Professional Documents
Culture Documents
Treatment of SLAC
Arthritis
Treatment 1
Options
SLAC 1
Radial styloidectomy
PRC, 4 corner-Fusion,
Arthroscopic
debridement
SLAC 2
Capitolunate fusion,
CLH arthrodesis, Wrist
denervation
SLAC 3
4 corner Fusion
Arthrodesis, wrist
denervation, Total wrist
arthroplasty
Watson HK, Ballet FL. The SLAC wrist: Scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg
1984;9A(3):358-365.
However
What is simple is always false.
But what is not is not usable
(Paul Valery, Poet, 1871-1945)
You can develop the simple,
only after a deep study of the
complexity (Gaston Bachelard,
Philosophe of sciences,
1884-1962)
Oversuse injury ?
Pollock et al. SLAC wrist in the absence of recognised trauma and CPPD. Hand Surg 2010; 15(3):
193-201.
Gharbaoui IS et al. Chronic asymptomatic contralateral wrist scapholunate dissociation. Plast Reconstr
Surg 2005;116:16721678.
Masmejean E et al. Bilateral SLAC Wrist : une lsion inhabituelle. A propos dun cas prhistorique vieux
de 7000 ans. Ann Chir Main Memb Super 1997; 16(3): 207-14.
SLAC 1
Limited
degenerative
arthritis between
the radial styloid
and the scaphoid
Distal pole ?
Watson, 1984
SLAC 1
SLAC 2
Arthritis between the
whole scaphoid and
radial fossa
Cartilage of the
radiolunate joint and
head of the capitate are
intact
SLAC 3
Capitatum penetrates
in the scapholunate
interval arthritis
between capitate,
medial side of the
scaphoid and distal
surface of the lunate
Radiolunate joint is
spared
Lane LB et al. Scapholunate dissociation with radiolunate arthritis without radioscaphoid arthritis. J Hand Surg Am 2010; 35(7):
1075-81.
Werner FW et al. Changes in patterns of scaphoid and lunate motion during functional arcs of wrist motion induced by
ligament division. J Hand Surg 2005; 30A: 1156-60
Natural history ?
Mostly unknown +++
1974
Asymptomatic cases
Age at presentation (63 years old)
11 cases with proven LSIOL injury
with 7 years FU found no
degenerative progression (no DISI)
Fassler PR et al. Asymptomatic SLAC wrist: does it exist? J Hand Surg 1993;18A:682686.
Laulan J. Dsaxation scapholunaire : physiopathologie et orientations thrapeutiques. Chirurgie de la main 2009 ; 28 : 192-206.
OMeeghan et al. The natural history of an untreated isolated scapholunate interosseus ligament injury. J Hand Surg Br 2003; 28(4):
307-10.
Stage 4 ?
Global wrist arthritis
(Trumble 2000)
Evolution of a stage
3 ?
Slope of the
lunotriquetral joint ?
(Kuhlmann 1997)
Type of Lunate ?
(Viegas, 1990)
Imaging techniques
X-rays
Localization of
degenerative arthritis
DISI deformity
?
?
Contralateral wrist ++
Do we need other
techniques ?
Lane LB et al. Scapholunate dissociation with radio- lunate arthritis without radioscaphoid
arthritis. J Hand Surg Am 2010 Jul; 35(7): 1075-81.
Arthro CT or ArthroMRI
Moser found ArthroCT to be
superior
Feydy found arthroMRI to be
superior
Arthroscopy is probably useful as
correlation with MRI is low (kappa
0,38)
Feydy A et al. Osteoarthritis of the wrist and hand, and spine. Radiol Clin North Am 2009 Jul; 47(4): 723-59.
Moser T et al. Wrist ligament tears: evaluation of MRI and combined MDCTand MR arthrography. AJR 2007;
188: 1278-86.
Mutimer J et al. Comparison of MRI and wrist arthroscopy for assessment of wrist cartilage. J Hand Surg Eur
Vol 2008 Jun; 33(3): 380-2.
Treatment
Non surgical modalities (i.e. splint, NSAID drugs,
steroid injections) may be used
No series available but should probably start with
Surgery is only palliative
Not a single technique has no complications
If conservative treatment fails, then SLAC staging
may help to decide which treatment to choose
SLAC 1
Limited area of degenerative
arthritis
Limited resection of that zone
i.e. radial styloidectomy ?
Vertical, no more than 3-4 mm
Barnard L, Stubbins SG. Styloidectomy of the radius in the surgical treatment
of non-union of the carpal navicular. J Bone Joint Surg 1947 ; 29 : 98102.
Nakamura T et al.. Radial styloidectomy: a biomechanical study on stability
of the wrist joint. J Hand Surg Am 2001 Jan; 26(1): 85-93.
Siegel DB, Gelberman RH. Radial styloidectomy: an anatomical study with
special reference to radio- carpal ligamentous morphology. J Hand Surg [Am]
1991 ; 16A : 404.
SLAC 1
SLAC 1
One series, 12 cases (4 SLAC),
good results at 21 months FU
For low demand and older
patients with good preserved
mobility ?
Day 4 postop
Case C. Mathoulin
SLAC 2
Arthroscopic resection of
Radio-scaphoid
joint is destroyed
Head of capitate
and radiolunate
joint are OK
Proximal row
resection
Partial wrist fusion
Wrist denervation
Arthroscopic resection
Non logical according to Cobb his promotor
Mean articular width resection 14 mm (9-20mm)
14 out of 17 patients, reviewed at 2 years FU
Less painful: From 6,6 to 1, 3 (older get better)
More functional: DASH decreases from 66 to 28
Keep functional wrist
8 patients presented ulnar wrist translation (average 6 mm)
and 7 had midcarpal joint decreasing.
3 failures (21%) (Lunatum type I and DISI deformity)
Cobb TK. Arthroscopic Resection Arthroplasty of the Radial Column for SLAC
Wrist. J Wrist Surg. 2014 ; 3(2) : 114-22
PRC
Idea is that the proximal aspect of
the capitatum has a similar shape to
the lunatum
A shortening of the wrist may improve
the range of motion and
translation of the capitatum under the
radius explains the good mobility
observed
loads over the head of the
capitatum (from 1,3 Mpa to 5 Mpa) on
a reduced area (25%) radiological
arthritis
Flexion-extension:
70-80
Frontal inclination:
30
Strength: 65-80%
RTW: 65-80%
PRC
Radiological deterioration of the
head of the capitatum and the radiocapitatum joint
No clinical modification with time (>
10 years FU)
Survival rate was 65% at 20 years
FU
10-25% complications
Wall LB et al. Proximal row carpectomy: minimum 20-year follow-up. J Hand Surg Am.
2013 Aug;38(8):1498-504.
4 corner fusion
Most used
technique
Many variations
(approach, device,..)
Seems to have little
influence
Flexion-extension:
60-80
Frontal inclination:
30
Strength: 65-80%
RTW: 65-80%
Non-union: 5-10%
Total arthrodesis:
7% (persisting pain)
No
prospective,
comparative
study
PRC is
favored at
the moment
SLAC 3
Deterioration of the cartilage
of the head of the capitatum
Considered a contraindication
to PRC
4 corner is the recommended
treatment
SLAC 3+ / 4
Wrist arthrodesis
Wrist denervation
Wrist replacement
Anecdotical
Technique
FU
Painless Strength Satisfaction Nonunion
re(months)
operation
Gaisne
1991
43
36 Iliac graft
Mannerfelt
48
22%
58%
Field
1996
46
20 AO plates
24
50%
74%
20%
Sauerbier
2000
48
60 AO Plates
37
5%
50%
8%
8%
De Smet
2003
42
36 Iliac graft,
AO plates
84
17%
63%
5%
58%
Adey
2005
58
22 AO Plates
72
18%
79%
80%
84%
TWA
Wrist denervation
Rothe (2006): 46 patients (10 SLAC,
36 SNAC), age 47 years, 32 reviewed
at 6,3 yrs
32% painless, 9% (effort), 19%
(still painful). 19/32 improved
Minimal loss of motion (72%
flexion/ext and 67% frontal
inclination compared to other
side)
Improved strength (70% of
normal)
DASH: 17,1
G van de Pol, J Hand Surg, 2006;31A:2834
Treatment 1
SLAC 1
SLAC 2
SLAC 3
4 corner Fusion
SLAC 4
Wrist denervation,
Total wrist arthroplasty >
arthrodesis