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Tratamiento del SLAC Wrist

Christian Dumontier, MD, PhD
Presentation is available at www.diuchirurgiemain.org

Treatment of SLAC
Arthritis

Treatment 1

Options

SLAC 1

Radial styloidectomy

PRC, 4 corner-Fusion,
Arthroscopic
debridement

SLAC 2

PRC - 4 corner fusion

Capitolunate fusion,
CLH arthrodesis, Wrist
denervation

SLAC 3

4 corner Fusion

Arthrodesis, wrist
denervation, Total wrist
arthroplasty

Watson HK, Ballet FL. The SLAC wrist: Scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg
1984;9A(3):358-365.

However
What is simple is always false.
But what is not is not usable
(Paul Valery, Poet, 1871-1945)
You can develop the simple,
only after a deep study of the
complexity (Gaston Bachelard,
Philosophe of sciences,
1884-1962)

(some) Problems we share
1. Does SLAC wrist means scapholunate
ligament injuries ?
2. Is SLAC wrist the natural evolution of
a scapholunate injury ?
3. Which imaging techniques do we need
to make a correct staging ?
4. Which technique for which stage ?

1

SLAC wrist is not synonymous of SLIOL injury

A SLAC wrist is frequently
noticed (26%) in calcium
pyrophosphate dehydrate
crystal deposition
(pseudogout)
Rheumatoid arthritis,
neurological diseases,
β2microglobulins,…

Chen C et al. Scapholunate advanced collapse: a common wrist abnormality in calcium
pyrophosphate dihydrate crystal deposition disease. Radiology 1990;177:459–461.

1

SLAC wrist is not synonymous of SLIOL injury

Some patients present with bilateral SLAC
wrist
➡ of radiolunate motion (?)
7000 B.C.

Oversuse injury ?

Pollock et al. SLAC wrist in the absence of recognised trauma and CPPD. Hand Surg 2010; 15(3):
193-201.
Gharbaoui IS et al. Chronic asymptomatic contralateral wrist scapholunate dissociation. Plast Reconstr
Surg 2005;116:1672–1678.
Masmejean E et al. Bilateral SLAC Wrist : une lésion inhabituelle. A propos d’un cas préhistorique vieux
de 7000 ans. Ann Chir Main Memb Super 1997; 16(3): 207-14.

2

Is SLAC wrist the evolution of
scapholunate ligament injury ?
Over 4000 wrist radiographs, Watson
identified 210 cases of wrist arthritis
57% were characteristics of what he
described as a SLAC wrist
Unifying theory of scapholunate ligament
incompetence to explain the initial
arthritic wear:
Radioscaphoid junction (stages I and
II),
Then progresses to involve the
midcarpal joint (stage III)
But spares the radiolunate articulation.

2

SLAC 1
Limited
degenerative
arthritis between
the radial styloid
and the scaphoid
Distal pole ?

Watson, 1984

2

SLAC 1

Scaphoid goes into
flexion
Arthritis between
proximal pole and
radial styloid ?

2

SLAC 2
Arthritis between the
whole scaphoid and
radial fossa
Cartilage of the
radiolunate joint and
head of the capitate are
« intact »

2

SLAC 3
Capitatum penetrates
in the scapholunate
interval ➜ arthritis
between capitate,
medial side of the
scaphoid and distal
surface of the lunate
Radiolunate joint is
spared

2

The radiolunate joint is preserved
Even in DISI deformity,
the radiolunate
surfaces are congruent
➡ Motion of the lunate
that protect from
degeneration
However DISI deformity
is probably an
aggravating factor

Lane LB et al. Scapholunate dissociation with radiolunate arthritis without radioscaphoid arthritis. J Hand Surg Am 2010; 35(7):
1075-81.
Werner FW et al. Changes in patterns of scaphoid and lunate motion during functional arcs of wrist motion induced by
ligament division. J Hand Surg 2005; 30A: 1156-60

2

Natural history ?
Mostly unknown +++
1974

Asymptomatic cases
Age at presentation (63 years old)
11 cases with proven LSIOL injury
with 7 years FU found no
degenerative progression (no DISI)
Fassler PR et al. Asymptomatic SLAC wrist: does it exist? J Hand Surg 1993;18A:682–686.
Laulan J. Désaxation scapholunaire : physiopathologie et orientations thérapeutiques. Chirurgie de la main 2009 ; 28 : 192-206.
O’Meeghan et al. The natural history of an untreated isolated scapholunate interosseus ligament injury. J Hand Surg Br 2003; 28(4):
307-10.

2

Stage 4 ?
Global wrist arthritis
(Trumble 2000)
Evolution of a stage
3 ?

2

Is there any role for the
anatomical variations ?

Slope of the
lunotriquetral joint ?
(Kuhlmann 1997)
Type of Lunate ?
(Viegas, 1990)

1

2

3

Imaging techniques
X-rays
Localization of
degenerative arthritis
DISI deformity

?
?

Contralateral wrist ++
Do we need other
techniques ?
Lane LB et al. Scapholunate dissociation with radio- lunate arthritis without radioscaphoid
arthritis. J Hand Surg Am 2010 Jul; 35(7): 1075-81.

3

Arthro CT or ArthroMRI
Moser found ArthroCT to be
superior
Feydy found arthroMRI to be
superior
Arthroscopy is probably useful as
correlation with MRI is low (kappa
0,38)

Feydy A et al. Osteoarthritis of the wrist and hand, and spine. Radiol Clin North Am 2009 Jul; 47(4): 723-59.
Moser T et al. Wrist ligament tears: evaluation of MRI and combined MDCTand MR arthrography. AJR 2007;
188: 1278-86.
Mutimer J et al. Comparison of MRI and wrist arthroscopy for assessment of wrist cartilage. J Hand Surg Eur
Vol 2008 Jun; 33(3): 380-2.

4

Treatment
Non surgical modalities (i.e. splint, NSAID drugs,
steroid injections) may be used
No series available but should probably start with
Surgery is only palliative
Not a single technique has no complications
If conservative treatment fails, then SLAC staging
may help to decide which treatment to choose

4

SLAC 1
Limited area of degenerative
arthritis
Limited resection of that zone
i.e. radial styloidectomy ?
Vertical, no more than 3-4 mm
Barnard L, Stubbins SG. Styloidectomy of the radius in the surgical treatment
of non-union of the carpal navicular. J Bone Joint Surg 1947 ; 29 : 98–102.
Nakamura T et al.. Radial styloidectomy: a biomechanical study on stability
of the wrist joint. J Hand Surg Am 2001 Jan; 26(1): 85-93.
Siegel DB, Gelberman RH. Radial styloidectomy: an anatomical study with
special reference to radio- carpal ligamentous morphology. J Hand Surg [Am]
1991 ; 16A : 40–4.

4

SLAC 1

Open or arthroscopic surgery

4

SLAC 1
One series, 12 cases (4 SLAC),
good results at 21 months FU
For low demand and older
patients with good preserved
mobility ?

Day 4 postop
Case C. Mathoulin

4

SLAC 2
Arthroscopic resection of

Radio-scaphoid
joint is destroyed
Head of capitate
and radiolunate
joint are OK

the radio-scaphoid joint

Proximal row
resection
Partial wrist fusion
Wrist denervation

4

Arthroscopic resection
Non logical according to Cobb his promotor
Mean articular width resection 14 mm (9-20mm)
14 out of 17 patients, reviewed at 2 years FU
Less painful: From 6,6 to 1, 3 (older get better)
More functional: DASH decreases from 66 to 28
Keep functional wrist
8 patients presented ulnar wrist translation (average 6 mm)
and 7 had midcarpal joint decreasing.
3 failures (21%) (Lunatum type I and DISI deformity)

Cobb TK. Arthroscopic Resection Arthroplasty of the Radial Column for SLAC
Wrist. J Wrist Surg. 2014 ; 3(2) : 114-22

4

PRC
Idea is that the proximal aspect of
the capitatum has a similar shape to
the lunatum
A shortening of the wrist may improve
the range of motion and ➚
translation of the capitatum under the
radius explains the good mobility
observed
➚ loads over the head of the
capitatum (from 1,3 Mpa to 5 Mpa) on
a reduced area (25%) ☞ radiological
arthritis

4

Proximal row carpectomy
Volar or dorsal approach (longitudinal,
transverse,…)
Capsular opening can be longitudinal, Z,
Berger,…)
En bloc excision or fragmentation
Complete or partiel excision of the scaphoid
+/- radial styloidectomy
Early mobilization vs immobilization

Technique seems to have little influence.
No comparative studies

4

Results of PRC (2-20 years FU)

Flexion-extension:
≈ 70°-80°
Frontal inclination:
≈ 30°
Strength: ≈ 65-80%
RTW: ≈ 65-80%

4

PRC
Radiological « deterioration » of the
head of the capitatum and the radiocapitatum joint
No clinical modification with time (>
10 years FU)
Survival rate was 65% at 20 years
FU
10-25% complications

Wall LB et al. Proximal row carpectomy: minimum 20-year follow-up. J Hand Surg Am.
2013 Aug;38(8):1498-504.

4

4 corner fusion
Most used
technique
Many variations
(approach, device,..)
Seems to have little
influence

4

4 corner fusion: clinical results

Flexion-extension:
≈ 60°-80°
Frontal inclination:
≈ 30°
Strength: ≈ 65-80%
RTW: ≈ 65-80%

Meta-analyses: Siegel, 1996; Larsen, 1997; Shin, 2001

4

4 corner fusion: technical points

A debate exists whether or not
correct the lunate position to
avoid impingement (the shape
of the head of the capitatum
is part of the decision)
Seems to have no influence in
a range of 20° around neutral
Wyrick et al. Motion-preserving procedures in the treatment of scapholunate advanced collapse wrist: proximal row
carpectomy versus four-corner arthrodesis. J Hand Surg 1995; 20A:965–970.
De Carli P et al. Four-corner arthrodesis: influence of the position of the lunate on postoperative wrist motion: a
cadaveric study. J Hand Surg 2007;32A:1356 –1362.

4

4 corner fusion: complication rate 10-20%

Non-union: ≈ 5-10%
Total arthrodesis: ≈
7% (persisting pain)

Neubrech F et al. Long-term results after midcarpal
arthrodesis. J Wrist Surg. 2012 Nov;1(2):123-8. (almost
600 cases)

4

Variations of partial arthrodeses
Three corners fusion:
between lunatum,
capitatum and
hamatum, with excision
of the scaphoid and
triquetrum
Capitolunate fusion,
with scaphoid excision
w/wo triquetrum
excision

To date, no argument exists to favor one of these modifications

4

Can we compare PRC and 4 corner ?
Saffar (1992): Az > PRC
Wyrick (1992): PRC > Az
Tomaino (1994): Az > PRC
Krakauer (1994): Az > PRC
Cohen (2001): No difference
Baumeister (2005): No difference
Dacho (2008): No difference, favor PRC
Mulford (2009): PRC > Az (systematic review)

No
prospective,
comparative
study
PRC is
favored at
the moment

Kiefhaber (2011): PRC > Az
Graham B, Detsky AS. The application of decision analysis to the surgical treatment of
early osteoarthritis of the wrist. J Bone Joint Surg 2001;83B:650 – 654.

4

SLAC 3
Deterioration of the cartilage
of the head of the capitatum
Considered a contraindication
to PRC
4 corner is the recommended
treatment

PRC has been performed in
small series with cartilage
or capsular interposition

4

SLAC 3+ / 4
Wrist arthrodesis
Wrist denervation
Wrist replacement
Anecdotical

Wrist arthrodesis for
post-traumatic cases
Age

n

Technique

FU
Painless Strength Satisfaction Nonunion
re(months)
operation

Gaisne
1991

43

36 Iliac graft
Mannerfelt

48

22%

58%

3

0

Field
1996

46

20 AO plates

24

50%

74%

0

20%

Sauerbier
2000

48

60 AO Plates

37

5%

50%

8%

8%

De Smet
2003

42

36 Iliac graft,
AO plates

84

17%

63%

5%

58%

Adey
2005

58

22 AO Plates

72

18%

79%

0

0

80%

84%

TWA

Few cases and
limited FU
Levadoux and Legré, 28 cases

Wrist denervation
Rothe (2006): 46 patients (10 SLAC,
36 SNAC), age 47 years, 32 reviewed
at 6,3 yrs
32% painless, 9% (effort), 19%
(still painful). 19/32 improved
Minimal loss of motion (72%
flexion/ext and 67% frontal
inclination compared to other
side)
Improved strength (70% of
normal)
DASH: 17,1
G van de Pol, J Hand Surg, 2006;31A:28–34

Wrist denervation (whatever
the cause)

Conclusion: My treatment of SLAC is
Arthritis

Treatment 1

SLAC 1

Arthroscopic radial styloidectomy

SLAC 2

PRC > 4 corner fusion

SLAC 3

4 corner Fusion

SLAC 4

Wrist denervation,
Total wrist arthroplasty >
arthrodesis