The Scapholunate Ligament Complex Syllabus

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10/17/2012

The Scapholunate Ligament
Complex

The Hand & Wrist Institute
Torrance, CA

David J. Slutsky MD
Assistant Professor
Dept of Orthopedics
Harbor- UCLA

DISCLOSURES
~ There is no commercial support for this
Talk
And….
~There are no conflicts of interest.

The Scapholunate ligament
Complex




the stability of the scapholunate joint is not
dependent wholly upon the scapholunate
interosseous ligament (SLIL) but rather upon
both primary and secondary stabilizers, which
form a scapholunate ligament complex (SLLC).
Each case of SL instability is unique and
therefore should be treated with tissue specific
repairs, which may partly explain why one
procedure cannot successfully restore joint
stability in every case.

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The Scapholunate ligament
Complex







Elsaidi et al sequentially divided the RSC, LRL,SRL, SLIL and
finally the dorsal capsule insertion on the scaphoid. 1 There was
no appreciable change in the radiographic appearance of the
wrist.
When the DRCL was then divided, a DISI deformity occurred
Short et al determined that the SLIL is the primary stabilizer of
the SL articulation and that the DRCL, DIC, ST and RSC
ligaments are secondary stabilizers.2
The SL joint is therefore dependent on a complex of ligaments,
each having a separate role but working in concert.

1.Elsaidi GA, Ruch DS, Kuzma GR, et al: CORR:152-7, 2004
2. Short WH, Werner FW, Green JK, et al: J Hand Surg 32:297-309, 2007

Geissler Classification of ligament injury

This classification quantifies the resultant instability and not
the actual size of the tear.

Geissler WB, Freeland AE, Savoie F et al.
JBJS(Am) 1996

Geissler II ?

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Dynamic Wrist Arthroscopy

Hagert E, Lalonde DH. Wide-awake wrist arthroscopy and open
TFCC repair. Journal of Wrist Surgery 2012;1:63– 68.
Ong M, Ho PC, Wong C, Cheng S, Tse W. Wrist Arthroscopy under Portal Site
Local Anesthetic without tourniquet. Journal of Wrist Surgery November 2012.

Grade IV SLIL tear

Scaphoid kinematics

video courtesy of Gregory Bain M.D.

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Type I Scaphoid


The scaphotrapezial
ligaments have a narrow
proximal (scaphoid)
attachment and is assoc.
with a type I lunate
This facilitates rotation
around the longitudinal
axis of the scaphoid, as
well as limiting flexion
and extension of the
bone.
Galley I, Bain GI, McLean JM. J Hand Surg 2007

Type II Scaphoid
broad proximal attachment
of the ST ligament limits
longitudinal rotation of the
scaphoid.

These scaphoids are associated
with type II lunates and therefore
are limited from rotation and
Translation
Galley I, Bain GI, McLean JM. J Hand Surg
2007

Type I
“rotating unicondylar
scaphoid”

Type II
“flexing bicondylar scaphoid”

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10/17/2012

Type I lunate – SL injury with a
rotating scaphoid will exhibit
abnormal flexion and requires a
procedure to limit scaphoid flexion
- dorsal capsulodesis
- DIC capsulodesis

Type II lunate – SL injury with a
flexing scaphoid will exhibit
abnormal rotation and require
procedures to limit
scaphoid pronation
- Bone-ligament-bone
- Tri-ligament tenodesis
- Brunelli

Volar
Palmar SLIL plication
Palmar capsulodesis
STT ligament plication
STT fusion

Dorsal
shrinkage

Capsulodesis
DRCL repair
Arthroscopic
capsuloplasty

Brunelli
Tri-ligament
tenodesis

Interosseous
Tendon graft
RASL
Bone-ligament-bone

Slutsky DJ. Current Innovations in Wrist Arthroscopy. J Hand Surg Sept 2012

SLLC arthroscopic assessment
Palmar SLIL – volar radial portal, MCR
Dorsal SLIL – 3,4 and 4,5 portal, MCU
 Dorsal capsule – volar radial portal, 6R
 ST ligaments – MCR, STT portal



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10/17/2012

Structure

Instability

Classification
A = ≤ 6 mths
no midcarpal step
B = ≥ 6 mths
Midcarpal step drive
through sign

Treatment Options

Palmar SLIL

Geissler I/II

P-1A

Shrinkage, volar plication, LRL transfer, SL pinning

Geissler III/IV

P-1B

RASL, interosseous graft, limited fusion

Geissler I/II

D-1A

Shrinkage, DIC capsulodesis

Geissler III/IV

D-1B

Acute repair, tenodesis, bone-lig-bone, limited fusion

Geissler I/II

C – 1A

Shrinkage, combined volar/dorsal plication

Geissler III/IV

C- 1B

Interosseous graft, RASL, limited fusion

Geissler I/II

DC – 1A

Shrinkage, dorsal capsuloplasty

Geissler III/IV

DC – 1B

Geissler I/II

ST – 1A

Blatt capsulodesis, ST ligament shrinkage/plication

Geissler III/IV

ST – 1B

STT/SC fusion

Dorsal SLIL

Combined

Dorsal Capsule

ST ligaments

Palmar SLIL

Arthroscopic suture of the Palmar SLIL. Del Pinal et al. J Hand Surg Sept 2011

VOLAR CAPSULODESIS FOR
SCAPHOLUNATE DISSOCIATION

Van Campen RJ, Moran SL. IWIW Chicago 2012

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DRCL TEAR

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Dorsal SLLC: capsuloplasty

36 patients, age 38 yrs - f/u 11 mths (7-19)
Geissler II/III, pain 5.4 mths (3-14)
 F = 63º (40-80), E = 71º (40-90)
 DASH: preop 34 (16-48), postop 9 (0-40)
 VAS: preop = 3.4 (3-4) , postop 0.31 (0-3)
 MMWS: E/G = 29, F = 4 P = 2


(Mathoulin C, Dauphin N, Wahegaonkar AL. Hand Clinic 2011)

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Arthroscopic Dorsal Capsuloplasty
Ch. Mathoulin, Adeline Cambon-Binder

Acknowledgements to all EWAS members,
Especially : Jane Messina (Italy)
Abhijeet Wahegaonkar(India)
Luc Van Overstraeten (France)
Emmanuel Camus (France)
David Slutsky (USA)
Pak-Cheong Ho (Hong-kong, SAR China)
Loris Pegoli (Italy)
Max Haerle (Germany)
Andrea Tandara (Germany)
Marc Garcia-Elias (Spain)
Marina Carrara (Brazil)
Gustavo Mantovani (Brazil)
Martin Caloia (Argentina)
Gabriel Clemboski (Argentina)
Tanya Burgess (Australia)
Antonio Pagliei (Italy)
Institut

de la Main

Classical ANATOMY

S

L

rsl

TFCC

Scapho lunate ligament :
anterior, dorsal and intermediate

Institut
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ANATOMY

IIM
Tp

S

R
Distal stabilization: FCR + STT Ligt + RSC Ligt

Importance of FCR
(Salva-Coll, Garcia-Elias et al, 2011)

Institut
de la Main

1

SCAPHOLUNATE LIGAMENT
Main scapholunate joint stabilizer
Meade et al 1990 – Short et al. – Looi et al. 2001

DORSAL

PALMAR

PROXIMAL

450
400
350
300
250
200
150
100
50
0

Yield Strength

260 +/18
118 +/21

63 +/- 32

Proximal

Palmar

Dorsal

Berger et al. ‘99
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SCAPHOLUNATE LIGAMENT
Contributes to carpal proprioception

Sensory innervation
Mainly
proximal
part

DORSAL

PALMAR

PROXIMAL

Palmar

Proximal

Dorsal

Mataliotakis et al. ‘09
Mataliotakis et al. ’11
Importance of AIO nerve and PIO nerve too !!!!

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ANATOMY

« Only with sectionning insertion of the DIC a dorsal intercalated
scapholunate instability deformity (DISI) ensued »
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ANATOMY

Normal aspect

Isolated dorsal capsule tear
with midcarpal SL spacing
Midcarpal
Institut
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de la
la Main
Main
de

ANATOMY

Normal aspect

Isolated dorsal capsule tear
with midcarpal SL spacing
Midcarpal
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de la
la Main
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ANATOMY

Normal aspect

Radiocarpal

Midcarpal
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la Main
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de

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ANATOMY

Normal aspect

Radiocarpal

Midcarpal
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la Main
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de

ANATOMY
Two days of laboratory work, 10 young fresh cadaver

Arthroscopic testing and X-Rays measuring with and
without load
1/
2/
3/
4/

Normal wrist,
section of Dorsal Capsulo-SL attachment (DCSS)
section of SLIOL
DIC section

( (J. Messina (I), L. Van Overstraeten (B), E. Camus (F), A. Wahegaonkar (In),
A. Tandara (G), A. Cambon-Binder (F), C. Mathoulin (F))

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ANATOMY
SEVERITY
SL LAXITY
GRADE

CASES EVOLUTION AFTER SECTIONS
Initial

6
section aDIC/SL

4
section SL

2

section DIC

5

1

3

0
9

7

section DRC
CASES work, 10 young fresh cadaver
Two days of laboratory

Systematic worsening of SL diastasis after simple
detachment of DCSS from dorsal SL
Institut
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de la
la Main
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de

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ANATOMY
7

INDICE GRAVITE

6
5
4
3
2
1
0
Initial

section aDIC/SL

section SL

section DIC

SECTIONS

This structure (Dorsal capsuloscapholunate Septum) is a bridge
between the DST ligt and the
dorsal SL ligt, and seems to be
essential to the SL stability, and
probably its tears could be
considered as a first stage of SL
instability…!!!
Institut
Institut
de la
la Main
Main
de

ANATOMY

C
C

DIC/DST
DCSS

L

S

DSL

R
R
Prominent role of dorsal radiocarpal ligaments:
DIC/Dorsal ScaphoTriquetral Ligt
Dorsal Scapholunate Ligt
Dorsal Capsulo-Scapholunate Septum
Institut
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de la
la Main
Main
de

ANATOMY
Four months of laboratory work, 17 fresh cadavers
The DCSS structure was identified between the scapholunate ligament and the DIC
DCSS always identified, consisting of three arches (two transverse arches in series
along the distal line of the scapholunate interval, forming a confluence into the third
which was larger than the previous mentioned)

(M. Carrara (Bra), T. Burgess (Aus), C. Mathoulin (F))

Institut
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de la
la Main
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de

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ANATOMY
Four months of laboratory work, 17 fresh cadavers
It demonstrated a wide diffuse attachment along the scapholunate ligament and
then arced dorsally fanning out to a longer insertion into the dorsal capsule.

Four months of laboratory work, 17 fresh cadavers
(M. Carrara (Bra), T. Burgess (Aus), C. Mathoulin (F))

Institut
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de la
la Main
Main
de

Arthroscopic Dorsal Capsuloligamentous Repair
ADCLR

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de la Main

Arthroscopic Dorsal Capsuloligamentous Repair
ADCLR

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Arthroscopic Dorsal Capsuloligamentous Repair
ADCLR

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Arthroscopic Dorsal Capsuloligamentous Repair
ADCLR
1 thread through 3,4 P, then DWC and ULNAR remnant

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Arthroscopic Dorsal Capsuloligamentous Repair
ADCLR
Retrieval through RMCP

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Arthroscopic Dorsal Capsuloligamentous Repair
ADCLR
Retrieval through RMCP

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Arthroscopic Dorsal Capsuloligamentous Repair
ADCLR
2nd thread through DWC and RADIAL remnant

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Arthroscopic Dorsal Capsuloligamentous Repair
ADCLR
Retrieval through the same RMCP

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Arthroscopic Dorsal Capsuloligamentous Repair
ADCLR
Knot made outside patient (Nicky’s knot)

Pulled inside MCJ by proximal traction

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Arthroscopic Dorsal Capsuloligamentous Repair
ADCLR
Second knot subcutaneous in 3,4 Portal

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Arthroscopic Dorsal Capsuloligamentous Repair
ADCLR
Second knot subcutaneous in 3,4 Portal

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Arthroscopic Dorsal Capsuloligamentous Repair
ADCLR

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Arthroscopic Dorsal Capsuloligamentous Repair
ADCLR
SL K-Wires +/- SC K-Wires only if unreductible

Without pinning!!!
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Material
• 57 patients
• 34 men

23 women

• Mean age : 38.7 yo (range 17 to 63)
• Sports injuries : 46 cases
high level : 12 cases

• Average time between injury and
surgery: 9.24 months (range 3 to 24)
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Material
EWAS Classification

Garcia-Elias’ Suggestion

• Stage 2 :

• Stage 2 : 3 cases

7 cases

• Stage 3A : 1 case

• Stage 3 : 25 cases

• Stage 3B : 16 cases

• Stage 4 : 26 cases

• Stage 3C : 18 cases

• Stage 5 :

• Stage 4 :

3 cases

16 cases

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RESULTS
Follow-up : 30.74 months (range 18 to 43)
• Pain :
Preop VAS : 6.17 Postop VAS : 0.7
Failure 2 cases (Stage 5 according Garcia-Elias)
• ROM :
normal flexion–extension in 28 cases (81,8%)
normal pronation-supination in all cases (100%)
• Strength :
Preop: 24.07 kgf

Postop: 38.42kgf

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Total functional outcomes
Flexion
Extension

Pre-op
52.45
50.62

post-op
63.55(p<0,01)
74.56 (p<0,01)

controlateral
71.43(p=0,26)
77.89 (p=0,35)

Radial deviation
Ulnar deviation
Pronation supination
Wrist strength

15.7
26.75
0-160
24.07

21.82 (p<0,01)
35.52 (p<0,01)
0-178 (p<0,02)
38.42 (p<0,01)

27.36 (p=0,48)
37.28 (p=0,27)
0-179 (p=0,16)
40.81(p=0,18)

•No problem with sporty level +++
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Results
Outcome was related to :
– Stage 5 Garcia-Elias (2/3)

Outcome was related to :
– delay surgery (better outcome if short delay)

Complications:
- Slight flexion stiffness 6 cases (range 40° to 60°)
- One Sudeck (healed)
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Results
DASH:
PreOp : Average 46.05 (range 13.64 to 90.91)
PostOp : Average 8.29 (range 0 to 40.91)
Mayo WS:
Excellent :

35 cases

Good:

18 cases

Average :

2

cases

Poor:

2

cases
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Clinical case

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Clinical case
ADCLR
Stage EWAS 4, Geissler 4, Garcia-Elias 4

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Clinical case
ADCLR
Stage EWAS 4, Geissler 4, Garcia-Elias 4

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Clinical case
ADCLR
SL pinning + Scapho-capitate pinning

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Clinical case
ADCLR
SL pinning + Scapho-capitate pinning

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Clnical case
ADCLR
SL pinning + Scapho-capitate pinning

Pre ADCLR

Post ADCLR

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Clnical case
ADCLR
SL pinning + Scapho-capitate pinning

Pre ADCLR

Post ADCLR

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Clinical case
ADCLR
SL pinning + Scapho-capitate pinning

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RESULTS
D + 2 months
Normal aspect

SLIOL unrepaired, Stability of dorsal part

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RESULTS
D + 2 months
Normal aspect

SLIOL unrepaired, Stability of dorsal part

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RESULTS
D + 9 months

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RESULTS

D + 19 months
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RESULTS

D + 19 months
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OUTSTANDING ISSUES
Is the SLIOL really useless ?

YES

What is the real importance of proprioception? Do we act on
proprioception with arthroscopic repair? YES

Does the distal volar ligamentous lesions (stt) exist?

??

Are isolated lesions of the DCSS pre-unstable lesions, or are
they another entity? YES

What is the real place of extrinsic ligaments?

SLLComplex
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Conclusion
DSL, DST, DCSS ligts seem essential in SL stability
SLLComplex: a new concept!!!!!!
Arthroscopic
capsuloligamentous
repair is a simple and reliable procedure
convenient for the patient
with chronic scapho-lunate tears,
except in stage 5 (GE)
These encouraging first results
need a longest follow-up.
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A TECHNIQUE FOR
ARTHROSCOPIC REPAIR
OF THE VOLAR S-L
LIGAMENT
Francisco del Piñal, MD, Dr Med. (*)
Hand and Plastic Surgery. Private practice.
Hand-Wrist Unit and Department of Plastic Surgery. Mutua Montañesa.

SANTANDER. SPAIN.
(*) nothing to disclose.

A TECHNIQUE FOR ALLINSIDE SUTURING IN THE
WRIST .
Francisco del Piñal
Hand and Plastic Surgery. Private practice.
Hand-Wrist Unit and Department of Plastic Surgery. Mutua Montañesa.

SANTANDER. SPAIN.
pacopinal@gmail.com

1B tear without instability

PERIPHERAL

COMPLETE

FOVEAL

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1B tear without instability

De Araujo, Poehling, Whipple. Arthroscopy .1995.

The problem…THE KNOT

DORSAL BRANCH OF THE
ULNAR NERVE

Arthoscopy 2007.

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BÖHRINGER

BADIA

GEISSLER

A TECHNIQUE FOR
ALL-INSIDE
SUTURING.

Piñal F del, et al. A technique for arthroscopic all-inside suturing in the wrist. J Hand Surg Eur 2010 ;35:475-9.

Requirements.

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TRIQUETRUM

TFC
ULNAR HEAD

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TECHNIQUE

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ALL-IN REPAIR

All-in VOLAR S-L suturing

All-in VOLAR S-L suturing

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All-in VOLAR S-L suturing

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All-in VOLAR S-L suturing

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CLOSURE SL- SPACE OF POIRIER-LT

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1 year postoper.

CLINICAL EXPERIENCE…

 8 Volar S-L Repair.
 6 Volar and Dorsal S-L Repair.
 4 Volar capsule and Ligaments repair (PLFD).

CLINICAL EXPERIENCE…

S

L

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In summary, …

Sardinero’s Beach. View from the Operating Room.

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WEBMINAR on SL lesion, 2013

Open scapholunate
ligament repair and
capsulodesis
Luchetti Riccardo
Rimini (Italy)

I

II

III

IV

V

VI

Partial injury

yes no

no

no

no

no

SL Repairable

yes yes no

no

no

no

Integrity STT lig

yes yes yes no

no

no

Reducible

yes yes yes yes no

no

Normal cartilage

yes yes yes yes yes no

Stage

Percutaneous
K-wire fixation
and/or Dorsal
capsulodesis

II

III

IV

V

VI

Partial injury

yes no

no

no

no

no

SL Repairable

yes yes no

no

no

no

Integrity STT lig

yes yes yes no

no

no

Reducible

yes yes yes yes no

no

Normal cartilage

yes yes yes yes yes no

Stage

I

Garcia Elias M

Ligament repair + Kwire fixation (+
Dorsal capsulodesis)

Garcia Elias M

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SLIL Tears
Algorithm of Treatment
• Arthroscopic Shrinkage & Pinning
• Open Repair
• Augmentation by Capsulodesis
• Reconstruction by B-L-B graft
• Reconstruction by Tenodesis

Historical Techniques

BLATT (1987)

LINSCHEID (1992)

HERBERT (1996)

Historical Techniques
• All of them crossed the radio
carpal joint

• Reduction of wrist flexion

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Dorsal ligaments
of the wrist
Dorsal Intercarpal Lig

Radio Triquetral Lig

Options

Szabo

Viegas

Berger
Cohen

Procedure
• Isolated
• Associated, with SLIL repair

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Surgical Technique

Surgical Technique
• Longitudinal skin incision
(Traditional)
• Transverse skin incision
(Short)

Traditional Technique

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Surgical Technique

Longitudinal dorsal skin incision

Surgical Technique
Capsulotomy
“Ligament splitting capsulotomy”
Berger – Bishop, 95

Surgical Technique

Step 1

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Surgical Technique

Step 2

Surgical Technique

Step 3

SL and SC pins fixation

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Present Series
•
•
•
•
•
•

2001- 2004
Cases : 18 (9 F, 9 M)
Age (mean) : 35 y.o. (15 to 57 y.o.)
Affected side : 11 L, 7 R
Type of lesion : all hyperext. but one
Time elapse from injury to surgery : 10 mo
(2 to 24 mo)
• Watson test ++ in all cases

Wrist ARS
• RC and MC ARS (18 cases)
– SL instability: 100% (Geissler type 3)

• Correlation with MRI : 87%
• Correlation with x-ray : 56%

ARS: gold standard

Type of SLIL lesion
• Partial
(stage 1) = 14
• Complete (stage 2) = 4

with SLIL tear
but still repairable

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Postop Rehab
• Spica cast immobilization for 4 weeks
– Immediate finger mobilization
– Hand edema drenage

• Rehab after first month
– Active and passive wrist mobilization

• Wrist splint protection for one month more
• Return to work after 3 months
• Sport activity after 3 months

Case # 1

• AA, f, 32 years old,
right dominant.
• Right partial SLIL tear
• MRI positive
• Watson test: positive
• MWS: 70

Case # 1

Wrist Arthroscopy
RC

• SLIL instability
type 3° according
with Geissler

MC

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Case # 1

•
•
•
•
•
•

Results

Pain: 2
Complete wrist ROM
Grip strength increased
Retur to previous work
Watson test: negative
MWS: 100

Case # 2
• CAS, f, 55 years old, right
dominant.
• Right wrist partial SLIL
tear
• X-rays: positive
• MRI: doubtful
• Watson test: positive
• MWS: 85

Case # 2

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Case # 2

Follow up at 1 month

Case # 2

F-up: 10 months
•
•
•
•
•

Pain: 0
Incomplete wrist ROM
Grip strength: 100%
MWS: 95
Return to prev. work

Clinical Results

18 cases

(F-up 15 mo)

Parameters
Pain (VAS)
Flex – Ext (°)

Preop Postop
8

5

p
<0,005

127

123

ns

24 / 75

27 / 87

<0,05 / ns

MWS (Cooney)

62

84

<0,005

MWS (Krimmer)

72

90

<0,005

DASH

38

20

ns

Grip Strength (Kg / %)

Pts didn’t require any
more surgical procedure

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Comparison with literature
AUTHORS

#

F-up

Grip
strength MWS

Pain

F/E

(months) (VAS)

(%)

(%)

Moran

31

54

83

70

73
83

Minami

17

49

87

93

Kobayashi

21

14

?

81

?

Luchetti

18

15

80

87

84

(Dorsal capsulodesis by using the DIC ligament)

Modification of the
Surgical Technique
According to the SLIL lesion
Clinical eval: Watson test +/X-ray:
no DISI def
Arthroscopy: stage 2/3

Surgical Technique

Dreant, 2009

Transversal dorsal skin incision
with ext. retinaculum preservation

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Surgical Technique

Double parallel incision with
dorsal capsule preservation

Surgical Technique
Capsulotomy
“Double parallel capsular incisiones

Surgical Technique

Ligament flap harvested from DIC

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Surgical Technique

Ligament flap passed under the
capsule ...

Surgical Technique

... and over the SL ligament ...

Surgical Technique

... and fixed to the lunate with
anchor

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Postop Rehab
• Immobilization (for 3 weeks)
• Earlier rehabilitation

Same results

… even better, related to minor SL lesion

Conclusion
• Valid surgical procedure
• Indication for stage 1 to 3 (with
SLIL repair)
• Easy technique
• Patients’ informed consent
about the risk of partial lost of
wrist flexion

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Thanks for your attention

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Results of a Modified Brunelli Procedure
for Chronic Scapholunate Instability

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1

Wrightington Hospital, UK

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2

Sir John Charnley

“Never operate on a bone that you can swallow”

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3

1

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Some things have changed

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Some things have changed

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Berger Approach

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7

Anakwe R E et al. J Hand Surg Eur Vol
2012;1753193412453414

Copyright © by The British Society
for Surgery of the Hand
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8

dorsal to volar
1.6mm K wire
2.9mm cannulated drill hole

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1/3 FCR passed along tunnel

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Emerges here

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Brunelli IV
Tri Ligament tenodesis
Stanelli

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14

15

15

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16

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Methods
162 patients with chronic SLD ‘95-02
Part 1
Postal questionnaire
VAS
Problem solve
WWS
Satisfaction
Surgery again
Compensation

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18

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Methods
162 patients with chronic SLD ‘95-02
74 Male

88 Female

Part 2
Clinical review
Grip Strength
Range of movement
Employment status

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19

Results
Part 1 Questionnaire
117 replied (72%)
Male 52
Female 65
Mean follow up 50.2 months (9-100)
Part 2 Clinical Review
55 Reviewed
Male 25
Female 30
Mean follow up 45.1 months (10-98)

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20

Wrightington Wrist Score
Hand in back pocket
Straight lift grip
Take change
Personal care
Hand to face
Use a screw driver
Do usual work
Rise from a chair

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•
•
•
•

1=no problem
2= with difficulty
3= with aid
4= unable

8
32

= best score
= worst score

21

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Wrightington Wrist Score

Worse

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VAS PAIN
VAS PAIN

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23

VAS Problem solved = 6.77
S.D. = 2.71

Completely cured

VAS Problem solved = 6.03 (sd 2.85)

Not at
all

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24

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Satisfaction
All responders
Reviewed

81%

%

19%

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25

Grip Strength = 79%

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26

Range of Motion
35˚ Loss of Flexion - Extension (26% of non operated side)
13˚ Loss of Radial - Ulnar deviation (12%)

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27

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Employment
21 (34%) of those reviewed were taking part in
heavy or light manual labour
4% unemployed

24 patients (43%) had changed their occupation
or duties

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28

Surgery again ?

88% would have the same again overall

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29

30

30

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Outcomes of Modified Brunelli
Procedure in Professional
Athletes with Scapholunate
Instability
Ashleigh Williams1, Chye Yew Ng 2, Mike Hayton

2

Presented BSSH 2012 York
1
2

University of Manchester, Manchester, UK.
Wrightington Hospital, UK.

Methods
Retrospective review
All procedures performed by senior author (MJH)
16 professional athletes who underwent a modified Brunelli
procedure between 2008 - 2011 identified from the database

Patients were emailed a
questionnaire and Fup
telephone interview

15 patients replied

11 rugby

1 motor cycling
(bilateral wrist)

2 boxing

1 golf

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32

Results
Patient demographics
Number of operations

16

Age

Mean 30 years (range 18 - 42)

Gender

All male

Dominance of hand operated on

9 dominant, 7 non dominant

Level of competition before injury

9 international, 7 national

Time to surgery after injury

Mean 30 weeks (range 2 - 78)

Follow up

Mean 24 months (range 3 - 43)

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Subjective outcome measures
Mann-Whitney U test
p value

VAS pain VAS pain
score
score at
ACTIVITY
REST
Instability

0.047

Preoperative

<0.001

<0.001

Postoperative
0.0000

2.5000

5.0000

7.5000

10.0000

VAS (Visual Analogue Score)
Error bar showing SEM (standard error of mean)

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34

Functional scores at final review
Quick DASH
7.66 SEM 2.11 (range 0-25)

Wrightington activity of daily living,
assessment for wrist function2
(8 is normal – 32 most abnormal)

9.25 SEM 0.38 (range 8-13)
2

Talwalkar SC, et al. J Hand Surgery (British and European Volume) 2006; 31: 110-117.

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35

Return to play
• 10 of 15 (67%) returned to play at their pre-injury
level of competition.
•5 of 15 (33%) returned to a lower competition
level:
- 3 directly related to the wrist injury
- 2 due to other unrelated injuries
But for other injuries 12 out of 15 (80%)
returned to playing

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Summary
Modified Brunelli procedure in professional
athletes generally
Relieves wrist pain with (p<00.1)
Appears to improve stability (not significant)
Improves functional outcome scores

But for other injuries 12 out of 15 (80%)
returned to playing

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37

Thank you

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38

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