Arthroscopic Suture Anchor Scapholunate Capsulodesis

Abstract

Background A retrospective review was performed of 15 adult patients who underwent arthroscopic suture anchor scapholunate capsuloligamentous repair between 2021 and 2023.

Materials and Methods There were 12 male and 3 female patients, with a mean age of 44.9 years. Eight patients had European Wrist Arthroscopy Society (EWAS) II (Geissler II), four patients had EWAS IIIC (Geissler III), and three patients had EWAS IV (Geissler IV). After a follow-up of 12 months (12–26), the mean grip strength significantly improved by 131% compared with presurgery. There was a significant improvement in the visual analog scale score from 6 to 1.2, the Mayo Wrist Score from 43.5 to 86.5, and the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire score from 65.9 to 6.5. Two EWAS IV patients had recurrent symptomatic scapholunate diastasis requiring scapholunate ligamentoplasty.

Conclusion The arthroscopic dorsal scapholunate capsuloligamentous repair with suture anchors is a reliable and safe technique with minimal complications. It is recommended for reducible acute or chronic injury to the scapholunate ligament complex with suspected avulsion injury.

Level of Evidence Level IV

 

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Keywords

wrist - arthroscopy - scapholunate interosseous ligament - arthroscopic suture anchor - scapholunate capsulodesis

Injuries to the scapholunate interosseous ligament (SLIL) are among the most common wrist injuries caused by high-energy trauma or falls on an outstretched hand. Failure to recognize and repair the SLIL injury may lead to functional impairment and posttraumatic arthritis, so-called scapholunate (SL) advanced collapse.[1]

Arthroscopy is a valuable tool in diagnosing and treating SL dissociation. Several classifications have been proposed, such as the Garcia-Elias, Geissler, and European Wrist Arthroscopy Society (EWAS) classifications, to assist in assessing the severity of SLIL tears and treating them surgically.[2] [3] [4] Wolfe and Kakar proposed the acronym “SCARCE” when considering the management of intrinsic carpal ligament injuries that looks at the degree of injury of the Secondary stabilizers, the Cartilage status, Alignment of the carpus, Reducibility of the carpus, Chronicity of injury, and Extent of SLIL injury.[5] Complete rupture of the SLIL with well-aligned or reducible scaphoid may be treated with various forms of capsulodesis, SLIL repairs, and reconstructions. The types of repairs vary from simple SL pinning,[6] open direct SLIL repair[7] to open[8] [9] and arthroscopic capsulodesis.[10] [11]

Bone anchors have been described for SLIL repairs when there is avulsion of the SLIL, usually from the scaphoid, and most of the repairs were described in an open manner.[12] [13] [14] Open repairs generally require extensive soft tissue dissection, potentially damaging the dorsal vascular supply of the carpus[15] and proprioceptive innervation of the posterior interosseous nerve (PIN).[16] Recently, an all-arthroscopic SLIL repair using suture anchors with dorsal capsule scapholunate septum (DCSS) plication has been described by Carratalá et al, avoiding some of the complications associated with open repair.[17] [18]

We describe a technique of an arthroscopic dorsal SL capsuloligamentous repair procedure with suture anchors that permit repair of this ligament when it is avulsed off the scaphoid or lunate or when the ligament cannot be primarily repaired in a series of patients.

Materials and Methods

After seeking ethics committee approval, all patients who underwent arthroscopic dorsal SL capsuloligamentous repair with suture anchors were retrospectively reviewed between 2021 and 2023 with systematic collection of data preoperatively and at 6 and 12 months after surgery.

The inclusion criteria were patients with symptomatic reducible SLIL injury (Garcia-Elias stages IV and V).[2] Patients with chronic, nonreducible SLIL injury or degenerative changes were excluded from this study. Preoperative patient-reported outcomes scores including visual analog scale (VAS) for pain where a score of 0 indicates no pain and 10 indicates the worst pain imaginable, Mayo Wrist Score (MWS),[19] and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH)[20] were recorded preoperatively and at 6 and 12 months postoperatively. Active range of motion (AROM) and grip strength were also measured during clinic follow-up. Complications and secondary interventions were recorded.

A total of 15 patients (12 right hand and 3 left hand dominant) were included in this study and were followed for at least 1 year after surgery. There were 12 male and 3 female patients with a mean age of 44.9 years (31–61 years) in this series. A total of 10 patients (67%) were injured on the right wrist and 5 (33%) on the left wrist. The mean time of wrist injury to surgery was 14 weeks (range, 6–22 weeks). All patients had standard preoperative wrist radiographs with scaphoid and stress views and magnetic resonance imaging (MRI). Radiographs that revealed degenerative changes were excluded from this study. The SL angle and the degree of dorsal intercalated segment instability (DISI) deformity were determined through the true lateral projection wrist radiograph.[21] None out of 15 patients had an SL diastasis of more than 3 mm on wrist posterior–anterior (PA) radiographs. SL diastasis was measured as the distance between the midpoints of the scaphoid and lunate at the SL interval on a standard PA wrist radiograph. None of the 15 patients had an SL angle of more than 60 degrees, indicating there was no DISI deformity.

 

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Statistical Analysis

Statistical analysis using the paired two-tailed t-test, assuming equal variance, was performed using Microsoft Excel version 16.74 with statistical significance set at a p-value < 0.05. The statistical analysis was performed with the help of the IBM SPSS program version 24.

 

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Surgical Technique

Indications and Contraindications

This technique is indicated in symptomatic, nonarthritic patients with reducible, partial, or complete acute and chronic dorsal SLIL tears (EWAS stages IIB, IIC, IIIB, IIIC, and IV) and Garcia-Elias stages II to V.[2] Contraindications to this procedure include irreducible carpal malalignment, posttraumatic arthritis, and ulnar translocation of the lunate.

 

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Patient Preparation

The arm is placed on a standard wrist traction tower, and longitudinal traction is applied through the index through small fingers.

Standard wrist arthroscopy portals are used: 3–4, 6R, midcarpal ulnar (MCU), and midcarpal radial (MCR). We prefer to use dry arthroscopy with intermittent irrigation for our procedure.[22]

 

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Arthroscopic Assessment of SLIL Injury

We begin our assessment with 3–4 portal as our visualization portal and 6R as our working portal. Both portals may be used interchangeably. We evaluate the radiocarpal (RC) joint for the integrity of the membranous and dorsal SLIL, the DCSS, and the condition of the articular cartilage at the scaphoid and lunate fossa, as well as the integrity of radioscaphocapitate, long radiolunate, short radiolunate, and ulnocarpal ligaments as well as the triangular fibrocartilage complex (TFCC). The 3–4 view may reveal a step-off at the SL joint, indicating SLIL injury. The camera is then placed into the 6R portal for visualization. Using the arthroscopic probe through the 3–4 portal, one may assess the integrity of the DCSS. The location of the dorsal SLIL tear, such as the avulsion of the SLIL (from the scaphoid or lunate bone) or midsubstance tear, may also be visualized through the 6R portal.

Attention is then turned to the midcarpal (MC) joint, where the MCU and MCR portals are created. Using the MCU portal for visualization and the MCR portal for instrumentation, the stability of the SL joint is assessed. Using the arthroscopic probe, the location of the SLIL injury (volar, membranous, dorsal, or complete), cartilage status, the reducibility of the carpus, and other symptomatic pathologies are assessed.

 

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Preparation of Anchor Placement

After performing an arthroscopic synovectomy and debridement of the torn SLIL and scar using an arthroscopic shaver through the MCR portal, we ensure that the SL joint is reducible. In addition, attention is paid to see if the dorsal intercarpal (DIC) ligament is attached to the lunate, as in more advanced cases of SL joint instability, a bare area of the dorsal lunate, indicating a DIC ligament detachment, may be seen.

 

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Suture Anchor Placement

Using the MCU as a viewing portal, a Kirschner wire from the 2.2 mm micro corkscrew anchor system (Arthrex, Naples, FL) is placed within the dorsal aspect of the scaphoid under oscillate mode to prevent soft tissue entanglement or through a cannula. The anchor is placed into the scaphoid ([Figs. 1] [2] [3]). Once the anchor is seated, the two sutures with needles are left outside the MCR portal. Using the same MCR portal, the procedure is repeated, placing an anchor within the dorsal aspect of the lunate ([Fig. 4]). One suture from each anchor is tied outside the skin to secure the knot. The two free ends of the sutures are pulled, delivering the knot inside the MCR portal onto the dorsal aspect of the SL joint ([Fig. 5]).

Fig. 1 Arthroscope placed within the ulnar midcarpal portal and cannula in the radial midcarpal portal allowing access the scapholunate joint.

Fig. 2 Anchor placed into the dorsal aspect of the scaphoid.

Fig. 3 Suture tails from the anchor placed within the scaphoid. The cannula is moved ulnarly to allow another anchor to be placed within the lunate.

Fig. 4 Suture anchor placed within the lunate. It is important for both anchors to be placed within the scaphoid and lunate via the cannula to prevent a soft tissue bridge between sutures.

Fig. 5 A double-loaded suture anchor is placed within the scaphoid and lunate. One needle from each anchor is cut off the suture (A) to allow these sutures to be tied together and delivered within the scapholunate joint via the radial midcarpal portal (B, C).

 

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Arthroscopic Dorsal Capsuloligamentous Repair (DIC/DCSS)

Attention is then turned to the RC joint, with the 6R portal as the viewing portal. Similar to the technique described by Mathoulin et al and Kakar and Kalapos, an 18-gauge needle with a nylon loop suture or nitinol loop inside it as a suture lasso is introduced through the 3–4 portal.[11] [23] The needle is directed distally through the capsule from the dorsal proximal edge at the SLIL stump (scaphoid side, if present) toward the MC joint. Through the 3–4 portal, the procedure is repeated with a second needle through the dorsal capsule and lunate SLIL stump, if present, into the MC joint.

The camera is then placed back into the MCU portal. One should be able to visualize the two needles within the MC joint. The suture lassos are retrieved and externalized through the MCR portal using an arthroscopic grasper. The needles are removed. The two remaining sutures (from the suture anchor) are placed within each suture lasso separately. The suture lasso is used to shuttle the sutures out of the 3–4 portal. The proximal free ends of the suture are then pulled proximally, allowing the distal knotted suture to be seated between the scaphoid and lunate bone within the MC joint. Alternatively, the surgeon can perform the above steps of needle passage with the suture lasso through the dorsal capsule from the RC to the MC joints sequentially as opposed to concurrently ([Fig. 6]).

Fig. 6 For the arthroscopic dorsal capsuloligamentous repair (DIC/DCSS), the arthroscope is placed within the 6R portal and a needle is placed through the capsule via the 3–4 radiocarpal portal into the midcarpal joint (A). A wire loop is placed through this needle and grasped outside the radial midcarpal portal (B) to shuttle the free suture that is within the anchor placed within the scaphoid back out through the 3–4 radiocarpal portal (C). The needle is then placed through the capsule on the ulnar side of the 3–4 radiocarpal portal (D) and the steps repeated to ensure both free ends of the suture are delivered through the 3–4 radiocarpal portal (E, F).

By visualizing the SL joint through the MCU portal, we can observe the reduction of the SL joint at this point as the free ends of the sutures are pulled proximally. Once the reduction is deemed satisfactory, traction is released, and the proximal suture is tied onto the dorsal capsule with the wrist slightly extended ([Fig. 7]). Care is taken to ensure the extensor tendons are free from suture entanglement. If the reduction is unsatisfactory, SL or scaphocapitate pinning may be necessary before tying the final knot.

Fig. 7 The wrist is taken out of traction and the free ends of suture tied down onto the capsule ensuring the extensors tendon are retracted out of the way.

 

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Mini-open Dorsal Capsuloligamentous Repair (DIC/DCSS)

Alternatively, the dorsal capsuloligamentous repair can be performed in a mini-open manner once the anchors have been placed within the scaphoid and lunate and the two free ends of the sutures tied and delivered within the SL joint. The 3–4 and MCR skin incisions can be connected, and the extensor tendons retracted. The needle from each end of the suture can then be passed sequentially through the dorsal radiocarpal (DRC)/DIC ligament and tied down to complete the capsulodesis ([Fig. 8]).

Fig. 8 For the mini-open dorsal capsuloligamentous repair (DIC/DCSS), the skin incisions between the 3–4 radiocarpal and radial midcarpal portal can be connected (A). With the extensor tendons retracted out of the way, the free needle from each remaining suture is passed through the dorsal capsule containing the DIC and DCSS (B, C) and tied down, once the wrist traction has been released ([Fig. 7]).

If the patient has concomitant volar SLIL injury, this will be addressed simultaneously.[10] [24]

 

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Postoperative Care

The patient is placed into a volar resting splint for 2 weeks and, once the sutures are removed, placed into a short arm cast for an additional 2 to 4 weeks. After 6 weeks, patients begin supervised rehabilitation with a hand therapist, working on dart throwers motion, extensor carpi radialis and flexor carpi radialis strengthening, and wrist proprioception. If Kirschner wires are placed to splint the SL joint, they are removed after 6 to 8 weeks, and rehabilitation starts immediately after removal.

 

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Results

All patients presented with dorsal central wrist pain following a fall of an outstretched hand with a degree of twisting mechanism. The preoperative mean VAS score was 6 (4–8), with dorsal SL tenderness in all patients. All 15 patients had positive scaphoid shift test for instability and pain.[1] Intraoperative arthroscopic assessment was performed in all patients prior to the SLIL repair. Seven patients had an isolated SL injury and eight had a concomitant distal radius fracture, for which the SL injury was addressed after the fracture had been treated. Eight patients had EWAS stage II (Geissler II) for SLIL injury (four with IIB and four with IIC), four with EWAS IIIC (Geissler III), and three with EWAS IV (Geissler IV) ([Table 1]). All patients underwent arthroscopic dorsal suture anchor capsulodesis ([Fig. 9]) and those with concomitant palmar SL instability (EWAS IIC, IIIC, IV) underwent arthroscopic volar repair.[10] [24]

Fig. 9 PA and lateral radiographs showing anchor placement within the scaphoid and lunate.

Table 1 Type of SLIL injury according to the Geissler and EWAS classification

Type of SLIL according to the Geissler classification
Type II	8
Type III	4
Type IV	3
Type of SLIL injury according to the EWAS classification
Type IIB	4
Type IIC	4
Type IIIC	4
Type IV	3

Abbreviations: EWAS, European Wrist Arthroscopy Society; SLIL, scapholunate interosseous ligament.

Two out of three patients with EWAS IV (Geissler IV) experienced a recurrence of symptoms and SL diastasis at a mean of 6 months after surgery. A secondary SL ligamentoplasty was performed successfully in both cases. Four out of 15 patients had concomitant TFCC injury, which did not require repair.

Preoperative and postoperative clinical and patient-reported outcome measures are reported in [Table 2]. Compared with preoperative measurements, there was a significant improvement in postoperative mean AROM at the 6-months (p = 0.001) and 12-months (p < 0.001) follow-up. The mean AROM improved from 83.5 degrees (standard deviation [SD], 18.9 degrees) preoperatively to 125.4 degrees (SD, 9.5 degrees) at 12 months postoperatively, indicating a 50% improvement in AROM from this procedure ([Table 2]). Similarly, there was a 131% improvement in grip strength from a mean of 13.5 kg (SD, 4.4 kg) to 31.3 kg (SD, 4.6 kg) at the 12-month follow-up, which was significant (p < 0.001) ([Table 1]). As early as 6 months after surgery, the improvement in grip strength was already significant, with a total improvement of 87% (p < 0.001). The clinical outcomes for each patient in our series are shown in [Table 3].

Table 2 Clinical and patient-reported outcome measures after arthroscopic dorsal scapholunate complex repair with suture anchor procedure

	Preoperative	6-mo follow-up, % improved	p-Value[a]	12-mo follow-up, % improved	p-Value[a]
Clinical outcome
Mean AROM, degree (SD; range)	83.5 (18.9; 50–105)	111.1 (6.3; 100–120): 33	0.001	125.4 (9.5; 105–135): 50	<0.001
Mean grip strength, kg (SD; range)	13.5 (4.4; 7–20)	25.2 (4.1; 18–32): 87	<0.001	31.3 (4.6; 22–39): 131	<0.001
Patient-reported outcome
Mean VAS (SD; range)	6 (1.3; 4–8)	2.4 (1.1; 1–4)	<0.001	1.2 (1; 0–3)	<0.001
Mean MWS (SD; range)	43.5 (13.3; 20–60)	79.6 (8.7; 70–90)	<0.001	86.5 (8; 75–100)	<0.001
Mean QuickDASH (SD; range)	65.9 (15.8; 38.5–84)	14.9 (8.7; 6.3–38.5)	<0.001	6.5 (4.4; 0–15.8)	<0.001

Abbreviations: AROM, active range of motion; MWS, Mayo Wrist Score; QuickDASH, Quick Disabilities of the Arm, Shoulder, and Hand questionnaire; SD, standard deviation; VAS, visual analog scale.

^a Paired t-test.

Table 3 Clinical outcome measures for each individual patient preoperatively, at 6 months, and at 12 months (final follow-up) after arthroscopic dorsal scapholunate complex repair with suture anchor

Patient	AROM, degree			Grip, kg
	Pre-op	6 mo post-op	12 mo post-op	Pre-op	6 mo post-op	12 mo post-op
1	100	110	125	16	32	34
2	60	110	135	9	28	34
3	100	120	135	14	22	26
4	105	110	120	6	21	22
5	N/A	110	125	N/A	31	39
6	N/A	120	135	N/A	29	36
7	80	N/A	N/A	14	N/A	N/A
8	100	120	135	18	26	29
9	N/A	110	115	N/A	24	34
10	N/A	115	115	N/A	22	28
11	90	100	N/A	11	18	N/A
12	80	110	130	8	26	34
13	70	110	130	7	22	30
14	N/A	100	105	N/A	24	29
15	50	110	125	20	28	32

Abbreviations: AROM, active range of motion; N/A, not available.

Patient-reported outcomes are shown in [Table 4] for each patient. Significant improvement in VAS scores was seen in all patients after the currently described method of SLIL repair from the score of 6 (SD, 1.3) preoperatively to 2.4 (SD, 1.1) and 1.2 (SD, 1) at 6 (p < 0.001) and 12 months (p < 0.001) after surgery, respectively. Similarly, there was a significant improvement in MWS and QuickDASH scores postoperatively. The MWS improved from 43.5 (SD, 13.3) preoperatively to 86.5 (SD, 8) at final follow-up at 12 months (p < 0.001), and the QuickDASH score improved from 65.9 (SD, 15.8) preoperatively to 6.5 (SD, 4.4) postoperatively at 12 months (p < 0.001) ([Table 2]).

Table 4 Patient-reported outcome measures for each individual patient preoperatively, at 6 months, and at 12 months (final follow-up) after arthroscopic dorsal scapholunate complex repair with suture anchor

Patient	VAS			MWS			QuickDASH
	Pre-op	6 mo post-op	12 mo post-op	Pre-op	6 mo post-op	12 mo post-op	Pre-op	6 mo post-op	12 mo post-op
1	7	3	1	55	80	90	50.3	11.3	4.5
2	7	4	2	25	70	85	82	9	5
3	6	2	0	55	90	90	54.1	6.3	2.5
4	6	3	3	40	80	80	61.3	22.5	11.3
5	5	2	1	N/A	80	85	N/A	11.3	9
6	4	1	1	N/A	85	90	N/A	9	4.5
7	7	N/A	N/A	35	N/A	N/A	84	N/A	N/A
8	5	1	0	60	90	100	38.5	9	2.5
9	5	2	1	N/A	70	80	N/A	13.3	4.5
10	4	3	2	N/A	70	75	N/A	22.5	11.3
11	7	4	N/A	50	70	N/A	61.3	38.5	N/A
12	8	1	0	50	90	100	82	9	0
13	6	1	1	45	90	90	61.3	13.3	4.5
14	5	3	3	N/A	70	75	N/A	22.5	15.8
15	8	3	1	20	75	85	82	11.3	9

Abbreviations: MWS, Mayo Wrist Score; N/A, not available; QuickDASH, Quick Disabilities of the Arm, Shoulder, and Hand questionnaire; VAS, visual analog scale.

Two of 15 patients had a recurrence of SL diastasis at a mean of 6 months after surgery through routine postoperative radiological imaging and underwent successful secondary SL ligamentoplasty using a free tendon graft.[25]

 

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Discussion

The SL joint is a complex joint comprised of SLIL, which is its primary stabilizer, and the secondary stabilizers, may include but are not exhaustive of the long radiolunate ligament, the DRC ligament, DIC ligament and the scaphotrapeziotrapezoid ligaments.[26] [27] Although the dorsal portion of the SLIL[28] has been shown to have the highest tensile strength (260 N) and thickness compared with palmar (118 N) and membranous (63 N), various studies have shown the importance of palmar SLIL ligaments in SL stability.[29] [30] [31] In addition, anatomical and clinical studies have shown the importance of the DCSS in stabilizing the SL joint.[32] [33]

Open SLIL repair techniques have been described in the literature.[12] [13] [14] These tend to require extensive soft tissue dissection and may result in disruption of the carpus blood supply and stiffness.[15] Arthroscopic repair minimizes such complications by preserving the remaining soft tissues or capsular attachments. Furthermore, arthroscopic repair results in less denervation, which is important given the role of the PIN on wrist proprioception.[16]

Arthroscopy not only allows for the diagnosis of SLIL injuries but also enables the surgeon to determine where the injury may occur. Traditional teaching has been that the SLIL is usually avulsed from the scaphoid and remains attached to the lunate[9] [34] but this can vary. According to Andersson and Garcia-Elias' study of the incidence of various types of SLIL injuries, there are several forms of dorsal SLIL tears, each requiring a different type of treatment.[35] Dorsal SLIL tears tend to occur more frequently at the scaphoid insertion (avulsion, 42%) and less commonly from the lunate (with or without avulsion fracture, 16%), midsubstance rupture (20%), or partial rupture or elongation (22%). In addition, the quality of the SL ligament may deteriorate over time and may not withstand the passage of a suture through it. Therefore, early surgery in symptomatic patients may be important to achieving the best possible recovery for ligament healing.[36]

There have been numerous publications regarding arthroscopic SLIL repair or reconstruction in the literature, but there remains no consensus regarding the optimal treatment of this injury. Mathoulin et al demonstrated that arthroscopic dorsal capsulodesis of the SLIL for chronic tears produces promising results for pain, motion, grip strength, and radiological parameters at 1 year postoperatively.[11] The arthroscopic repair technique that we described addresses dorsal SLIL avulsion tear and DIC ligament avulsion by placing two suture anchors into the dorsal scaphoid and lunate, respectively, and performing a dorsal capsulodesis at the same time. Having the suture anchors in both the scaphoid and the lunate bones allows us to plicate the DIC ligament and tighten the DCSS, especially in the injuries involving extrinsic wrist ligament incompetence.

Carratalá et al described a similar technique of SLIL avulsion repair by placing the suture anchor either into the scaphoid or lunate (depending on where the SLIL has detached) through the 3–4 RC portal and an all-inside repair technique using a knot pusher.[17] [28] Their results showed significant improvement in clinical and functional outcomes at 6 and 12 months postoperatively for pain, motion, grip strength, and functional outcome scores. Also, 79% of cases in their series of 19 patients achieved good to excellent results.[18] The technique proposed in our article is a modification whereby the suture anchors are placed through the MC portals. The MC portals allow easier access and visualization of the SLIL footprint and more accurate placement of the suture anchors. We achieved promising results in our series of 15 patients. Significant improvement in VAS, MWS, and QuickDASH scores were achieved at 6 and 12 months postoperatively compared with preoperatively ([Table 2]).

The role of the DIC ligament in the SL complex is well-studied.[4] [27] [32] [33] Wessel et al demonstrated in their cadaveric study that the deep component of the DIC ligament, also known as the dorsal scaphotriquetral ligament, has a significant insertion onto the lunate bone at a mean area of 59 ± 4 mm². This ligament is critical in the stability of the MC joint, especially the SL joint.[37] Therefore, by placing suture anchors on the lunate, we can anchor the deep component of DIC back onto the lunate bone while performing a dorsal SL capsulodesis and DIC ligament plication simultaneously.

Limitations of this study include its retrospective nature and intermediate length of follow-up. Notwithstanding these, we feel that arthroscopic dorsal SL capsuloligamentous repair with suture anchors is a reliable and safe procedure for acute or chronic SL injuries. Using MC portals allow surgeons to visualize the dorsal SLIL and DIC ligament footprint, making suture anchor placement and plicating the SL complex safe and efficient.

 

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Conflict of Interest

R. K. is an employee of Arthrex Inc.

S. K. is a consultant to Arthrex Inc, Restor3D, and IBRA and receives royalties from Arthrex.

P. J. D. is a consultant to Arthrex and Newclip.

V. C. is a consultant to Arthrex Inc and Newclip.None of the authors received financial compensation regarding this manuscript.

Acknowledgments

The authors would like to thank Kelly Chappell, Medical Illustrator III, Marketing Arthrex Inc., for her help with the drawings within the manuscript.

Authors' Contributions

All authors were actively involved in the planning, enactment, and writing up of the study.

Ethical Approval

This study was approved by the Ethics Committee of the Hospital Quironsalud Valencia.

Patients' Consent

Informed patient consent was obtained for this study.

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Eingereicht: 02. Juli 2024

Angenommen: 30. August 2024

Artikel online veröffentlicht:
03. Oktober 2024