Scapholunate instability: why are the surgical outcomes still so far from ideal?

The wrist is a universal joint with intrinsic and extrinsic ligaments that function and fail as ligamentous complexes. Those related to scapholunate instability (SLI) include the dorsal scapholunate complex (DSLC), volar radiolunate complex and scaphotrapeziotrapezoid complex. Together the DSLC, scaphoid and lunate create an 'acetabulum' for the capitate, with the dorsal intercarpal ligament being a labrum to contain the capitate. SLI results from failure of the DSLC, typically from its scaphoid attachments. Failure of the lunate and or triquetral attachments increases the instability. DSLC failure leads to radioscaphoid instability, which is the symptomatic clinical problem. SLI reconstruction with open surgery and trans-osseous tendon graft techniques have been challenging. We discuss a biological arthroscopic approach to identify, mobilize and debride the disrupted DSLC. This ligament/capsular/periosteum sheet is then advanced and secured to the debrided footprint. Thereby reconstituting the acetabulum, labrum and scaphoid stability.