Published online: 2020-05-20

Scientific Article

Arthroscopic Reinsertion of Acute Injuries of the

Scapholunate Ligament Technique and Results
Vicente Carratalá, MD1 Francisco Javier Lucas, MD1 Ignacio Miranda, MD, PhD2 Alfonso Prada, MD3
Eva Guisasola, MD1 Francisco J. Miranda, MD, PhD4

1 Hand and Upper Limb Surgery Unit, Department of Orthopaedics, Address for correspondence Vicente Carratalá, MD, Unidad de Cirugía de
Hospital Quirónsalud Valencia, Valencia, Spain Mano y Miembro Superior, Hospital Quirónsalud Valencia. Av. Blasco Ibáñez
2 Department of Orthopaedics, Hospital Universitari i Polit ecnic La Fe. 14, 46010 Valencia, Spain (e-mail: vtecabaix@gmail.com).
Valencia, Spain
3 Department of Orthopaedics, Hospital General de Villalba, Madrid, Spain
4 Departamento de Fisiología, Universitat de València, Valencia, Spain

J Wrist Surg

Abstract Objective To describe a technique for treating acute injuries of the scapholunate
ligament (SLL) by performing an arthroscopic reinsertion of the SLL and dorsal
capsulodesis and to present the results obtained.

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Methods The study deals with an analytical, prospective clinical study that included 19
consecutive patients with acute injury of the SLL. The range of joint motion, grip strength,
pain according to the visual analog scale, functional outcomes according to the Mayo Wrist
Score (MWS), and the QuickDASH Score were studied preoperatively and 6 and 12 months
postoperatively. The complications and necessary reinterventions were recorded.
Results Nineteen patients with acute injury of the SLL were studied; mean age was
44  2 years, 74% males, 58% complete rupture, and 42% partial rupture, treated with
the above-mentioned technique. Thirty-seven percent also had a distal radius fracture
Keywords and there was one case of perilunate dislocation. Improvement in pain, grip strength,
► acute injury of the joint balance, and functionality was observed 6 and 12 months postoperatively, with
scapholunate 79% of the cases with good or excellent results
ligament Conclusion The arthroscopic reinsertion and dorsal capsular reinforcement of the
► scapholunate SLL, allow a reliable and stable primary repair of the dorsal aspect of the ligament in
ligament complex acute or subacute SL injuries where there is tissue that can potentially be repaired, thus
► arthroscopy achieving an anatomical repair similar to that obtained with open surgery, but without
► dorsal capsular the complications and stiffness secondary to aggressive interventions on the soft
reinforcement tissues that are inherent to the open dorsal approach.

Scapholunate ligament (SLL) injury is the lesion that most
commonly occurs in the intrinsic ligaments of the carpus,
generally as a result of falling on the outstretched hand.1
The term scapholunate (SL) dissociation refers to injuries
that go from a partial tear of the SLL to a complete injury of
this ligament, which can also include injury to the secondary
stabilizers,2 giving rise to rotatory subluxation of the scaph-
oid bone, dorsal-intercalated segment instability and, finally,
osteoarthritis of the wrist, known as scapholunate advanced
collapse (SLAC), when not treated appropriately.3
The different imaging tests used for diagnosing SL dis-
sociation, including magnetic resonance imaging and
arthrography, have a high percentage of false negatives.4,5
The gold standard for diagnosing SL injuries is wrist
arthroscopy, which also allows for in situ treatment of
the lesion.6

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Arthroscopic Reinsertion of the Scapholunate Ligament
The SLL does not function on its own; it is part of the SLL
complex formed by an intrinsic component, which is the
actual SLL with its dorsal, palmar, and proximal aspects,7 and
an extrinsic component, comprising the secondary stabil-
izers, which include the dorsal intercarpal ligaments (DIL),
dorsal radiocarpal ligaments, and the palmar radioscapho-
capitate, long radiolunate, and short radiolunate ligaments.2
The dorsal aspect of the SLL is the thickest and most
resistant and plays the most important role in SL stability,
mainly due to its attachment to the dorsal capsule.8 The
dorsal capsuloligamentous scapholunate septum (DCSS) is
also a part of the SL complex, joining the ligament to the
dorsal capsule and the DIL, and it has been demonstrated that
it plays an important role in stabilizing it.9
Both the dorsal and the palmar aspects of the SLL are
vascularized structures: the dorsal aspect is mainly supplied
through the dorsal capsuloligamentous septum and the
palmar aspect is supplied through the radioscapholunate
ligament (ligament of Testut).10 The healing potential of SL
injuries is limited, despite vascularization in these areas, and
treatment during the acute phase of the injury is crucial.5
Several arthroscopic or arthroscopy-assisted treatments
have been described for SLL injuries, but only a few are aimed
at primary repair of the ligament, especially its dorsal aspect,
which, as previously indicated, is the segment that is most
relevant for SL stability.11
Arthroscopy-assisted reduction and temporary fixation
with Kirschner wires (KW) is indicated for acute, Geissler II-
III injuries. Fixation should be maintained for a minimum of 6
to 8 weeks.6,12
This technique has given varying results. The best results
were observed in a series of patients with Geissler grade II-III
acute or subacute injuries and incomplete SL tears.13 The
results of complete SLL injuries and those of patients who
were not treated during the acute phase were considerably
worse, with satisfactory results being achieved only in 55% of
the cases.14
Garcia-Elias et al2 published a series of prognostic factors
for grading and directing treatment of SL injuries. Acute
injuries of the SLL are integrated in the three first stages, can
be one the first three, not only one; the extension of the
injury and the possibility of repairing the ligament are key
factors for directing treatment.
In cases of an acute complete rupture of the SLL (Geissler
Grade IV) with a repairable dorsal ligament, the recommended
conventional treatment is direct repair using an open dorsal
approach, with direct suture, transosseous suture, or reinser-
tion with bone anchors, sometimes in combination with
capsular reinforcement or dorsal capsulodesis.15,16 This repair
can be performed in combination with temporary fixation
with KW or with fixation placing a screw between the
scaphoid and semilunar bones, thereby allowing for earlier
recovery of movement.6 Satisfactory results have been pub-
lished with open SLL repair techniques15–17 but they are
associated with significant wrist stiffness.
In addition to damaging soft tissues and increasing fibro-
sis and joint rigidity, the dorsal wrist approach used for
treating SL injuries almost always injures the posterior
Journal of Wrist Surgery
Carratalá et al.
interosseous nerve (PIN), which is involved in the proprio-
ception of the SLL18 and can be fundamental for dynamic
stability and functional recovery. Moreover, during the ap-
proach and dorsal capsulotomy, there is also a significant
aggression on the vascular supply to the SLL, which impairs
its healing capacity. Finally, the secondary dorsal stabilizers
are also affected by this surgical approach.19
There are reports of dorsal and palmar arthroscopic
capsuloligamentous suturing techniques,20,21 but none of
these cases deal with acute primary repair of the
injured/detached ligament, and therefore do not reproduce
the repair like it could be done in open surgery.
The objective of this study was to describe an all arthro-
scopic technique for treating acute injuries of the SLL per-
forming a reinsertion of the SLL with dorsal capsulodesis and
to present the results obtained.
Materials and Methods
A prospective study was conducted including 19 consecutive
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patients with acute SLL injury who underwent arthroscopic
suturing of the SLL. The study protocol was approved by the
Ethics Committee of the Hospital Center.
Prospective follow-up of the patients was performed with
systematic collection of data preoperatively at 6 and 12 months.
Minimum follow-up was 12 months from surgery (range:
12–38 months). It was not possible to collect preoperative
data for patients with a distal radius fracture or with fracture
dislocation.
During follow-up, the range of joint motion, grip strength,
pain according to the visual analog scale (VAS), functional
outcomes according to the Mayo Wrist Score (MWS), and the
QuickDASH Score were measured, and the complications and
necessary reinterventions were recorded.
Nineteen patients were included: 11 patients with an
isolated SLL injury, seven with associated distal radius frac-
ture, and one patient with associated perilunate dislocation.
All patients had simple X-rays of the wrist and some were
submitted to a magnetic resonance scan to complete the
study and CT scan in cases of distal radius fracture. Arthros-
copy was performed in all cases to confirm the diagnosis and
treat the injury. In the seven cases that had an associated
distal radius fracture, open reduction and osteosynthesis
were performed first, followed by wrist arthroscopy.
Degenerative changes were studied using the simple X-
rays to rule out any possible old lesions. Patients showing any
kind of degenerative change or with nonacute lesions of the
SLL were excluded.
Arthroscopic Suturing of the SLL
Ideal candidates are those with a partial or complete, acute or
subacute injury (up to 2–4 weeks from the injury), with
competent secondary stabilizers, and with no chondral in-
volvement, i.e., predynamic SL instability according to the
García Elías classification,2 in which the SLL still preserves
some potential for healing and the state of the tissue permits
direct repair. This technique can be performed on acute
isolated injuries of the SLL and those associated with distal
 Arthroscopic Reinsertion of the Scapholunate Ligament
Fig. 1 Arthroscopic portals: 3 to 4, 6R, midcarpal ulnar (MCU) and
midcarpal radial (MCR).
radius fractures.22 This technique is not indicated for chronic
lesions or nonreducible instability.
The arthroscopic portals used for this technique are: 3–4, 6R,
midcarpal ulnar (MCU), and midcarpal radial (MCR; ►Fig. 1).
1. Insertion of the anchor and ligamentous suture
With the scope in the 6R portal, directing vision toward
the dorsal aspect of the carpus, using the 3–4 portal as a
working portal, a 2.2-mm Micro Corkscrew suture anchor
(Arthrex, Naples, FL) is introduced into the dorsal and proxi-
mal edge of the scaphoid or lunate bone, depending on where
the SLL has been detached (►Fig. 2) until it is completely
buried in the articular surface. Through the 3–4 portal both
bones can be accessed. This anchor needs a predrill before its
application that is done through the same 3–4 portal.
The anchor sutures ends are left in the 3–4 portal, and, using
the TFCC SutureLasso 70° (Arthrex, Naples, FL) from the 3–4
portal, we cross the remains of the SLL from dorsal to proximal,
recovering the nitinol loop through the same portal (►Fig. 2).
Using the loop, one of the sutures’ ends of the implant is passed
through the detached edge of the ligament and is pulled out
again through the 3–4 portal (►Fig. 3). Subsequently, using a
knot pusher, we tie both sutures in a sliding knot over the
implant, leaving a simple stitch through the SLL with the
sutures tied and uncut (►Fig. 3).
More than one implant may sometimes be necessary to
complete the repair of the dorsal aspect of the SLL, depending
Carratalá et al.
on the configuration of the injury. The position of the implants
in the scaphoid, the lunate, or both, will depend on the location
and characteristics of the rupture. The sutures of one implant
will then be used for the subsequent dorsal plication.
From the MCU portal, the correct alignment and stability
of the scaphoid and lunate bones are checked.
2. Dorsal capsulodesis (dorsal capsular reinforcement)
With the scope in the 6R portal, an 18G needle is intro-
duced with a Nylon suture inside through the 3–4 portal,
directing it from the proximal border of the SLL toward the
midcarpal joint, through the ligament tissue (►Fig. 4). From
the MCU portal, we check that the needle with the suture
crosses the SLL through to the midcarpal space. The Nylon
suture is pushed through the needle and recovered through
the MCR portal (►Fig. 4). As a result, one end of the Nylon
suture will enter the 3–4 portal, crossing the SLL from the
radiocarpal space through to the midcarpal joint and exiting
through the MCR portal. This Nylon suture is used to pass one
of the ends of the implant suture through to the midcarpal
space and to recover it through the MCR portal (►Fig. 4). The
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MCR suture is recovered from the 3–4 portal incision through
the space in between the dorsal capsule and the extensor
tendons (►Fig. 5). As these portals are created in the radial
edge of the extensor digitorum communis (EDC) and the
suture is recovered parallel to the tendons, the risk of
trapping the EDC tendons in the suture is very low.
3. Finalization of the capsuloligamentous suture
With the scope in the 6R portal, the implant sutures are
tied again, withdrawing traction. The closure of the dorsal
interval of the SL with the capsular plication performed by
reconstructing the dorsal capsuloligamentous union of the
SLL complex can be seen (►Fig. 5).
Consequently, a simple suture of the SL ligament over its
insertion in the scaphoid or the lunate is achieved, comple-
mented by a dorsal arthroscopic capsulodesis.
KW are used to pin the scaphoid and lunate bones and
protect the suture performed.
4. Postoperative period
After surgery, a forearm splint is placed that allows the
patient to move fingers and elbow. After 2 weeks, the stitches
are removed, maintaining the forearm splint up to 4 weeks,
when the secondary KW is removed and movable wrist brace is
placed. Four weeks postoperatively, after removing the forearm
splint, the patient starts specific rehabilitation treatment.22
Statistical Analysis
The data have been included in a database created in Micro-
soft Excel 2013. The statistical analysis was performed with
the help of the IBM SPSS program version 24. It consisted of a
descriptive analysis of the variables, calculating distribution
of frequencies for the qualitative variables and the arithmetic
mean and standard error of the mean for the quantitative
variables. Statistical comparisons were made with a one-way
ANOVA (analysis of variance) with a post-hoc Bonferroni
multiple comparison test to determine the statistically sig-
nificant differences between the means at different evalua-
tion time points. Values of p < 0.05 were considered to be
statistically significant.
Journal of Wrist Surgery
Arthroscopic Reinsertion of the Scapholunate Ligament Carratalá et al.

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Fig. 2 (A, B) View from the 6R portal. Introduce a 2.2-mm Micro Corkscrew suture anchor (Arthrex, Naples, FL) in the dorsal and proximal
margins of the scaphoid or lunate bone, depending on where the SLL has detached. (C, D) Using a TFCC SutureLasso of 70° (Arthrex, Naples, FL)
from 3 to 4, cross the remains of the SLL from dorsal to proximal, recovering the nitinol loop through the same portal. L, lunate; R, radius; SC,
scaphoid; SLL, scapholunate ligament; TFCC, triangular fibrocartilage complex.

Results
Nineteen patients with an acute injury of the SLL were
studied, treated with arthroscopic suturing of the SLL with
the above-mentioned dorsal capsulodesis procedure. The
mean age of patients was 44  2 years (range 31–57), and
74% were male. Fifty-eight percent of patients had injured
their right hand. Thirty-seven percent had an associated
distal radius fracture and one patient had associated perilu-
nate dislocation. SLL rupture was complete in 58% of the
patients, whereas 42% had a partial dorsal rupture. ►Table 1
lists the types of SLL injury according to the Geissler and
EWAS (European Wrist Arthroscopy Society) classifications.
No significant differences were observed between the
variables studied depending on the injured side.
Pain was measured with a VAS and there was a statisti-
cally significant improvement between the pre- and postop-
erative measurements, with a significant difference between
the 12-month and 6-month evaluations (►Fig. 6).
In the preoperative evaluation, patients presented with
reduced grip strength of 57.7  5.3%, with a statistically
significant improvement at 6 and 12 months, and another
statistically significant improvement between the 6th and
the 12th month. A reduction of 12.7  2.4% in strength
compared with normality was observed at 12 months; in
absolute values, grip strength improved from 13.7  1.3 kg at
the preoperative measurement to 30.8  1.1 kg (►Fig. 7a).
The absolute value of grip strength was significantly higher
(p < 0.001) in males than in females at 12 months; however,
there were no statistically significant differences between

Journal of Wrist Surgery

 Arthroscopic Reinsertion of the Scapholunate Ligament Carratalá et al.

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Fig. 3 (A, B) View from the 6R portal. Pass one of the ends of the implant suture through the rest of the SLL with the help of the nitinol loop. (C,
D) The two ends of the suture are tied with a sliding knot over the implant, leaving a simple stitch through the SLL and do not cut the tied sutures.
L, lunate; R, radius; SC, scaphoid; SLL, scapholunate ligament.

the two sexes in the reduction of grip strength compared
with normality. The preoperative range of motion showed a
statistically significant improvement with the intervention
at 6 and 12 months, and there was also a statistically
significant improvement between the 6th and 12th month
(►Fig. 8).
The functional evaluation performed using the Quick-
DASH Score (►Fig. 9) and the MWS (►Fig. 10) improved
significantly between the preoperative situation and the
evaluations at 6 and 12 months, and the improvement
between the 6th and the 12th month was also statistically
significant with the QuickDASH Score. The functional evalu-
ation measured with the MWS was significantly better
(p < 0.05) in the group of patients that did not have an
associated fracture at 6 and 12 months. The MWS evaluation
was also significantly better (p < 0.05) at 6 months in
patients who had a partial injury compared with those
who had a complete injury, and in patients with Geissler
type II lesions versus those with Geissler type IV. At
12 months, 79% of the patients presented with good or
excellent results according to the functionality scales and
10.5% had satisfactory results.
Two patients had a poor outcome and needed a second
operation. In both cases, arthroscopy-assisted ligamento-
plasty was performed for axial and dorsal reconstruction
of the SLL, described by Carratalá et al in 2016.23
No other complications were reported in the rest of the
cases.
Discussion
SL dissociation is the most common cause of acquired carpal
instability. The natural course of SL dissociation without
treatment is still unclear. What has been demonstrated by
several studies is that the treatment of acute SLL injuries
generally yields better results than treatment of chronic

Journal of Wrist Surgery

Arthroscopic Reinsertion of the Scapholunate Ligament Carratalá et al.

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Fig. 4 (A, D) View from the MCU portal. Through the 3 to 4 portal an 18G caliber needle with a nylon suture inside is introduced, aiming it from
the proximal edge of the SLL to the midcarpal joint, through the ligament’s tissue. (B, E) The nylon suture is recovered through the MCR portal.
(C, F) This nylon suture is used to pass one of the implant suture ends through to the midcarpal space to the MCR portal. MCR, midcarpal radial;
MCU, midcarpal ulnar; SLL, scapholunate ligament.

Fig. 5 (A–C) The MCR suture is recovered from the 3 to 4 portal incision through the space in between the dorsal capsule and the extensor
tendons; (D–F) With the scope in the 6R portal, the implant sutures are tied again, withdrawing the traction. The closure of the dorsal SL interval
with the capsular plication performed by reconstructing the dorsal capsuloligamentous union of the scapholunate ligament complex can be
seen. MCR, midcarpal radial; SL, scapholunate.

Journal of Wrist Surgery

 Arthroscopic Reinsertion of the Scapholunate Ligament
Table 1 Type of SLL injury according to the Geissler and the
EWAS (European Wrist Arthroscopy Society) classifications
Type of SLL injury according to the Geissler classification
Type 2
Type 3
Type 4
Type of SLL injury according the EWAS
(European Wrist Arthroscopy Society) classification.
Type 2B
Type 2C
Type 3C
Type 4
Abbreviation: SLL, scapholunate ligament.
lesions.6 The ideal time for performing a repair in the acute
phase is not well defined: the intercarpal ligaments degen-
erate rapidly in the first 2 to 6 weeks, after which primary
repair or reinsertion may be difficult, and with an often poor
result due to poor tissue quality and poor healing capacity.24
However, the difficulty of diagnosing isolated acute injuries
means that in the majority of cases, treatment is performed
when the acute phase has already passed. This handicap is
different in cases of distal radius fractures treated with
arthroscopic assistance, in which the percentage of associat-
ed injuries involving the SLL is high (16–40%)25 and an
adequate diagnosis could be made early on to proceed to a
potentially more effective treatment.
The importance of treating in the acute phase has fre-
quently been highlighted in the literature. In a series of 17
patients treated in the nonacute phase (22 weeks after the
injury), Pomerance26 published poor functional results and
only three patients were able to resume their previous
activities (17.64%), while Rohman et al27 observed a signifi-
cantly lower percentage of reinterventions in patients
treated in the acute phase (4%) compared with those treated
Fig. 6 Evaluation of pain using the visual analog scale before the
surgery (0 months) and during the postoperative course (6 and 12
months). The data are expressed as mean  SEM. Significantly dif-
ferent, p < 0.01, p < 0.001.
Carratalá et al.
in the chronic phase (18%), taking the acute phase to be the
first 6 weeks following the injury and a tendency, though not
significant, to superior radiographic results with less SL gap
and a smaller SL angle, with a lower QuickDASH score
4 compared with patients treated after 6 weeks. A study by
8 Whipple12 reported results of arthroscopic treatment of SL
dissociation via arthroscopic reduction and fixation with
7
multiple KW and also showed greater maintenance of reduc-
tion and symptom relief in the group of patients treated
within 3 months of sustaining the injury, and highlighted the
3 need for early diagnosis and treatment of acute SLL instabili-
1 ty, and a reduced healing capacity after the lesion becomes
8 chronic.
Restoration with preservation of the anatomy and func-
7
tion of the SLL after traumatic dissociation is a formidable
challenge for hand surgeons. The literature contains innu-
merable references in this respect, relating to a great variety
of surgical procedures that aim to restore the interrupted
carpal architecture. Zarkadas et al conducted a survey of
468 hand surgeons on the management of acute and
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chronic SLL instability.28 In acute cases, the procedures
that involved the tissues (97%) were favored although a
huge variety in surgical procedures was seen, with more
than 20 different procedures. However, the results pub-
lished on these techniques have been contradictory and
confusing due to the enormous variability of techniques
and there is no consensus regarding optimal management
of this condition. On the other hand, and in accordance with
the basic principle of all ligament conditions, acute injury
with direct repair of the SLL offers optimal conditions for a
favorable result. Early surgery, preferably within the first
3 weeks following the injury, is fundamental for achieving
the best possible recovery.29
The preferred open surgery method for treating acute
injuries is direct repair of the ligament using bone anchors or
transosseous tunnels, sometimes in combination with dorsal
capsulodesis and fixation with KW.30 In the survey by
Zarkadas et al28 more than two-thirds of the interviewees
preferred direct repair with (44%) or without (33%) associat-
ed dorsal capsulodesis. However, the arthroscopic techni-
ques described to date for acute injuries did not reproduce
the open surgery treatment and in many cases were limited
to arthroscopic reduction and fixation with KW.11 After
publication of their studies, Mathoulin et al20 demonstrated
that arthroscopy-guided dorsal capsuloplasty gave promis-
ing results in the short-term with regards to improving pain,
mobility of the wrist, strength, and reduction in the SL angle.
With the development of arthroscopy techniques, it is now
possible to perform a treatment similar to that described for
open surgery, with reinsertion of the dorsal portion of the SL
ligament and to add dorsal capsular reinforcement over the
repair performed,22 thereby reproducing DCSS described as
an important element in SL stability.31
Acute injuries of the SLL usually fall into García Elías type
II category,2 a complete tear with a repairable dorsal liga-
ment and good carpal alignment. Moreover, the injury occurs
more frequently at the insertion on the scaphoid, in approxi-
mately 40% of the cases.32
Journal of Wrist Surgery
Arthroscopic Reinsertion of the Scapholunate Ligament
Fig. 7 Evaluation of grip strength before the surgery (0 months) and during the postoperative course (6 and 12 months). The results are
expressed as absolute values (A) and as a reduction in percentage compared with normality (B). Significantly different, p < 0.01, p < 0.001.
Fig. 8 Evaluation of range of joint motion (in degrees) before the
surgery (0 months) and during the postoperative course (6 and 12
months). Significantly different, p < 0.01, p < 0.001.
Fig. 9 Results of the functional evaluation with the QuickDASH Score
before the surgery (0 months) and during the postoperative course (6
and 12 months). Significantly different, p < 0.01, p < 0.001.
Journal of Wrist Surgery
Carratalá et al.
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Fig. 10 Results of the functional evaluation with the Mayo Wrist
Score before the surgery (0 months) and during the postoperative
course (6 and 12 months). Significantly different, p < 0.001.
The results published on SL reinsertion using open surgery
have been satisfactory in regard to SL stability when the
treatment was performed in the acute phase of the le-
sion.26,33–35 However, the treatment has been linked to greater
joint stiffness and restricted motion due to the surgical
approach, scarring, and association of dorsal capsulodesis.33,34
Bickert et al33 published the results of 12 patients with
acute injury of the SLL treated with open repair, a mean of
40 days after the injury and with a follow-up of 19 months.
They obtained eight good or excellent results (66.6%), two
satisfactory results, and two poor results. Motion was reduced
to 78%, and grip strength to 81% compared with the contralat-
eral hand. Rosati et al34 published the results of a series of 18
patients treated in the acute phase with open SL reinsertion,
with a mean follow-up of 32 months (9–68). They obtained
excellent results in 13 cases (72.22%), good results in three
cases (16.66%), and poor results in two cases (11.11%).
The reduction in the range of joint motion also appeared
in the results of Minami et al,35 in a series of 17 patients in
whom direct repair and Blatt capsulodesis were performed,
 Arthroscopic Reinsertion of the Scapholunate Ligament
with 70% flexion motion and 87% extension motion. The
radiographic results were good in patients treated during the
acute phase and poor in the three patients treated at a later
stage. The reduction in the range of joint motion was also
reported by Szabo15 as one of the main points against open
repair due to the scarring and rigidity caused by the dorsal
approach, with a reduction of almost 20% in range of joint
motion compared with the contralateral side.
In our study, the percentage of good or excellent results was
high at almost 79% of patients (six excellent and nine good). It
was superior to most of the published results. Analyzing the
results, it is clear that the reduction in range of motion is
markedly lower than that published in the above-mentioned
papers, with a mean loss of only 10 degrees (0 to 20degrees)
compared with the contralateral wrist, probably due to the
lower degree of soft tissue aggression, less scar tissue, and the
fact that the dorsal reinforcement performed is much more
selective and limited in space than that performed using open
capsulodesis techniques.
Fig. 11 Clinical case. (A, B) Perilunate dislocation; (C, D) X-ray result after arthroscopic reduction and scapholunate suture. (E, F) X-ray results
after 12 months of follow-up.
Carratalá et al.
In our series, the cases that required a second surgery due to
a poor outcome with the initial suture and symptomatic
instability of the carpus corresponded to patients who were
treated at a later stage, 31 and 48 days after onset of the injury,
probably related to loss of healing capacity after the first week,
whereby we believe that treatment of acute injuries in the first
2 to 3 weeks22 gives good results with regard to pain, grip
strength, motion, and functional outcomes (►Fig. 11).
Arthroscopic repair of the SLL with dorsal capsular rein-
forcement has the advantage of avoiding the above-mentioned
aggressions of the soft tissues and makes possible to perform
reliable and stable primary repair of the dorsal aspect of the
ligament in cases of acute or subacute SL injury where there is
tissue which can potentially be repaired. The use of 3–4, 6R,
MCU and MCR arthroscopic portals avoids injuring the PIN,
minimizes damage to the dorsal vascularization of the SLL
complex and avoids injury of secondary stabilizers. All of this
can help the ligament to heal after primary repair and to
recover motion and function of the wrist. The use of bone
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Journal of Wrist Surgery
Arthroscopic Reinsertion of the Scapholunate Ligament
anchors for repair and their placement on the border of the
injury provides greater resistance to the suture and reinser-
tion. The association of a plication or dorsal capsular reinforce-
ment, reconstructing the dorsal capsuloligamentous union,
increases resistance and stability of the SL.
Conclusion
The arthroscopic technique for repair/reattachment of the
SLL with dorsal capsular reinforcement, allows a reliable and
stable primary repair of the dorsal aspect of the ligament in
acute or subacute SL injuries where there is tissue that can
potentially be repaired, thus achieving an anatomical repair
similar to that obtained with open surgery, but without the
complications and stiffness secondary to the injury of the
soft tissues which is inherent to the open dorsal approach.
Note
This study was performed in Unidad de Cirugía de Mano y
Miembro Superior. Hospital Quirónsalud Valencia. Valencia,
Spain.
Ethical Approval
This study was approved by the Ethics Committee of the
Hospital Quirónsalud Valencia.
Funding
None.
Conflict of Interest
None declared.
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