The incidence of wrist interosseous ligament and triangular fibrocartilage articular disc disruptions: a cadaveric study

doi:10.1016/j.jhsa.2004.02.011

The Journal of Hand Surgery

Volume 29, Issue 4, July 2004, Pages 676-684

https://doi.org/10.1016/j.jhsa.2004.02.011 Get rights and content

Abstract

Purpose

The purpose of this cadaveric wrist study was to determine the incidence and size of defects of the scapholunate interosseous ligament (SLIL), lunotriquetral interosseous ligament (LTIL), and triangular fibrocartilage (TFC) articular disc, and to determine their relationship to wrist arthrosis.

Methods

The status of the SLIL, LTIL, and the TFC articular disc was determined in 96 cadaveric wrists with an average age of 75 years (range, 61–92 y). The location and length of the SLIL and LTIL ligament disruptions and the site of ligament detachment were noted. Ligament disruptions were classified into 1 of 3 grades based on the size of the ligament disruption and the absence (grade 1 and 2 disruptions) or presence (grade 3 disruption) of wrist arthrosis. The location, size, and configuration of the TFC articular disc disruptions also were noted.

Results

Disruptions of the SLIL were noted in 34 wrists (35%). There were 20 grade 1, 4 grade 2, and 10 grade 3 ligament disruptions. The average length of ligament disruption was 10.9 mm, or 40% of the length of the ligament. Twenty-four of 34 SLIL disruptions occurred without wrist arthrosis. Disruptions of the LTIL were noted in 47 wrists (49%). There were 23 grade 1, 10 grade 2, and 14 grade 3 ligament disruptions. The average length of ligament disruption was 7.6 mm, or 52% of the ligament length. Thirty-three of 47 LTIL disruptions occurred without wrist arthrosis. Disruptions of the TFC articular disc were noted in 58 wrists (60%). The most common patterns of disruption were either a linear defect at the radial attachment of the articular disc or a centrally located oval defect. Thirty-seven of the 58 TFC articular disc disruptions were noted in wrists without distal radioulnar joint (DRUJ) arthrosis.

Conclusions

There is a high incidence of SLIL, LTIL, and TFC articular disc disruptions in the cadaveric model. Large ligament and TFC articular disc disruptions without wrist arthrosis are very common.

Section snippets

Materials and methods

Ninety-six cadaver wrists were dissected. There were 49 male and 47 female wrists, with 47 right and 49 left wrists. The age of the specimens was known in 61 of the 96 wrists, with the average age of the specimens being 75 years (range, 61–92 y). Ninety-two of the 96 wrists had been embalmed previously. The remaining 4 fresh-frozen wrist specimens had been thawed immediately before dissection. There were 33 pairs of wrists (66 wrists) that were dissected.

The radiocarpal joint was exposed after

Scapholunate interosseous ligament

The average length of ligament attachment to the scaphoid and lunate was 28 mm (range, 18–34 mm) and 24 mm (range, 16–30 mm), respectively (Table 1). Disruption of the SLIL was noted in 34 wrists (35.4%). There were 20 grade 1, 4 grade 2, and 10 grade 3 ligament disruptions. The average length of ligament disruption was 11 mm (range, 2–31 mm) or 40% of the overall ligament length (range, 7% to 100%). The average length of grade 1 ligament disruptions was 6 mm (range, 1–11 mm) or 22% of the

Discussion

Several bilateral wrist arthrographic studies1, 2, 3 have shown a high incidence of symmetric interosseous ligament (30% to 59%) or TFC disruptions (59% to 88%) in the asymptomatic wrist. An increasing incidence of age-related interosseous ligament and TFC disruptions was noted.4

Most cadaveric wrist dissection studies have found an increasing incidence of age-related degenerative disruptions of the interosseous ligaments5, 9, 10 and TFC articular disc.5, 6, 7, 8, 9, 10 A correlation between

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Wrist instability
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Le terme d’instabilités du poignet regroupe plusieurs types de lésions ligamentaires du poignet affectant de manière isolée ou combinée les ligaments intrinsèques et extrinsèques du poignet. Elles peuvent être regroupées sous le terme d’instabilité dissociative ou non dissociative. Nous traiterons ici des instabilités scapho-lunaire, luno-triquétrale et médio-carpienne.
Ces lésions affectent plus fréquemment les hommes jeunes. Leur diagnostic précoce est primordial afin d’éviter l’apparition d’arthrose médio et radio-carpienne invalidante. Un examen clinique dédié associé à des clichés radiographiques dynamiques permettent fréquemment de porter le diagnostic qui pourra être conforté par des examens paracliniques spécifiques. Le développement de l’arthroscopie a joué un rôle important tant sur le plan diagnostique que thérapeutique des lésions ligamentaires responsables d’instabilité du poignet, notamment en ce qui concerne l’instabilités scapho-lunaire. Le bilan arthroscopique permet une meilleure étude de l’importance des lésions du ligament scapholunaire mais également des lésions extrinsèques associées. L’arthroscopie a surtout l’avantage de permettre un traitement mini invasif lorsque les lésions sont diagnostiquées à un stade précoce.
Wrist instabilities define several types of wrist ligament lesions affecting intrinsic and extrinsic ligaments of the wrist, isolated or combined. They can be grouped under the term of dissociative or non-dissociative instability. We will deal here with scapho-lunate, luno-triquetral and midcarpal instabilities.
These lesions more frequently affect young men. Early diagnosis is essential to avoid the appearance of disabling mid- and radio-carpal osteoarthritis. A dedicated clinical examination associated with dynamic X-ray images frequently allows to carry out the diagnosis which can be confirmed by specific paraclinical examinations. Arthroscopy development has played an important role both in terms of diagnosis and treatment of ligament lesions in wrist instability. Mainly for scapholunate instabilities, where arthroscopic assessment allows a better study of importance of scapholunate ligament lesions but also of the associated extrinsic lesions. Arthroscopy has the asset of allowing minimally invasive treatment when lesions are diagnosed at an early stage.
Assessing the scapholunate and lunotriquetral interosseous ligament in MR arthrography: Diagnostic advantages of paraxial reformatting
2021, European Journal of Radiology
Citation Excerpt :
Since wrist surgeons largely rely on imaging when deciding the necessity of surgical treatment, radiological assessment has to be precise and consider the respective ligamentous anatomy: Both intrinsic ligaments resemble a horseshoe in the sagittal plane with a membranous proximal mid-section that does not contribute to joint stability (Fig. 1) [7]. The dorsal portion of the SLIL is the main internal stabilizer of the scapholunate compartment and can withstand force vectors up to 300 N, whereas the thinner palmar part is less durable [8,9]. Isolated lesions of the dorsal SLIL can temporarily be compensated by external stabilizers, e.g., the scaphotrapeziotrapezoid and radioscaphocapitate ligaments, resulting in dynamic forms of instability that only become apparent under load or in motion.
The scapholunate (SLIL) and lunotriquetral interosseous ligament (LTIL) function as the main stabilizers of the proximal carpal row. Even with MR arthrography, component assessability is often limited in orthogonal standard planes due to their horseshoe-like shape and resulting partial volume effects. This study aims to investigate the diagnostic value of reformatting isotropic 3D sequences with respect to the anatomical orientation of the intrinsic carpal ligaments.
In 110 MR arthrograms of the wrist, we investigated the diagnostic accuracy of two radiologists (R1/R2) for SLIL and LTIL injuries in orthogonal standard planes vs. ancillary angulated reformatting of isotropic 3D dual echo steady state sequence. Component assessability and diagnostic confidence were compared between datasets.
The addition of paraxial reformations improved diagnostic accuracy for lesions of the palmar (R1: 0.87 vs. 0.93; R2: 0.86 vs. 0.93; all p < 0.05) and dorsal LTIL (R1: 0.85 vs. 0.93; R2: 0.82 vs. 0.90; all p < 0.05). No significant increase in accuracy could be ascertained for palmar (R1: 0.92 vs. 0.94, p = 0.50; R2: 0.86 vs. 0.92, p = 0.07) and dorsal (R1: 0.95 vs. 0.95, p = 1.00; R2: 0.90 vs. 0.94, p = 0.29) lesions of the SLIL. Interrater reliability was almost perfect with and without angulated planes for SLIL (κ = 0.88 vs. 0.82) and LTIL assessment (κ = 0.88 vs. 0.86). For the LTIL, observer confidence and component assessability were superior with anatomical reformations available (all p < 0.05).
In contrast to SLIL injuries, diagnosis of LTIL lesions benefits from ancillary paraxial reformations of 3D sequences in MR wrist arthrography.
Carpal Motion in Chronic Geissler IV Scapholunate Interosseous Ligament Wrists
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This study evaluated the biomechanics of Geissler IV (G4) wrists in cadavers and compared them with intact specimens after multiple ligament sectioning to create scapholunate instability. It also evaluated carpal motion changes after sectioning of the lunotriquetral interosseous ligament (LTIL).
Eight cadaver wrists determined to be G4 arthroscopically were tested using a wrist joint motion simulator. The LTIL was then sectioned, and carpal motion was recorded again. Carpal motions were compared with 37 normal wrists after sectioning of the scapholunate interosseous ligament and other ligaments to create a G4 wrist.
Carpal motion of the 37 normal wrists after ligamentous sectioning was similar to motion of the 8 specimens noted to be G4. These wrists did not demonstrate subluxation of the scaphoid that may occur after ligament sectioning. After sectioning of the LTIL, there were significant changes in lunate and triquetral motion.
These findings support the hypothesis that sectioning multiple ligaments in normal wrists to create scapholunate instability causes average motion comparable to that seen in G4 wrists. Ligamentous sectioning can cause a range of scaphoid instability. Lunotriquetral interosseous ligament sectioning in native G4 wrists caused greater changes in triquetral than scaphoid range of motion.
Patients with arthroscopically determined G4 lesions have an incompetent SLIL and scapholunate instability but do not necessarily have scapholunate dissociation and subluxation. Cadaver studies that evaluate instability by sectioning specific intact wrist ligaments are similar to the G4 specimens and thus are a good approximation of naturally occurring wrist instability. The functionality of secondary stabilizers not seen arthroscopically may explain the differences in motion. Geissler IV wrists and ligament-sectioned wrists are points on the spectrum of carpal instability, which is determined by the extent of damage to multiple ligamentous structures.
Carpal Instability Reconstruction and Wrist Procedures in the Medicare Population
2019, Journal of Hand Surgery Global Online
We conducted a retrospective study to determine the annual number of patients undergoing various wrist procedures in the Medicare population as well as the revision rate and common revision procedures after carpal instability reconstruction surgeries (Current Procedural Terminology [CPT] billing code 25320).
We examined the Medicare orthopedic datasets using the PearlDiver application to identify patients who underwent 12 different common wrist procedures, including carpal instability reconstruction procedures, from 2005 to 2014. Carpal instability reconstruction procedures were those identified by CPT 25320, which includes various methods of reconstruction such as capsulodesis, ligament repair, and tendon transfer or graft. Medicare covers approximately 51 million Americans and consists of those aged 65 years and older as well as younger patients enrolled in Social Security disability or with end-stage renal disease. Demographic and payment data were determined for the entire cohort. Patients with less than 3 months of active insurance records after the wrist procedure were excluded.
A total of 29,898 wrist procedures were performed over the study period. The most commonly performed procedure was wrist arthroscopy with joint debridement or triangular fibrocartilage complex repair (6,557 patients). A total of 2,949 patients underwent carpal instability reconstruction procedures, 174 of whom underwent revision or salvage surgeries (5.9%). The most common revision procedure was an additional reconstruction operation whereas the most common salvage procedure was proximal row carpectomy. Average Medicare payment was $4,107.67 for the index procedure and $3,760.95 for revision procedures. The number of wrist procedures increased 43% over the study period.
Carpal instability reconstruction procedures and wrist arthroscopies with joint debridement or TFCC repair are performed more commonly in elderly patients than anticipated or indicated. Procedures such as these, without quality evidence supporting their use in elderly patients, are going to be scrutinized as the United States moves toward value-based health care. Although it appears that carpal reconstruction procedures have a low revision rate in the short to medium term in the Medicare population, the wide variety of procedures captured by CPT 25320 makes outcome measurements challenging. A more specific coding system should be created to reflect the surgeon’s effort more accurately, as well as better track revision rates.
Therapeutic III.
Scapholunate Ligament Tears: Acute Reconstructive Options
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Original Articles: WristThe incidence of wrist interosseous ligament and triangular fibrocartilage articular disc disruptions: a cadaveric study1

Abstract

Purpose

Methods

Results

Conclusions

Section snippets

Materials and methods

Scapholunate interosseous ligament

Discussion

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

Original Articles: Wrist
The incidence of wrist interosseous ligament and triangular fibrocartilage articular disc disruptions: a cadaveric study¹