Modified Brunelli Procedure for the Treatment of Chronic Scapholunate Instability
Moran SL1, Ford K1, Wulf C1, and Cooney W2. (1) Division of Plastic Surgery/ Department of Orthopedic Surgery, Mayo Clinic, Mayo Clinic, 12th Floor, 200 1st Street SW, Rochester, MN, USA, (2) Department of Orthopedic surgery, Mayo Clinic, 200 First Street, SW, Rochester, MN, USA
Purpose: The ideal treatment for chronic scapholunate (SL) instability is not yet established. Several soft tissue procedures have been described to limit scaphoid flexion in the hopes of preventing further rotary subluxation and the progression to radiocarpal arthritis. The modified Brunelli procedure utilizes the flexor carpi radialis, passed through the distal palmer scaphoid and then attached to the dorsum of the lunate, as a means of limiting scaphoid rotation. We wished to examine our long term results with the use of the modified Brunelli procedure. Methods: A retrospective chart review was conducted examining all modified Brunelli procedures performed at our institution since 1995. Patient's wrist pain had to have been present for greater than 3 months to be included in the study. Wrist motion and grip strength were compared to the normal wrist pre and post-operatively. Radiographs were reviewed for changes in SL angle, SL diastasis and radiolunate angle following surgery. 17 patients with a diagnosis of chronic scapholunate instability underwent a modified Brunelli procedure. Average patient age was 40, and pain had been present for an average of 20 months. 9 patients presented with static scapholunate instability and 8 presented with dynamic instability. Average follow-up was 22 months. Results: The flexion-extension arc decreased from 90% of the normal wrist pre-operatively to 60% post-operatively. Radial and ulnar deviation remained stable at 88% before and after surgery. Grip strength also remained unchanged at 85% of normal following surgery. Pain was significantly improved in 77% of patients. Frank failures occurred in 2 patients in the static group, one due to infection requiring fusion and the second failure was due to persistent pain. There were no failures in the dynamic group. Average Mayo wrist score was 74, with 2 excellent, 5 good, 7 fair and 3 poor results. Follow up films revealed evidence of radiocarpal arthritis in one patient and midcarpal arthritis in another. Abnormalities in scapholunate distasis were not consistently corrected by the surgery. Conclusion: The modified Brunelli procedure provided improvement for patients with chronic SL instability. Though wrist motion was decreased, the majority of patients experienced significant pain relief and were able to return to employment. In selected patients the modified Brunelli procedure may provide a reliable alternative for the treatment of chronic scapholunate instability.