4/20/2015. SL Reconstruction: Long-Term Results of RASL Reconstruction. No Disclosure relevant to this subject

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1 SL Reconstruction: Long-Term Results of RASL Reconstruction No Disclosure relevant to this subject Case: yo M Chronic Static SL diastasis (DISI) Persistent pain, weakness, functional limitation Presentation films Aug

2 @ yr Reduction stable Saggital screw axis volar to midline- KEY 18.7 year F/U - NO SCREW MIGRATION DASH=44.83 ROM Measures Flexion: 60 Extension: 75 Radial Dev: 20 Ulnar Dev: 20 2

3 @18.7 year (April 2015) F/U (video) This is my solution to a difficult and not uncommon problem SLIL complex when disrupted will inevitably lead to a SLAC wrist Pain and weakness with accompanying functional limitations result Static DISI prior to onset of DJD at the capitolunate joint can be corrected with a motion sparing RASL procedure Others are reporting their results with modifications of soft tissue repair but with trans-osseous screw fixation Diego-Fernandez ASSH 2014, Osterman ASSH specialty day 2015 ( now published JHS this month) 3

4 Additionally the RASL can be done arthroscopically Arthroscopy 2007 Forces are too great for K wires or tenodesis fixation alone SL complex must maintain physiologic intercarpal rotation of 25 degrees Scaphoid continues to flex after the lunate stops Fixation must neutralize forces which cause the deformity 4

5 SLAC Wrist Watson Classification Some apparent 1 and 2 patients may already have C-L cartilage changes silent on x=ray Watson, JHS 1984 Images from Contraindications Preexisting SIGNIFICANT radiocarpal, STT or capitolunate OA Focal radio-scaphoid OA SLAC 1 as depicted NOT a contraindication! Case : 47yo RHD male dentist Chronic Static DISI NO SLAC 5

6 MR more sensitive to pick up CL early arthritis Check for Capitolunate joint narrowing or cystic changes My Preference RASL Concept is Like an Axle s L Allows motion around the axis of rotation 6

7 For the RASL procedure Do Not Use a fully threaded screw It will break This is not a fusion SL screw maintains reduction during soft tissue healing All screws loosen at lunate threads overtime to permit the obligatory SL rotation RASL NOT A FUSION Technique Longitudinal dorsal incision Radial styloid incision Transverse capsular incision preserves dorsal capsular ligaments (DIC- secondary restraint) K wire joy sticks placed distally in both S and L Avoid wire placement in axis of intended screw path Dorsal Incision 7

8 Dorsal Ligament ( DIC ) Secondary Restraint preserved Radial Incision- Styloidectomy REQ- axis Reduction & Association of the Scaphoid & Lunate (RASL) Fluoro 20s no fade.wmv (VIDEO) 8

9 Subchondral burring creates bleeding Promotes scar response Kocher Clamp maintains reduction Placement of Screw CRITICAL X 9

10 Guide wire must target the central to volar lunate axis Reduction K wires avoid the intended path of screw Obligatory physiologic SL intercarpal rotation after RASL procedure RASL video 23s.wmv 10

11 Critical Technical points Radial styloidectomy Axis of screw directed towards medial corner of the reduced lunate on coronal view Axis central to slightly palmar on lateral view This closely approximates the center of rotation of the SL joint NEVER PLACE THE SCREW DORSAL Back to our Case: 7 Year 8 years 11

12 @ 8 years 12 years (video) 15 Year Clinical Follow-up 12

13 Unfortunately Dr.Stern s article did not report If radial styloidectomies were done ANY LATERAL XRAYS demonstrating saggital screw placement No demonstration of the accuracy of the lunate reduction and derotation Also several of his illustrated cases had scaphoid screw placement too proximal - another sign of off axis alignment Despite all of that none of his cases had secondary surgery and at 38 months F/U all had low DASH disability scores His study s conclusion, in only 7 patients, focused on x -ray alignment alone 13

14 My RASL Results Patient based outcomes: N = 31, Age = 50 ( ) 6.1 years follow-up (1.4 to 18) Outcome Value ± Standard Deviation Range DASH 19.2 ± SF-36 PCS 48.0 ± SF-36 MCS 53.1 ± VAS - rest 0.6 ± VAS - active 1.7 ± Results Physical Exam: N = 22, Age = 49.6 ( ) 6.0 years follow-up (1.4 to 18) Parameter Value Range Percent of Contralateral Side p-value Flexion/Extension Arc 107 ± Radial Deviation 19 ± Ulnar Deviation 26 ± Grip Strength 33 kg ± 7.6 kg kg Results Radiographs N = 29, Age = 50.3 (31 67) 2.1 years follow-up ( ) Pre-Operative Post-Operative Value Value p-value SL-Gap 4.4 mm ± 2.7 mm 2.1 mm± 1.0 mm < SL-Angle 77 ± ± 13 <

15 Thank You 15

16 4/15/2015 CAVEATS Acute SL repair does work Repair requires prolonged protection Inherent problems with K-wires after 6 weeks 1

17 4/15/2015 Injury pattern: Andersson % 16% 20% 22% Andersson JHSE: 2012 Workup History Exam Radiographs- incl stress views MRI Arthroscopy 2

18 4/15/2015 ACUTE TRAUMATIC TEARS Within 6 weeks (empirical) Secondary restraints intact Partial or complete disruption of SLIL Partial- K wire SL joint Complete- Suture anchor repair of SLIL Capsulodesis augmentation 3

19 4/15/2015 Surgical technique 4

20 4/15/2015 5

21 4/15/ weeks postop 3 months postop 6 months postop 6

22 A New Method for SLL reconstruction Mark Ross Associate Professor of Orthopaedic Surgery University of Queensland Brisbane, Australia Greg Couzens Brisbane Hand and Upper Limb Clinic Modification of 3LT ( mod Brunelli ) Stanley, Garcia-Elias 1

23 ? * 2

24 Interference screw Minimise instrumentation of lunate V VI 3

25 R S L R S L R S L 4

26 R S L R S L R S L 5

27 ALTERNATE MINI OPEN APPROACH V VI R S L ALTERNATE MINI OPEN APPROACH 6

28 3mm graft 3mm tunnel- 3mm interference screw 7

29 8

30 12 weeks postop 12 months postop Pre op 9

31 Right Wrist- Dorsal S L D V D DORSAL R S L T 10

32 Performed > 80 recon since 2009 Initial Cohort 11 patients* F/U months *Ross et al JWS May 2013 Quick DASH PRWE SLL interval 4.18mm 1.6 mm SL angle 80º 56º 11

33 Complications 1 # lunate in high impact injury 10 months post reconstruction Professional footballer returned to playing professional rugby league -heavy spear tackle - full body weight onto wrist -salvage with scaphocapitate fusion -4mm tunnel 3 x 8 PEEK screw 3mm cannulated drill Number of temporary wires? 2, 1, 0 Wire location? SL, SC Future Directions Biocomposite screws mini open and A/S assisted technique Targeting jigs, graft sizers 12

34 Augmentation of acute repair Especially perilunate injuries 13

35 Delayed presentation 5 weeks post injury 12 Month followup 14

36 SUMMARY Graft Volar to STT restrains scaphoid flexion No tether to Dorsal radius Isometric tunnel placement Normal sagittal plane rotation maintained Uniform dorsal and volar reduction Reduction of rotary subluxation through graft tensioning SUMMARY Central graft position allows repair of residual SLL Triquetrum ideally suited to anchoring Stabilisation of LT interval Robust reinforcement of DICL Transosseous graft avoids dorsal soft tissue bulk Thankyou 15

37 A Volar Capsulodesis for Scapholunate Dissociation R.J. van Kampen M.D., Steven. L. Moran M.D. Division of Hand Surgery, Mayo Clinic, Rochester, MN No disclosures Introduction SL instability difficult to treat 1

38 Introduction Sl instability difficult to treat Injuries begin volarly and progress to dorsum Introduction SL instability difficult to treat Injuries begin volarly and progress to dorsum Few techniques address volar aspect of ligament x Introduction SL instability difficult to treat Injuries begin volarly and progress to dorsum Few techniques address volar aspect of ligament x 2

39 Tears begin volarly and migrate dorsally Midcarpal Joint 3

40 Dorsal SL ligament Tq L Palmar SL ligament S Concerns with volar approach Carpal instability Vascularity Exposure Garcia-Elias JHS 1988 Technique 4

41 Ligament Sparing Capsulotomy Ligament Sparing Capsulotomy Volar Capsulodesis 5

42 Volar Capsulodesis Volar Capsulodesis Volar Capsulodesis 6

43 Through a small modified Henry approach the volar capsule is visualized and the space of Poirier is opened to separate the LRL and radioscaphocapitate ligament (RSC). Volar carpal ligaments RSC S c L LRL 7

44 The LRL is split in the fiber direction. The distal half is cut laterally and sutured to the proximal pole of the scaphoid with a suture anchor. 8

45 Radial artery Radial epiphyseal arch 9

46 S L s l 10

47 Methods Fourteen cadaver arms were injected with red colored epoxide (10) and latex (4). In all arms the vascularization of the volar wrist capsule was dissected. The four latex-filled arms were digested with bleach. The vascular supply to the ligaments and scaphoid and lunate were investigated. Dorsoradial side of the wrist showing the vascular supply to the scaphoid from the radial artery 11

48 Dorsoradial side of the wrist showing the vascular supply to the scaphoid from the radial artery Results In all arms a branch of the radial artery or radiocarpal arch supplied the volar radioscapholunate ligament at the medial border of the LRL. The proximal half of the scaphoid was supplied by dorsal branches of the radial artery. In all cases a vessel entered the lunate on the ulnar volar side. At the lunate the volar SLIL inserted directly under the LRL. Methods The strength of this reconstruction was tested on 5 cadaver arms by potting the scaphoid, lunate and radius and pulling the capsulodesis to rupture (axially) using a servo-hydraulic vertical displacement testing machine. (Instron testing device) 12

49 Results The average strength of the intact LRL strip was 97.4 N ( ) The average strength of the ligamentsuture interface was 43.5 N ( ) All repairs failed at the suture anchor Case 1 56 y.o surgeon 2 year history of wrist pain Active tennis player 13

50 Case 1: 34 months FU Return to sports at 6 months Achilles rupture at 12 months while playing tennis No pain at wrist Flexion 60 Extension 60 Case 2 22 year old lineman 6 months of wrist pain Arthroscopy with large volar tear 12 months following surgery 14

51 12 months 15

52 Conclusion This approach does not compromise the vascularity of the scaphoid or the lunate A more anatomic reconstruction of the scapholunate ligament is achieved The strength of the capsulodesis appears to be less than the strength of the native volar SLIL 1 More clinical data necessary 1 Berger, R.A., et al., Constraint and material properties of the subregions of the scapholunate interosseous ligament. Journal of Hand Surgery, (5): p Thank You 16

53 Scapholunate Axis Method (SLAM) Scapholunate Reconstruction Jeffrey Yao, MD Associate Professor Department of Orthopaedic Surgery Stanford University Medical Center Disclosures The following relationships exist: 1. Grants American Foundation for Surgery of the Hand 2. Royalties and stock options Arthrex, 3D Systems 3. Consulting income Smith and Nephew Endoscopy, Arthrex 4. Research and educational support Arthrex 5. Editorial Honoraria Elsevier, Current Orthopaedic Practice 6. Speakers Bureaus Arthrex, Trimed, Smith and Nephew Endoscopy Chronic Scapholunate Ligament Injuries WITHOUT arthritis Garcia-Elias Grade 3/4 (reducible, unrepairable ligament, +/-DISI, no arthritis 1

54 Garcia-Elias Staging of SLD From Garcia-Elias, et al. JHS 2006 Options? Capsulodeses Blatt, Szabo, Mayo Ligament reconstruction Brunelli Linscheid Garcia-Elias 3LT Ross SLT Bone Ligament Bone RASL, SLIC screws Ho Arthroscopic Box Recon ETC, ETC Salvage Intercarpal arthrodesis Scaphocapitate, STT SE4CF PRC Three-Ligament Tenodesis Thanks to Marc Garcia-Elias MD 2

55 Is this OK? S L S L Look Familiar? 6 months later Scapholunate Axis Method (SLAM) SL ligament reconstruction that: associates scaphoid and lunate via a biologic central axis tether Biologic RASL ACL of the Wrist reconstructs the dorsal SL ligament corrects SL position in sagittal and coronal planes Less tendon creep due to fixation in both the lunate and scaphoid 3

56 Compared the biomechanical characteristics of the following methods for scapholunate reconstruction: ScaphoLunate Axis Method (SLAM) Blatt Capsulodesis 3-Ligament Tenodesis (3LT) Lee, et al. JHS

57 Methods 12 fresh frozen cadaveric below-elbow specimens Mounted on a jig that allowed for wrist and finger motion by tendon loading via attached weights 4 specimens placed in each of the 3 groups: SLAM reconstruction Blatt capsulodesis 3LT tenodesis Lee, et al. JHS 2014 Lee, et al. JHS 2014 Methods Specimens were evaluated in four states: intact SL and dorsal/volar extrinsic ligaments cut after reconstruction after reconstruction followed by 100 cycles of simulated motion Lee, et al. JHS

58 Lee, et al. JHS 2014 Lee, et al. JHS 2014 Lee, et al. JHS

59 Results After cycling, both 3LT and SLAM reconstructions performed significantly better than BC in recreating intact SL interval in a clenched fist posture (3LT p=0.013, SLAM p=0.003) Lee, et al. JHS 2014 Scapholunate intervals compared to the intact states between cycled reconstruction groups. 3LT and SLAM were significantly smaller than BC (p=0.013, p=0.003, respectively) Lee, et al. JHS 2014 Scapholunate angle change when compared to cut state between cycled reconstruction groups. Lee, et al. JHS

60 The SLAM leads to improved: SL interval gapping SL angle correction when compared to current techniques of SL reconstruction Blatt 3LT Lee, et al. JHS 2014 First Clinical Case SL Reduction 8

61 Palmaris Longus Harvest Starting Point on Scaphoid Place Central Guidewire 9

62 Center-Center Guidewire Placement Place Accessory Wire Insertion of Step Drill 10

63 CT MAPPING: 14% OF SURFACE AREA Load Bullet Anchor Placement of Anchor and Graft 11

64 Tensioning and Placement of Tenodesis Screw Remaining Tendon Brought Dorsally to Reconstruct the Dorsal SLIL Final Images 12

65 6 Months Post Op 6 Months Motion Initial Results 13 patients (2012-Present) Age: 48 yo (range 29-65) Follow up: 11 months (3-25) Preop SL gap 5.4 mm, post op 2.1 mm* Preop SL angle 70, postop 59* ROM flex 45, ext 56 VAS Pain 1.7 (0-4) Grip 55 lbs (62%) 1 failure (65 yo pt) PRC *p<0.05 Thanks to Steve Lee, Jerry Huang 13

66 SLAM SLIL reconstruction: Two-tailed tendon autograft placed along the axis of rotation of the scaphoid and lunate secured using novel fixation coupled with reconstruction of the critical dorsal SL ligament secure fixation of the autograft is achieved near SL joint both in lunate and scaphoid Theoretical advantage of lower creep when compared to previous methods Improved biomechanics compared to other techniques Preliminary clinical results are encouraging Thank You! Scapholunate Axis Method (SLAM) 14

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