and specificity for the diagnosis of scapholunate interosseous ligament (SLIL) tears (82.1 and 92.8%) when compared to 3T MRI and 1.5T MRI.4 MRA is an expensive and time‐consuming test. Lee et al. compared CT arthrography, conventional MRI, and MRA, and found that CT arthrography was the most sensitive, specific, and accurate (100% for all) of the three methods for diagnosing SLIL tears. Multidetector computed tomography (MDCT) Arthrography has sensitivity of 100%, specificity from 86–100%, and a sensitivity of 94% for detecting partial injuries.6–8 In Lindau’s 2015 review, the role of arthroscopy in carpal instability was determined to be the most valuable diagnostic tool despite the lack of any level I evidence on the topic. Arthroscopy allows for direct visualization of the ligaments, assessment of the type of injury, and the severity of the injury. It is highly sensitive and specific.9 Disadvantages include that it is user‐dependent, requires an invasive procedure with associated risks, the surgeon must determine whether findings are truly the pathology causing the patient’s symptoms, and it is more expensive than imaging. Injury to the SLIL can lead to the development of deformity and arthritis about the wrist if not properly identified and treated early. Although management with direct ligament repair in the acute phase is generally the best option, the successful reconstruction of subacute injuries remains a challenge. SLIL injury results in dissociation of the scaphoid and the lunate, causing abnormal movement in the proximal carpal row and leading to cartilage wear and eventual arthritis. Recapitulating this relationship and preventing the aberrant biomechanics is the best way to avoid accelerated wrist degeneration; however, many of the techniques described and used have inadequate outcomes (stiffness, persistent pain, recurrent SL relationship changes, etc.). The majority of available evidence pertaining to the treatment of acute and chronic scapholunate injuries is limited to level IV and V studies; however, there are a few level III studies addressed here. Additionally, multiple narrative and literature reviews have attempted to address this issue. The treatment options for symptomatic SLIL tears are based upon the chronicity of the injury, the degree of instability, and the presence or absence of wrist arthritis. Urgency is needed in diagnosing and treating SLIL injury because treatment within six weeks of injury has the best results, as demonstrated by Rohman et al. Treatment options include direct repair (open or arthroscopic), soft tissue stabilization (tenodesis, capsulodesis, bone‐ligament‐bone reconstruction, reduction and association of the scapholunate ligament [RASL]), or arthrodesis.10 Proponents of arthroscopic SL debridement and/or reconstruction have proposed specific indications for these techniques, including partial tears, patients wishing to avoid open surgery,11
152 Carpal Instability
Clinical scenario
Top three questions
Question 1: In patients with wrist pain, what is the role of arthroscopy in diagnosing and treating ligamentous injuries of the wrist?
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Question 2: In a young, healthy patient with subacute scapholunate ligament tear and no radiographic arthritic changes, what is the best treatment option to ensure optimal outcomes?
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Available literature and quality of the evidence
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