AAHS - Less is More in Acute Perilunate Injuries? Early Success with Arthroscopic-Assisted Fixation of the Proximal Row Without Ligament Repair

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Less is More in Acute Perilunate Injuries? Early Success with Arthroscopic-Assisted Fixation of the Proximal Row Without Ligament Repair
Jonathan Persitz, M.D.^{^1,2}, Norah Matthies, MD FRCSC^³, Andrea HW Chan, MD, MA, FRCSC^⁴; Ryan Paul, MD^{^1,3}
(¹)University of Toronto, Toronto, ON, Canada, (²)University of Toronto, Toronto Western Hospital, Toronto, ON, Canada, (³)Toronto Western Hospital, Toronto, ON, Canada, (⁴)Hospital for SickKids, Toronto, ON, Canada

Introduction
Perilunate dislocations and fracture-dislocations are high-energy injuries often associated with poor functional outcomes and post-traumatic arthritis. Recent advances in wrist arthroscopy have enabled more precise and minimally-invasive management. This case series demonstrates the preliminary safety and effectiveness of an arthroscopically-assisted technique involving reduction and percutaneous fixation of the proximal row without additional soft tissue repair.

Methods
Ten patients with acute isolated perilunate injuries treated at a single tertiary care institution between 2021 and 2025 were reviewed. Arthroscopic-assisted reduction and percutaneous fixation of the proximal row and associated fractures was performed using Kirschner wires and/or headless compression screws. Outcomes included range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and visual analog scale (VAS) for pain. Radiographic evaluation included scapholunate (SL) gap and angle, radiolunate (RL) angle, posterior radioscaphoid angle, dorsal scaphoid translation, fracture union, and Kellgren-Lawrence (KL) grade for arthritis.

Results
All patients were male with mean age 36 (±14) years. Average time-to-surgery was 5 days (±3). Fifty percent involved the dominant wrist and 40% presented with median neuropathy.

Injury patterns were classified as Mayfield stage 3 (n=8) and 4 (n=2). Five patients (50%) sustained greater arc injuries (3 trans-scaphoid, 2 trans-radial styloid). Four had associated ulnar styloid fractures. No open injuries.

At mean follow-up of 10 months, the mean DASH score was 4 (±5) and all patients had a VAS score of 0 at rest. Wrist range of motion averaged 63° (±15) flexion, 57° (±17) extension, 79° (±4) supination, 79° (±4) pronation. Grip strength averaged 39 kg (±16) compared to 48 kg (±12) on the contralateral side. No complications or reoperations occurred aside from elective Kirschner wire removal in three patients.

Radiographically, mean SL gap was 2.3 mm (�0.8), SL angle 56� (�14), RL angle 0� (�16), and posterior radioscaphoid angle 101� (�14). Three patients demonstrated dorsal scaphoid translation. All fractures healed. KL arthritis grade was 0 (n=6), 1 (n=2), and 2 (n=2), most pronounced at the distal radioulnar joint in 4 cases. Six patients resumed unrestricted manual labour at 28 weeks (�16) postoperatively.

Conclusions
This small case series supports the feasibility, safety, and early efficacy of arthroscopically-assisted reduction and percutaneous fixation of the proximal row without ligament repair for acute perilunate injuries. Early results show excellent functional and radiographic outcomes with minimal complications or arthritis - particularly compared to previous experience with open techniques. Further studies are warranted to assess long-term durability.

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