The Scapholunate Dilemma
The evolution of techniques used in anterior cruciate ligament reconstruction in the knee over a 50-year period highlights the importance of reconstruction based on anatomical principles and understanding the biomechanical properties of the graft material. The inadequacy of extra-articular techniques became apparent, and anatomical reconstruction techniques followed. As a consequence, graft positioning became important. The free patellar tendon became the gold standard for anatomical reconstruction. The biomechanical properties of the graft material used then gained importance. A double bundle reconstruction was seen to more closely resemble an anatomical reconstruction, potentially correcting residual instability. Synthetic devices such as Dacron, Kevlar, and carbon fiber met with some initial clinical success but ultimately failed because of inappropriate initial biomechanical properties, material fatigue profiles, and material shedding.    The abraded synthetic particles collected in the joint space, lymph nodes, and other tissues and led to a chronic inflammatory response. Xenograft attempt also failed and was abandoned. Although the mechanism of failure for the bovine-based devices were mixed, poor biocompatibility attributed to excess glutaraldehyde, improper preimplantation biomechanical properties, the lack of host integration, and immunological rejection were key variables leading to poor clinical results.
In the wrist, the primary and secondary stabilizers that contribute to scapholunate (SL) stability and the kinematic consequences of sequential sectioning of these structures are well documented. Numerous techniques have been described  to address the SL injured wrist where primary repair is not possible, and the radiological measures of reconstructive success was based on the approximation of the SL interval and reestablishment of scaphoid and lunate alignment. However, static radiological realignment does not necessarily result in reestablishment of normal carpal kinematics, and the kinematic consequence of the described procedures have not been determined. It may be that the alterations to joint contact loading, particularly at the scaphoid fossa and midcarpal joint, may become a more important measure. More recently, the importance of taking into account the lessons learned from cadaveric studies have gained popularity, and reconstructive techniques that address both the primary and secondary stabilizers anatomically, including the dorsal and volar components of the SL to control the rotatory stability of the scaphoid and lunate, have been described.      
Nonetheless, the material used for reconstruction must allow the differential motion  that exists between the scaphoid and lunate. It is influenced by the biomechanical characteristics of the graft material used. The process of ligamentization is more prolonged in humans than animals, and the biomechanical characteristics of different donor tendons differ.  More importantly, the biomechanical characteristics of the donor tendon is significantly reduced at the conclusion of the maturation phase of ligamentization. Stiffness and load to failure measures quoted on graft material do not take into account the biomechanical consequences and the physiological changes that occur as a result of ligamentization. Other variables that may also influence the results of a reconstructive technique are the size of the graft used and the degree of tensioning. Reconstructive techniques that use a combination of autologous tendon, to provide a biological graft material, and a ligament substitute, for immediate biomechanical strength, go against the “law of functional adaptation,” as the ligament substitute will protect the biological graft material, preventing it from undergoing changes in its mechanical and biological properties that occur when tendon grafts are exposed to different mechanical loading in a suitable biological environment.
The purpose of this special review edition is to throw the spotlight not on the techniques used for scapholunate reconstruction, but on the graft material, as reestablishing the soft-tissue anatomy is the foundation from which normal joint kinematics, and contact pressures, can be regained, and the graft material used is an important building block.
Artikel online veröffentlicht:
01. Dezember 2021
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- 1 Chambat P, Guier C, Sonnery-Cottet B, Fayard J-M, Thaunat M. The evolution of ACL reconstruction over the last fifty years. Int Orthop 2013; 37 (02) 181-186
- 2 Bolton CW, Bruchman WC. The GORE-TEX expanded polytetrafluoroethylene prosthetic ligament. An in vitro and in vivo evaluation. Clin Orthop Relat Res 1985; (196) 202-213
- 3 Lukianov AV, Richmond JC, Barrett GR, Gillquist J. A multicenter study on the results of anterior cruciate ligament reconstruction using a Dacron ligament prosthesis in “salvage” cases. Am J Sports Med 1989; 17 (03) 380-385 , discussion 385–386
- 4 Schindhelm K, Rogers GJ, Milthorpe BK. et al. Autograft and Leeds-Keio reconstructions of the ovine anterior cruciate ligament. Clin Orthop Relat Res 1991; (267) 278-293
- 5 Weiss AB, Blazina ME, Goldstein AR, Alexander H. Ligament replacement with an absorbable copolymer carbon fiber scaffold–early clinical experience. Clin Orthop Relat Res 1985; (196) 77-85
- 6 Margevicius KJ, Claes LE, Dürselen L, Hanselmann K. Identification and distribution of synthetic ligament wear particles in sheep. J Biomed Mater Res 1996; 31 (03) 319-328
- 7 Teitge RA. Bovine xenograft reconstruction of the ACL. In: Feagin JA. ed. The Crucial Ligaments. New York, NY: Churchill Livingstone Inc; 1988: 529-534
- 8 Galili U. Interaction of the natural anti-Gal antibody with alpha-galactosyl epitopes: a major obstacle for xenotransplantation in humans. Immunol Today 1993; 14 (10) 480-482
- 9 Rajan PV, Day CS. Scapholunate interosseous ligament anatomy and biomechanics. J Hand Surg Am 2015; 40 (08) 1692-1702
- 10 Naqui Z, Khor WS, Mishra A, Lees V, Muir L. The management of chronic non-arthritic scapholunate dissociation: a systematic review. J Hand Surg Eur Vol 2018; 43 (04) 394-401
- 11 Crawford K, Owusu-Sarpong N, Day C, Iorio M. Scapholunate ligament reconstruction: a critical analysis review. JBJS Rev 2016; 4 (04) e41-e48
- 12 Short WH, Werner FW, Green JK, Masaoka S. Biomechanical evaluation of ligamentous stabilizers of the scaphoid and lunate. J Hand Surg Am 2002; 27 (06) 991-1002
- 13 Berger RA, Imeada T, Berglund L, An KN. Constraint and material properties of the subregions of the scapholunate interosseous ligament. J Hand Surg Am 1999; 24 (05) 953-962
- 14 Dunn MJ, Johnson C. Static scapholunate dissociation: a new reconstruction technique using a volar and dorsal approach in a cadaver model. J Hand Surg Am 2001; 26 (04) 749-754
- 15 Short WH, Werner FW, Sutton LG. Dynamic biomechanical evaluation of the dorsal intercarpal ligament repair for scapholunate instability. J Hand Surg Am 2009; 34 (04) 652-659
- 16 Henry M. Reconstruction of both volar and dorsal limbs of the scapholunate interosseous ligament. J Hand Surg Am 2013; 38 (08) 1625-1634
- 17 Ho PC, Wong CW, Tse WL. Arthroscopic-assisted combined dorsal and volar scapholunate ligament reconstruction with tendon graft for chronic SL instability. J Wrist Surg 2015; 4 (04) 252-263
- 18 Corella F, Del Cerro M, Ocampos M, Larrainzar-Garijo R. Arthroscopic ligamentoplasty of the dorsal and volar portions of the scapholunate ligament. J Hand Surg Am 2013; 38 (12) 2466-2477
- 19 Marcuzzi A, Leti Acciaro A, Caserta G, Landi A. Ligamentous reconstruction of scapholunate dislocation through a double dorsal and palmar approach. J Hand Surg [Br] 2006; 31 (04) 445-449
- 20 de Roo MGA, Muurling M, Dobbe JGG, Brinkhorst ME, Streekstra GJ, Strackee SD. A four-dimensional-CT study of in vivo scapholunate rotation axes: possible implications for scapholunate ligament reconstruction. J Hand Surg Eur Vol 2019; 44 (05) 479-487
- 21 Moojen TM, Snel JG, Ritt MJPF, Kauer JMG, Venema HW, Bos KE. Three-dimensional carpal kinematics in vivo. Clin Biomech (Bristol, Avon) 2002; 17 (07) 506-514
- 22 Claes S, Verdonk P, Forsyth R, Bellemans J. The “ligamentization” process in anterior cruciate ligament reconstruction: what happens to the human graft? A systematic review of the literature. Am J Sports Med 2011; 39 (11) 2476-2483
- 23 Butler DL, Grood ES, Noyes FR. et al. Mechanical properties of primate vascularized vs. nonvascularized patellar tendon grafts; changes over time. J Orthop Res 1989; 7 (01) 68-79