Minimally Invasive Surgery of Perilunate Dislocations and Fracture Dislocations

Background: The gold standard for the treatment of perilunate dislocations (PLD) and fracture dislocations is currently an open reduction and internal fixation. However, as many authors have suggested, minimally invasive surgery (MIS) is being positioned as an alternative management of the condition. Purpose: The purpose of this retrospective, nonrandomized study was to evaluate the clinical and radiographic outcomes of a series of acute PLD and trans-scaphoid perilunate dislocation (TSPD) treated operatively by a minimally invasive technique. Patients and Methods: In all, 11 patients (2 PLD and 9 TSPD) had surgery performed between 2005 and 2010. All patients were males with an average age of 34.6 years (range, 17-55) at their final evaluation. The procedure involves (1) closed reduction of the carpus; (2) closed reduction and percutaneous screw fixation of the scaphoid fracture; (3) closed reduction, k wires, and screws for stabilization of the carpal dissociation. Clinical outcomes were evaluated on the basis of range of motion, pain, functional status, and Mayo scores. We performed a radiographic assessment of the radiolunate angle, scapholunate angle, and gap between these 2 bones. The right wrist was involved in 7 patients, and the left in 4 patients; the dominant hand was affected in 6 occasions. Seven patients sustained a fall from a height with the wrist in hyperextension, 2 cases occurred during sport practice (1 rugby, 1 skiing), and the other 2 were involved in traffic accidents (1 motor vehicle, 1 motorcycle). The average time from injury to operation was 6 days (range, 4-22). Five patients had associated fractures: 3 in upper limb (1 elbow dislocation, 1 clavicle fracture, 1 radial head fracture), 2 in lower limb (1 patellar fracture, 1 calcaneal fracture). Results: The average follow-up period was 28 months (range, 14-52) and no patient was lost to follow-up. All patients achieved satisfactory reduction of the midcarpal joint and intercarpal bone alignment by closed reduction. Clinically, patients had functional mobility with an average loss of about 23% compared with the contralateral wrist. The mean Disabilities of the Arm, Shoulder and Hand (DASH) outcome score was 23, demonstrating a moderate average disability in activities of daily living (ADL). The average Mayo wrist score was 84 with 4 excellent, 6 good and 1 fair result. On the basis of radiographic parameters, reduction obtained during the operation was maintained within normal ranges in all patients. Scaphoid fracture union occurred at an average time of 16 weeks (12-27 weeks) and there was no case of nonunion. Radiographic results showed an average scapholunate angle of 52°, a radiolunate angle of 10°, and a scapholunate distance of 1.6 mm. No case of lunotriquetral instability was noted. In pure injuries, there was almost no loss of scapholunate reduction after removal of trans-articular screw at 7 month. At the last follow-up, arthritis had not developed in any patient. Conclusions: This study suggests that a percutaneous procedure (MIS), with reduction of carpal dislocations and fixation of scaphoid fracture, seems an acceptable method for the treatment of acute and reducible PLD and TSPD in selected cases.