Scapholunate InterosseousLigament Disruption inProfessional Basketball PlayersTreatment by Direct Repair and DorsalLigamentoplasty

Charles P. Melone Jr, MDa,*, Daniel B. Polatsch, MDa,Gary Flink, MSPTb, Bradley Horak, MDa, Steven Beldner, MDa

KEYWORDS

� Scapholunate interosseous ligament repair � Scapholunate dissociation � Carpal instability� Sports injuries wrist

KEY POINTS

� Surgical repair with augmentation ligamentoplasty is indicated for disabling scapholunate inteross-eous ligament (SLIL) disruption before the occurrence of static, fixed scapholunate dissociation(SLD).

� Successful SLIL surgery depends on early diagnosis and operative intervention presenting witha reducible scaphoid, a reparable ligament, and an arthritis-free wrist.

� Intensive sport-specific rehabilitation is aprerequisite for optimal recoverywith anunrestricted returnto competition.

� Radiographic evidence of degenerative joint disease is apt to occur with increasing follow-up butseldom correlates with functional decline and rarely requires additional surgery.

Functioning as the primary stabilizer of the sca-pholunate (SL) articulation,1–5 the intact SL inter-osseous ligament (SLIL) is vital to normal carpalmechanics. The integrity of the ligament is a requi-site for unimpaired synchronous kinematics of thecomplex carpal articulations. In contrast, trau-matic disruption, a not infrequent occurrence, ofSLIL results in SL dissociation (SLD) (Fig. 1) anda highly dysfunctional wrist prone to debilitatingdegenerative joint disease. Moreover, disruptionof the SLIL is the initial and constant lesion in thecontinuum of progressive perilunar instability thatresults in a wide spectrum of increasingly severe

Disclosure: The authors have nothing to disclose.a Division of Hand Surgery, Department of OrthopaedicCollege of Medicine, The Hand Surgery Center, 321 EaOrthopaedic Rehabilitation, 605 Main Street, Hackensac* Corresponding author.E-mail address: cmelone@chpnet.org

Hand Clin 28 (2012) 253–260doi:10.1016/j.hcl.2012.05.0020749-0712/12/$ – see front matter � 2012 Elsevier Inc. All

carpal derangement and culminates in perilunatedislocation.6,7 In a previous report of the operativepathology and management of advanced-stageperilunate injuries, the senior author (CPM)concluded that for the skilled athlete, preciserepair and thorough healing of this lesion is essen-tial for a successful return to competitive sports.8

Unanimity exists that for complete SLIL disrup-tion with resultant SLD, especially in the high-demand athlete, operative treatment is necessaryand that the acute injury affords the optimal condi-tions for direct ligament repair and an expectantfavorable outcome.9–11 This article reports the

Surgery, Beth Israel Medical Center, Albert Einsteinst 34th Street, New York, NY 10016, USA; b Excel

k, NJ 07601, USA

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Fig. 1. Scapholunate interosseous ligament disruptionwith resultant scapholunate dissociation in the profes-sional basketball player. Ulnar deviation radiographaccentuates the characteristic wide scapholunate dia-stasis and rotatory subluxation of the scaphoid.

Melone et al254

authors’ experience with comprehensive surgicalmanagement of disabling SLD in a select groupof professional basketball players and emphasizesthe critical need for prompt detection and earlyrepair of destabilizing SLIL disruption.

CLINICAL STUDY

Between 1995 and 2010, 25 professional basket-ball players, actively competing in national or inter-national professional basketball leagues and in theprime of their careers, required surgery fordisabling SLIL disruption incurred during competi-tion. All injuries were categorized asMayfield stageI perilunar injuries,6,7 aswell asMayo type I A carpaldislocations.12 Eighteen players of the group havebeen available for sequential postoperative evalua-tion over a period averaging 62 months (18–180months). The average age of the players was 26years (21–34years). Thedominantwristwas injuredin 15players and thenondominant side in 3.By theirposition in thegame, 14of thegroupwereguardsorsmall forwards (1, 2, and 3 positions) and 4 werepower forwards or centers (4 and 5 positions, socalled bigs). The time of surgery ranged from1 week to 18 weeks after injury. Sixteen players ofthe group were treated between 4 and 8 weeksafter injury, a time frame considered relatively briefwhen compared with intervals between injury andsurgery reported in others series of direct SLILrepair.13–16

Common to all in this series were a static butflexible SLD (demonstrated clearly by standardradiography), a reducible scaphoid, a reparableligament, and a wrist devoid of articular damage.For the group, comprehensive management com-prised direct SLIL repair, dorsal intercarpal liga-ment (DICL) augmentation, and long-arm cast

immobilization for 8 weeks followed immediatelyby intensive sport-specific rehabilitation.

DIAGNOSTIC FEATURES

Despite initial treatment with oral and topical antiin-flammatory modalities, analgesics, and short-termsplinting, persistent wrist pain with any attempt atskilled or strenuous usage was the paramountsymptom preoperatively. Repeated examinationdemonstrated classic signs of SLIL disruption:dorsal wrist swelling and tenderness; a prominent,tender proximal pole of the scaphoid, often associ-ated with a palpable gap at the SL juncture; a pain-fully positive scaphoid shift test17; and severelimitations of both wrist motion and grip strength.High-quality radiography18–20 with standard post-

eroanterior, lateral, and oblique projections, supple-mented with anteroposterior views of radioulnardeviation and clenched fist , and alwayswith contra-lateral comparison studies, consistently confirmedthe diagnosis. An SL gap exceeding 3mm, accentu-ated by the clenched fist compression and ulnardeviation views, comparedwith thatof the contralat-eral wrist, and an SL angle in excess of 70� as visu-alized on the true lateral projection have beendefined as the radiographic hallmarks of SLD19–22

and have been demonstrated in all patients. In thisseries of patients, preoperatively, the SL gap aver-aged 6.5 mm (4–12mm) and the SL angle averaged81� (71�–93�), clearly indicating substantial liga-ment damage with carpal instability. Although thesemeasures usually suffice for an accurate diagnosis,the professional athlete often requires additionalobjective corroboration before authorization forsurgery. In such patients, precision magnetic reso-nance imaging techniques, such as those describedby Moser and colleagues,23 have provided confir-mation of the complete ligament disruption.

SURGICAL TECHNIQUES

The operative techniques used for the treatment ofthese patients are similar to those described previ-ously for direct ligament repair.13–15,22,24,25 Theoperation incorporates a ligament sparing capsu-lotomy (Fig. 2), accurate carpal reduction, directSLIL repair through small scaphoid drill holes, per-cutaneous Kirschner wire internal fixation, DICLadvancement —ligamentoplasty, and partial radialstyloidectomy, as preoperative radioscaphoidimpingement invariably has been present.A pneumatic tourniquet is used in all patients,

and balanced regional anesthesia in most patients.A 3-cm dorsal incision (Fig. 3A) with its apex at theSL interval provides access to the partially disrup-ted radiocarpal capsule in the interval betweenthe third and fourth extensor compartments. The

Fig. 2. (A) The ligament sparing capsulotomy, with a radially reflected capsular flap, preserves the dorsal radio-carpal (RCL) and dorsal intercarpal (DICL) ligaments, provides clear exposure of the operative pathology, and (B)facilitates accurate surgical repairs. For augmentation of subacute and chronic scapholunate interosseous liga-ment repairs, the dorsal intercarpal ligament is split transversely (dotted line), and the proximal half is advancedand secured to the scaphoid (S), scaphoid lunate interosseous ligament (SLIL), and the lunate (L). (From Gregory J;with permission.)

SLIL Disruption in Professional Basketball Players 255

capsulotomy is incised along the radial margin ofthe dorsal radiocarpal ligament (DRCL) and theproximal edge of the dorsal intercarpal ligament(DICL). A radial-based capsular flap is createdand reflected to the radial styloid, clearly exposingthe SLIL disruption, and the adjacent carpal mala-lignment, while preserving the major substance ofboth the DRCL and DICL (see Fig. 3B).

Invariably the SLIL is ruptured or avulsed withsmall bony fragments (6 patients) from the scaphoidand demonstrates a characteristically substantiveligamentous cuff attached to the lunate, which aftercarpal reduction is readily advanced to the site ofscaphoid detachment (see Fig. 3C). The SLIL is de-brided to healthy tissue, and the adjacent surfacesof the scaphoid and lunate are abraded with fineKirshner wires to promote local vascularity, fibroushealing, and SL ligament reattachment. In themajority of patients, radioscaphoid impingement isevident and judicious excision of the styloid, sparingthe origin of the volar radiocarpal ligaments, is per-formed with a rongeur and fashioned to a smoothsurface with a rasp. The direct ligament repair isthen accomplished with absorbable mattress su-turespassed throughsmall drill holesat theproximaledge of the scaphoid (see Fig. 3D). Before securingthe sutures, an atraumatic carpal reduction isachievedbydorsal to volar compressionof the capi-tate, volar to dorsal compression of the scaphoidtubercle, and lateral compression of the SL juncture,thereby restoring SL coaptation and realigning thecarpus in both the coronal and sagittal planes. Thereduction is secured with two 0.045-in percuta-neous Kirshner wires passed from the proximalscaphoid into the coapted lunate, and 1wire passed

from the distal scaphoid into the reduced capitate.The accuracy of reduction is affirmedwith intraoper-ative radiography (see Fig. 3E), and the repair iscompleted by advancing the ligament and knottingthe sutures.

For augmentation of these typically delayedrepairs, the readily accessible DICL is split trans-versely (see Fig. 3F), and the more substantiveproximal half is advanced in a V-configuration andsutured, with or without drill holes, to the dorsalcomponent of the SLIL and the adjacent scaphoidand lunate. Reinforcement is thus achieved bydirect suturing to the conjoined components ofthe SL articulation. A key focus throughout theoperation is the avoidance of excessive soft tissueand skeletal surgical trauma apt to compromisevascularity and structural integrity of the inherentlyischemic carpus.26

The capsular flap, as well as the overlying reti-naculum, is repaired, the tourniquet deflated,hemostasis achieved, and the skin incision isclosed. The surgical repairs are protected witha long-arm thumb spica cast for 8 weeks, at whichtime the wires are removed in the office and reha-bilitation is begun.

SPORT-SPECIFIC REHABILITATION

A favorable surgical outcome depends on a care-fully planned, intensive, and skillfully executedtherapy program. A creative therapist experiencedin themanagement of handandwrist sports injuriesandanathletededicated toparticipating in rigorousrehabilitation on a near-daily basis for an uninter-rupted period of at least 2 months are essential

Fig. 3. Surgical techniques for scapholunate dissociation. (A) Dorsal incision centered over the scapholunateinterval provides access for (B) the ligament sparing capsulotomy and exposure of the disrupted scapholunateinterosseous ligament with resultant scapholunate dissociation (arrow). (DICL, dorsal intercarpal ligament;DRCL, dorsal radiocarpal ligament; L, lunate; S, scaphoid). (C) A substantive scapholunate interosseous ligament(SL), attached to the lunate (L), is advanced and (D) secured with sutures passed thorough drill holes at the prox-imal edge of the scaphoid. (E) After restoration of carpal alignment and stabilization with Kirschner wires, thesutures are knotted, completing the ligament repair. (F) For augmentation ligamentoplasty, the dorsal intercarpalligament (DICL) is split transversely (at tip of forceps) and the substantive proximal half is secured to the dorsalcomponent of the scapholunate interosseous ligament, the scaphoid (S), and the lunate (L).

Melone et al256

for the success of the program. In the authors’experience, a strongly favorable factor in the reha-bilitation process is the positive enthusiastic atti-tude, especially as progress becomes apparent,and an exceptional level of motivation with anintense desire for a rapid return to competition dis-played by the professional basketball player.The knowledgeable therapist has a keen aware-

ness of normal wrist anatomy and kinematics, thespecific alterations in function that occur with SLD,and the methodology to achieve an expeditiousbut thorough recovery. Realistic goals with a ra-tional time frame for recovery are established at

the outset of therapy, and progress is continuallyconveyed from the surgeon and therapist, in con-cert, to the athlete, team management, medicalstaff, and usually to personal agents or advisors.This constant communication is an essential aspectof patient management for the professional athlete,which avoids confusion and facilitates uninter-rupted and successful rehabilitation. Although thebasic goal is restoration of a pain free, stable andfunctional wrist with a minimal risk of reinjury, re-covery of mobility, strength, and dexterity specificto individual needs must also be acknowledged.The requirements of a player playing in a point or

SLIL Disruption in Professional Basketball Players 257

shooting guard position are different from those ofa player playing in a power forward or center posi-tion. For all players, irrespective of their position,attainment of wrist and hand speed, agility, anddurability is essential.

Investigative studies have demonstrated thatthe dart throwers’ motion27,28 (the arc of wristmotion progressing from extension and radial de-viation to flexion and ulnar deviation) transmitsminimal stress to the SLIL while restoring the im-portant functional needs. This maneuver is usedin the initial stages of therapy as a rational methodof mobilizing the stiffened postoperative wrist andsimultaneously permitting additional healing of therepaired ligament. As patient tolerance increases,the program advances to aggressive mutliplanaractive and passive mobilization, followed byprogressive strengthening. The final phase oftherapy focuses on the restoration of dexteroussport- and position-specific maneuvers essentialfor a skillful return to competition.

The reactivated player requires careful moni-toring and is encouraged to continue a wriststrengthening program as further improvement in-variably occurs with time, usage, and increasedconfidence in the repaired wrist. The player isalso urged to use protective but flexible wristsupports whenever possible.

OUTCOME ASSESSMENT

Follow-up evaluation averaged 62 months (18–180months) and demonstrated considerable improve-ment in symptoms, function, and carpal alignment.Based on the Mayo clinical scoring system,12

which incorporates the alleviation of pain, returnto regular activity, recovery of wrist mobility, andrestoration of grip strength, all of the patients ratedhighly satisfactory (good or excellent) with anaverage score of 85 points. In this comprehensivesystem, the patient scoring ranged from 80 to 95

Fig. 4. Clinical outcome Case 1. Thirty-two–year old activefunction 6 years after surgery. (A) Preoperative radiograpscapholunate gap and the classical cortical ring sign of scapthe radiograph demonstrates preservation of carpal align

points, with 100 points considered a normallyfunctioning wrist.

Radiographic analysis revealed substantial im-provement in the previously distorted parametersof carpal alignment. SL angles averaged 62� com-pared with 81� measured preoperatively, and theSL gap averaged 2.5 mm compared with the wide,6.5 mm average diastasis noted before surgery(Fig. 4). Furthermore, with the exception of 3patients, the radiographs demonstrated preserva-tionof radiocarpal andmidcarpal articular congruity.The 3 exceptions, all evaluated 7 years ormore aftersurgery, displayedvariable, butminimally symptom-atic, degrees of wrist arthrosis (Fig. 5).

Patient satisfaction was consistently highbecause all the players returned to full competitionand were able to pursue their careers without wristimpairment for periods of at least 5 years aftersurgery. Reinjury was not reported, and no addi-tional surgery has been necessary.

OVERVIEW OF SLD IN PROFESSIONALBASKETBALL PLAYERS

Restoration with the preservation of SL anatomyand function after traumatic SLD is a formidablechallenge to the hand surgeon. Supporting thisconcept, the literature is replete with a myriad ofsurgical procedures attempting to restore the dis-rupted carpal architecture. However, reportedresults of these varied techniques have been con-flicting and confusing, and a consensus regardingoptimal management is nonexistent. Differences inpatient selection, timing of surgical intervention,diverse operative techniques, and methods andlength of outcome assessment are among thefactors contributing to the dilemma. Most reports,however, do concur that despite early and sub-stantial functional improvement, a process ofradiographic deterioration with the developmentof intercarpal and radiocarpal arthrosis tends to

player reports occasional pain but unrestricted wristh displays scapholunate dissocation with a 4- to 5-cmhoid rotatory subluxation. (B) 6 years postoperatively,ment with no evidence of arthrosis.

Fig. 5. Clinical outcome Case 2. Forty-three–year old player has completed an illustrious career and, 11 years aftersurgery, functions as a full-time coach without wrist impairment. (A) Follow-up radiograph demonstrates residualcarpal malalignment with periscaphoid arthrosis. (Note the previous radial styloidectomy has eliminated radio-scaphoid impingement) Despite radiographic evidence of arthrosis, examination (B–D) of the repaired dominantright wrist (to the left) illustrates near-normal grip strength and wrist mobility.

Melone et al258

occur with increasing intervals between surgeryand outcome assessment. To date, an arthritis-free wrist has not been consistently documentedfor any surgical procedure with long-term assess-ment exceeding 5 years.29 However, neitherthe extent and effect of associated disability northe incidence of secondary surgery are well de-fined, and require further documentation andclarification.Although the literature, aswell as personal experi-

ence, does not support a strict correlation betweenfunctional outcome and radiographic arthrosis, thepotential for disabling traumaticarthritis nonethelessremains a major concern. This disturbing fact isespecially relevant to the professional basketballplayer whose wrist is continually subject to theinherent trauma of competitive sports and prone torepeated injury and ultimately the development ofdegenerative joint disease. SLD should be recog-nized as a precursor to arthrosis for which timelyaccurate restoration with preservation of carpalanatomy is an essential measure of prevention.In a previous study of surgical treatment of more

extensive perilunate injuries, the senior author(CPM) reported delayed treatment and residualcarpal malalignment as the major factors compro-mising recovery and emphasized the efficacy ofearly comprehensive repair of all soft tissue andskeletal components of injury for preservation of

carpal anatomy and recovery of maximum func-tion.8 The same concepts of management havebeen applied to this series of stage I perilunate in-juries with consistently favorable results. Regard-less of the stage, the spectrum of perilunar injurycauses SLD with severe carpal derangement,which is optimally treated by prompt anatomicrepair, restoration of carpal alignment, and secureinternal fixation. The previous study also empha-sized the importance of accurate restoration ofthe SL articulation as the key method of lesseningthe occurrence and severity of radiographic carpaland radiocarpal arthrosis.In this series of professional basketball players

with SLD, a consistent surgical protocol hasbeen used for a uniform group of young, healthypatients with similar functional requirements andgoals. In all patients, direct repair of a substantiveSLIL has been possible and reinforcement of therepair has been achieved with the DICL. Althoughdirect SIL repair does not address all componentsof SL instability, it does restore the primary carpalstabilizer. A successful repair of the SLIL hasprovided the keystone for a favorable outcome.With recognition that the SLIL is not the only

stabilizer of the SL articulation and awarenessthat all ligaments, regardless of the site of injury,are prone to a variable process of devitalizationwith delayed treatment, augmentation of the direct

SLIL Disruption in Professional Basketball Players 259

repair with the DICL has been a constant com-ponent of the operative procedure. Anatomic, bio-mechanical, and clinical studies25,29–31 havedemonstrated that the DICL is an importantsecondary stabilizer of the SL articulation andthat the DICL is also prone to detachment fromits scaphoid and lunate insertions with the occur-rence of SLD. Furthermore, its ease of accesslessens surgical trauma and renders it highly suit-able for augmentation. In this series, the DICL hasprovided a sturdy method of reinforcement for theSLIL and SL articulation.

Similar to all surgical techniques for SLD, thelong-term efficacy of direct SLIL repair with DICLaugmentation remains uncertain and requires fur-ther evaluation. Nonetheless, this surgical protocolhas provided a highly satisfactory method ofachieving the essential requirements and goalsfor professional basketball players at a vital timeof their life. Moreover, for most, it has proved dur-able not only throughout their professional careersbut also for extended periods thereafter.

For professional athletes with SLD, the authorshave not used reconstructive operative proce-dures, such as capsulodesis,29,32,33 tenodesis,33,34

3-ligament repair,35,36 or intercarpal athrode-sis.37,38 These procedures are most suitable forchronic SLD with irreparable SLIL damage andprovide alternative methods of restoring carpalstability. Although reconstructive surgery canfavorably alter the deteriorating pattern of carpalinstability, it is limited in its capacity to restore suffi-cient function for the skilled athlete becausestability can only be achieved at the expense ofmobility. For the professional athlete, seldom isa satisfactory solution available when treatment isconsiderably delayed. In contrast, and in accor-dance with the basic principle of all ligamentdisruptions, the acute injury with direct SLIL repairoffers the optimal conditions for a favorable out-come. The significance of early surgery, preferablywithin 3 weeks from the time of injury, cannotbe over emphasized as critical to successfulrecovery.

SUMMARY

The fundamental principle of successful surgery isrestoration of superior function with consistent pa-tient satisfaction. At present, this study of profes-sional basketball players with static SLD indicatesthat direct SLIL repair with DICL augmentation isa highly satisfactory method of restoring wriststability and function commensurate with theneeds of these skilled and physically challengedathletes. The techniques of treatment used forthis select group have consistently facilitated their

goals at a critical period of their professional lifeas all have returned to unrestricted competition.Factors undoubtedly contributing to the successfulrecovery of the group are the homogenous patientpopulation, the presence of substantive soft tissueand skeletal structures with an enhanced poten-tial for healing, relatively early surgical intervention,and a consistent surgical protocol. The favorableoutcome reported in this article supports thecontentions that prompt surgical interventionaffords the optimal prospect for preservation ofcarpal stability and that early direct SLIL repair forcarefully selected patients is apt to result in a supe-rior recovery.

ACKNOWLEDGMENTS

The authors express sincere gratitude to Jill K.Gregory, MFA, Certified Medical Illustrator, forher original artwork in Fig. 2. Special appreciationalso is extended to Jacqueline Lopez of the BethIsrael Hand Surgery Center for her invaluableassistance in the preparation of this manuscript.

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