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Outcomes of Three-Ligament Tenodesis for Scapholunate Interosseous Ligament Injury are Favorable at One Year

Key findings

  • A retrospective study of 203 patients who underwent three-ligament tenodesis for scapholunate interosseous ligament reconstruction yielded significant improvement in pain and function in four-fifths of patients at one year after surgery
  • 79% of patients reported improvement on the Patient-Rated Wrist Evaluation that was at greater than or equal to the minimum clinically important difference
  • Three ligament tenodesis should be utilized judiciously because 11% reported worse pain and function than before surgery
  • Ten percent of patients reported outcomes that were similar to their preoperative state

Injuries of the scapholunate interosseous ligament (SLIL) may be problematic in a subset of patients. Three ligament tenodesis is an option for treatment, but to date clinical outcomes are limited to relatively small series of patients.

Julia Blackburn, MD, Fulbright scholar at the Hand and Arm Center at Massachusetts General Hospital, and Neal C. Chen, MD, chief of the Hand and Arm Center, studied the results of the Garcia-Elias three-ligament tenodesis (3-LT), sometimes called the modified Brunelli procedure, performed across 18 different international clinical centers. In the Journal of Hand Surgery (European Volume), they report that 80% of patients reported substantial improvement.

Study Cohort and Surgical Procedure

The researchers identified 203 patients who underwent 3-LT for SLIL reconstruction between December 2013 and December 2017. Their average age was 47 and 54% were men. The average duration of symptoms prior to surgery was 24 months.

The 3-LT technique aims to enhance or replace the scaphotrapeziotrapezoid ligament, the dorsal scapholunate ligament and the dorsal radiotriquetral ligament.

Unlike in the original description of the technique, most surgeons did not use K-wires to immobilize the wrist after reconstruction. Another difference was that most patients had short immobilization periods of one to two weeks postoperatively where in the past most surgeons immobilize for several weeks.


Patients completed online questionnaires before surgery, three months after surgery, and one year after surgery:

  • A pain questionnaire
  • The Patient Rated Wrist Evaluation (PRWE) questionnaire
  • One year after surgery, patients were also asked, "Are you satisfied with the result so far?"

Senior hand therapists measured range of motion before surgery and three months postoperatively. Ninety patients were available for follow-up visits at one year.

Patient-Reported Outcomes

Overall, the pain and function scores significantly improved from baseline to one year postoperatively:

  • Pain score improved from 53 to 25 (P < .001)
  • PRWE pain score improved from 30 to 15 (P < .001)
  • PRWE function score improved from 26 to 11 (P < .001)

At one year, 79% of patients had an improvement on the PRWE that was greater than the minimum clinically important difference (MCID). However, for 10% of patients, the improvement in PRWE score was less than the MCID, and the other 11% of patients had worse PRWE scores.

Therapist-assessed Wrist Motion

Forearm/wrist rotation in patients were similar from before surgery to three months or one year after surgery.

Patient Satisfaction

Thirty-five patients reported "excellent" satisfaction, 84 reported "good," 59 reported "satisfactory," 17 reported "fair" and eight reported "poor."

Counseling Patients Preoperatively

Most patients undergoing 3-LT reconstruction for SLIL injury will see substantial improvements in pain and function by three months postoperatively. After three months, the wrist function continues to improve. At one year, wrist motion will be reasonably preserved compared to motion before surgery.

One-tenth of patients will have no substantial change in their symptoms by one year after surgery, and about another tenth may find that their pain and function is worse than it was preoperatively.

of patients undergoing 3L-T for SLIL reconstruction had clinically meaningful improvement in pain and function one year after surgery

of patients undergoing 3L-T for SLIL reconstruction had improvement in pain and function one year after surgery, but less than the minimum clinically important difference

of patients undergoing 3L-T for SLIL reconstruction had worse pain and function one year after surgery than preoperatively

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