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New concept of scapholunate dissociation treatment and novel modification of Brunelli procedure - anatomical study
© Elsaftawy et al.; licensee BioMed Central Ltd. 2014
Received: 15 January 2014
Accepted: 19 May 2014
Published: 23 May 2014
This paper describes a novel method in treatment of scapholunate dissociation accompanied with rotatory subluxation of the scaphoid. The idea of this method is to create a kind of axial lever that can fully reconstruct anatomical relationship between the scaphoid and the lunate, with no involvement of extrinsic ligaments, and with simultaneous restriction of pathological alignment of the scaphoid. Based on this technique, we have also proposed a new modification of Brunelli procedure in scapholunate dissociation with rotatory subluxation of the scaphoid and dorsal intercalated segmental instability.
At the initial stage of the study, 20 human wrists fixed in Ethanol were used, followed by 12 fresh human wrists used in part two. The first stage included functional, biomechanical and strength tests carried out by means of a 5 kg load and intended to find the most anatomical and durable treatment method. The second stage involved testing the proposed methods on fresh cadaver wrists.
We have discovered that the new method is able to recreate anatomical forces and properties of scapholunate ligament; what’s more, it can also prevent rotatory subluxation of the scaphoid. The performed strength tests have proven that it is possible to treat scapholunate instability also in case of dorsal intercalated segmental instability.
We highly recommend using both the new technique and the new modification of Brunelli procedure for treatment of scapholunate dissociation in both dynamic and static instabilities.
This paper aims at presenting a novel method of free tendon reconstruction of scapholunate ligament complex, which proves particularly useful on scapholunate ligament dissociation with rotatory subluxation of the scaphoid. We also propose a new modification of Brunelli procedure in scapholunate dissociation with rotatory subluxation of the scaphoid and dorsal intercalated segmental instability (Figure 1).
The first part of the study involved 20 human wrists fixed in Ethanol, while at the second stage 12 fresh human wrists were used (whose donors had voluntarily donated their bodies for scientific purposes after their demise). The proposed method of free tendon reconstruction of scapholunate ligament complex involves formation of a stable axial lever for the scaphoid and the lunate, which restores the anatomical pattern of scapholunate ligament complex as well as prevents occurrence of rotatory subluxation of the scaphoid.
While an average gap width after sectioning of the SLIL and the secondary stabilizers of scapholunate complex amounts to 2,59 mm (range 2–3 mm) under 5 kg load, after applying the new procedures it was only 1,31 mm (range 1–2 mm). The average difference of scaphoid shift in relation to the lunate surface from the side of midcarpal joint used to be 8,1 mm (range 6–12 mm) and we managed to reduce it to 2,62 mm (range 1–4 mm) by means of the new procedures. The method discussed withstood 5 kg load with no signs of scapholunate dissociation or rotatory subluxation of the scaphoid. The set p-value was less than 0.05 (0.00078 and 0.00279 respectively). Thus, the comparison of the two features had to be performed by a paired Wilcoxon’s test. In both cases, the differences between groups were significant. The p-value for this test was 5.96-08 (for reducing the SL gap), and for prevention rotatory subluxation of the scaphoid was 3.73-09.
To prevent the gap from increasing between the scaphoid and the lunate when applying this method, the tendon graft in place of intersection has to be sutured to itself in three points: at the intersection point and its both sides over the lunate and proximal pole of scaphoid. The shape and the way of fastening of the new anchors were very helpful due to the possibility of their multiple use.
An average gap width after modified Brunelli procedure was 1 mm (range 1–2 mm). After the modified Brunelli procedure was performed, average difference of scaphoid shift in relation to the lunate surface from the side of midcarpal joint was 2,33 mm (range 2–3 mm). Since in this group there were only 3 cases it was decided that a comparison of unpaired Wilcoxon’s test should be performed. In both cases, the differences between groups were significant. The p-value for this test was 0,00145 for reducing the gap between scaphoid and lunate, and for prevention rotatory subluxation of the scaphoid was 0,00402.
The modified Brunelli procedure seemed to both reduce the SL gap and prevent rotatory subluxation of the scaphoid, yet it limited wrist flexion movements because of involvement of dorsal extrinsic ligaments. The average angle of maximum wrist flexion after applying modified Brunelli procedure was 53.3° (range 50°-60°), however when we attempted to obtain a greater flexion by applying more strength, the place of suturing FCR to itself started to break in all three cases. The new modification of Brunelli procedure was more stable, with no evidence of scapholunate dissociation or scaphoid subluxation.
Carpal instability with some of its clinical manifestations had been described by Destot  in 1926, but the term „instability” was introduced by Dobyns  in 1967. In scapholunate dissociation the capitate migration down into the scapholunate joint tends to create a gap between the scaphoid and the lunate. This will cause extension of the lunate and flexion of the scaphoid, giving rise to an increased scapholunate angle as a result of scapholunate interosseous ligament attenuation. This is also accompanied by an increased capitolunate angle. An additional factor is the increased ulnar translation of the lunatotriquetral complex due to the release of the scapholunate interosseous ligament. Acute injuries can practically always be improved without surgery if standard x-rays and stress views show no obvious signs of instability [13–15]. Each method of surgery treatment requires a level of experience. If the result of injury is partial tear of the SLIL, it will represent occult or predynamic instability [18, 19]. For these injuries, most specialists recommend starting the treatment with splinting and/or casting [19, 20]. Arthroscopic debridement with or without pinning can be an option for patients for whom the initial conservative treatment failed to succeed. With complete SLIL tears, immobilization does not reduce or prevent scapholunate dissociation . Significant force occurs at the scapholunate interval on wrist loading. Options for acute management of these tears include direct repair with or without dorsal capsulodesis or arthroscopic debridement, reduction, and pinning. For chronic SL instabilities variable tendon reconstruction techniques and tenodesis have been described and tested with variable success, but when Brunelli and Brunelli  presented their method in 1995 it was a breakthrough in treatment of scapholunate instability, not because of its effectiveness in treatment of the scapholunate dissociation, but because it restricted and prevented the occurrence of rotatory subluxation of the scaphoid. It limited the flexion movements of the wrist, though, therefore three years later the procedure was modified by Abbeele  and became the best applicable technique in cases of dynamic scapholunate instability with rotatory subluxation of the scaphoid. Garcia-Elias described his own modification  of this procedure in 2006 and called it the three-ligament tenodesis for treatment of scapholunate dissociation. since 1995 only one case of avascular necrosis of the scaphoid  has been mentioned in available literature When logically reasoning about anatomical relationship between the scaphoid and the lunate, the new method presented here will restore better functioning of scapholunate ligament complex. Maintaining the distal part of the scaphoid in the axis of scapholunate complex by anchoring it, the free tendon graft will prevent rotatory subluxation of the scaphoid without the need of involvement of dorsal extrinsic ligaments as it is happening in modified Brunelli procedures. Since 1998, when Abbeele introduced his own modification to Brunelli procedure, we have found less than 400 cases treated with this technique [15, 21–28]. The largest number of patients treated with this method were presented by Talwalker . Most authors who revealed the results of implementing this technique unanimously agree that this is a method suitable for carefully selected cases; in addition better results were obtained in case of dynamic instabilities. Wrist range of motion got decreased in the range of 20% in dynamic instabilities to even 50% in static ones. The grip strength was also reduced even to 30% when compared to healthy wrists. Some publications informed of even better results than these after performing 4-corner fusion procedure .
Although this is not a clinical study, it shows that the mechanism of the new technique can restore the correct anatomical topography of scapholunate ligament complex with no deterioration of wrist movements. We also believe that in case of scapholunate instability with DISI deformity, the proposed modification of Brunelli technique could improve long-term results of surgical treatment.
The proposed new technique was found to recreate anatomical forces and properties of scapholunate ligament and to prevent the occurrence of rotatory subluxation of the scaphoid. Modified Brunelli procedure proved to work very well in reducing the scapholunate gap and rotatory subluxation of the scaphoid, however it may limit the wrist movements because of involvement of dorsal extrinsic ligaments. Therefore the proposed new modification of Brunelli procedure could result in a more mobile wrist, with no evidence of scapholunate dissociation or scaphoid subluxation. In conclusion, we recommend the new technique and the new modified Brunelli procedure in treatment of scapholunate dissociation in both dynamic and static instabilities.
The authors hereby declare that the novel methods presented in the manuscript has been entirely developed by dr Ahmed Elsaftawy. After obtaining approval from prof. Jerzy Jablecki, the study entered the implementation stage. Dr Bohdan Gworys and Dr Tomasz Jurek enabled us to use their laboratories in order to carry out biomechanical tests on cadavers and were involved in technical support. The entire manuscript has been prepared and written by dr Ahmed Elsaftawy and has been further accepted by the co-authors.
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