Treatment of Complications after Scapholunate Ligament Repair

18 Treatment of Complications after Scapholunate Ligament Repair

Marc Garcia-Elias, Mireia Esplugas, and Alex Lluch

Abstract

Systematic analysis of complications after ligament reconstruction for carpal instabilities is difficult, due to inconsistent reporting of the great number of surgical techniques used. Mistaken indications should not be considered as complications. Loss of scaphoid or lunate correction, loss of scapholunate joint reduction, dorsolateral scaphoid subluxation, wrist stiffness, and problems affecting the bones, tendons, and nerves are some of the complications that may happen after scapholunate ligament reconstruction and will be discussed in this chapter.

Keywords: scapholunate ligament, scapholunate complication, scapholunate gap, scapholunate ligament reconstruction, carpal collapse, wrist stiffness, tendon complication, nerve complication

18.1 Complication versus Mistake

A mistake is defined as an act or judgment that is misguided or wrong. On the contrary, a complication is an extra problem that appears and makes a situation more difficult than it previously was.

There seems to be a good agreement in literature to when a ligament reconstruction is indicated in an unstable scapholunate (SL) joint and when it is not. If problems arise after a tendon reconstruction performed while misalignment is not easily reducible, there is a combined instability, or, even worse, there is damaged cartilage or carpal collapse, these situations should not be considered complications but mistaken indications. Poor results are not always the consequence of a complication after a ligament reconstruction; sometimes they result from a wrong interpretation of what is unstable and what is not.1

Complications after scapholunate ligament (SLL) repair procedures are frequent.²^,³ SL dysfunction represents a broad spectrum of injuries, from a partial stable lesion to arthropathy. Depending on the stage of SL instability, different techniques may be indicated. Considering this, and also the trend to minimally invasive procedures, we will focus on the prevention and treatment of the complications found after the following four procedures:

●Open three-ligament tenodesis procedure (3LT).⁴^,⁵

●Open antipronation spiral SLL tenodesis using extensor carpi radialis longus (ECRL) slip.⁶

●Arthroscopic dorsal-SLL tenodesis with flexor carpi radialis (FCR) or ECRL.⁷

●SL screw fixation to maintain reduction of SL interval after SLL reconstruction.⁸ Each technique may have its own specific complications. The complications most often seen are discussed in this chapter and are shown in Table 18‑1.

Table 18.1 Complications after SLL reconstruction

1.Loss of SL reduction:
SL gap widening
Dorsal scaphoid translation
Scaphoid flexion
Lunate flexion

2.Loss of carpal reduction: Ulnar carpal translation

3.Stiffness:
Extracapsular origin
Intracapsular origin: Carpal collapse, chondrolysis

4.Tendons:
Flexor tendons: FCR tendonitis, FDP adhesions
Extensor tendons: Rupture, adhesions

5.Bone:
Fracture: Scaphoid, Lunate, radius
Avascular necrosis
Osteolysis

6.Nerve: Radial, median, ulnar

7.Infection

Abbreviations: FCR, flexor carpi radialis; FDP, flexor digitorum profundus; SL, scapholunate; SLL, scapholunate ligament.

18.2 Treatment of Complications after Scapholunate Ligament Repair

18.2.1 Loss of Scapholunate Reduction

Scapholunate Gap Tyranny

●Problem: Maintenance of SL joint intraoperative reduction in the frontal plane is usually not achieved, despite the use of SL or scaphocapitate Kirschner wires (KW), or even with tendon fixation with biotenodesis screws (Fig. 18‑1).

●Treatment: Postoperative SL gap recurrence is common, but frequently this radiological finding is clinically asymptomatic and doesn’t need to be treated. Only cases associated with dorsoradial translation of the scaphoid, sometimes with a positive Watson test, require surgical treatment as will be explained later.

●Rehabilitation: Strengthening of distal row supinator muscles (APL in neutral forearm rotation and ECRL/ECRB in forearm pronation), as in all SLL reconstructive procedures.⁹

●Tips and Tricks: Ligament augmentation with internal brace devices may, theoretically, decrease recurrence of the SL gap. A systematic review for anterior cruciate ligament repair in the knee with some form of internal bracing concludes that it increases the success rate.¹⁰ This aspect has not yet been demonstrated in the wrist.
Avoid ligament reconstruction procedures in static SL dysfunction.

Fig. 18.1 Widening of scapholunate (SL) joint intraoperative reduction 3 years after a three-ligament tenodesis (3LT) procedure. Despite the moderate gap, the scaphoid is no longer flexed or pronated and the patient is asymptomatic.

Dorsal Scaphoid Translation

●Problem: Dorsoradial scaphoid translation is directly related to persistent pain and weakness. Scaphoid remains flexed, which is associated with a limited wrist extension. Secondary degenerative radioscaphoid cartilage changes will certainly develop in the future (Fig. 18‑2a–c).

●Treatment: When symptomatic, proximal carpal row (PCR) resection or radioscapholunate (RSL) fusion may relieve patient’s symptoms and maintain functional mobility. In both cases, cartilage of the head of the capitate needs to be preserved. If the lunocapitate joint is affected but radiolunate cartilage remains in good condition, scaphoid resection and midcarpal (MC) fusion (lunocapitate, lunocapitohamate, or four corner) are indicated.
Dorsal scaphoid translation increases when a dorsal distal radius malunion is associated. In such cases, prior correction of the dorsally tilted distal radius can limit dorsoradial scaphoid translation and facilitate symptomatic improvement. For the same reason, any SLL reconstruction performed in a wrist with a distal radius dorsal malunion has a higher failure rate (Fig. 18‑3).

●Rehabilitation: MC mobility around dart throwing motion axis in RSL fusion. Radiocarpal (RC) mobility in MC fusion.

●Tips and Tricks: Arthroscopic PCR, RSL, or MC fusion preserves extra-articular vascularization and, so, facilitates bone fusion. Correct lunate extension deformity to allow proper range of motion. Avoid overcorrection at the lunocapitate fusion in the frontal plane. MC joint stabilization with KW avoids RC joint screw protrusion if some degree of collapse occurs before MC fusion is achieved.

Fig. 18.2 (a–c) Recurrence of scapholunate (SL) malalignment after an antipronation spiral tenodesis (a,b). Scaphoid flexion and dorsal translation induce high loading in a small joint area of the scaphoid fossa that will end in chondral damage (c).

Fig. 18.3 (a,b) Early symptomatic malalignment recurrence after a three-ligament tenodesis (3LT) procedure performed in a wrist with a distal radius dorsal malunion. (Courtesy of Dr. P. Forcada.)

Scaphoid Flexion Persistence

●Problem: Postoperative scaphoid flexion persistence can be either associated or not associated to a dorsoradial scaphoid translation. When scaphoid flexion is associated with a scaphoid dorsoradial translation, both should be faced as described previously.
Isolated scaphoid flexion is associated with a carpal height loss. This condition may evolve to an MC misalignment. Whether this misalignment will lead to an MC clinical instability or not is uncertain.

●Treatment: No preventive surgical treatment of isolated scaphoid flexion persistence should be planned while the patient is free of symptoms.

●Rehabilitation: Strengthening of distal row supinator muscles.9

●Tips and Tricks: Using ECRL as a donor tendon for SLL reconstruction induces greater scaphoid extension and supination than FCR.⁵

Volar Intercalated Segment Instability (VISI) of the Lunate

●Problem: Permanent malalignment in flexion of the lunate after SLL surgery or development of a progressive flexion deformity. A fixed VISI deformity in a static lunotriquetral (LT) dysfunction may be confused with an SL joint gap, and may explain a permanent lunate flexion malalignment even after an SLL reconstruction. This describes a wrong indication rather than a complication (Fig. 18‑4). Overcorrection of lunate position during SL ligamentoplasty followed by several weeks of pinning would also explain a lunate flexion deformity (Fig. 18‑5).

●Treatment: Any soft tissue procedure aimed to correct a static VISI deformity has high chances of failure. PCR or MC fusion will probably be needed.

●Rehabilitation: Strengthening of distal row pronator muscle (ECU) with the forearm in supination after LT ligament repair or pinning.¹¹

●Tips and Tricks: In arthroscopic SLL ligamentoplasty,⁵ the lunate intraosseous tunnel must be parallel to the distal lunate surface to avoid lunate overcorrection in VISI; a temporary radiolunate KW may help to stabilize a floating lunate during drilling. Check for an LT origin in cases of an apparent SL space widening plus a flexed lunate.

●Extension of the whole proximal carpal row, as it happens in a dorsal nondissociative instability, may be wrongly considered as secondary to an SLL dysfunction. Performing an SLL reconstruction in such cases has also to be considered a mistake and not a complication.

Fig. 18.4 Static flexion deformity of the lunate (volar intercalated segment instability [VISI]) in a lunotriquetral (LT) dysfunction may create confusion as the scapholunate (SL) space seems to be wider in the anteroposterior (AP) view. Look at the altered Gilula lines in the ulnar side of the wrist.

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