title: Distal tunnel placement improves scaphoid flexion with the Brunelli tenodesis procedure for scapholunate dissociation.
abstract: OBJECTIVE
  Treatment of scapholunate dissociation remains difficult. The modified Brunelli procedure, a flexor carpi radialis tenodesis through the scaphoid and secured with dorsal wrist ligaments, has shown promising results. This study compares the biomechanical effects on scaphoid flexion and scapholunate gap between proximal and distal tunnel placement in the modified Brunelli procedure.
  
  
  METHODS
  Eight fresh-frozen cadaveric forearms were used. A dorsal approach to the wrist through the floor of the fourth compartment was used. Metallic markers were implanted into the scaphoid and lunate. Tunnels were drilled through the proximal and distal poles of the scaphoid. Wrists were positioned in neutral and loaded to 100 N through the wrist flexor and extensor tendons. Posteroanterior and lateral radiographs were taken with the scapholunate interval intact, with the scapholunate interval sectioned, and after the modified Brunelli tenodesis was performed through the proximal and then distal tunnels using Mersilene tape. Radiographs were analyzed for change in scapholunate angle and scapholunate gap. Multivariate analysis of variance was performed to assess statistical significance for each state compared with the intact wrist.
  
  
  RESULTS
  In the intact wrist, the mean scapholunate gap was 1.6 mm +/- 0.1. With the scapholunate interval sectioned, the scapholunate angle increased by 26 degrees +/- 12 and gap increased to 4.2 mm +/- 1.2. With a proximal tunnel for the modified Brunelli procedure, the change in scapholunate angle decreased to 15 degrees +/- 10 and gap decreased to 1.8 mm +/- 0.3. With a distal tunnel for the modified Brunelli procedure, the change in scapholunate angle decreased to 4 degrees +/- 7 and gap decreased to 1.3 mm +/- 0.2.
  
  
  CONCLUSIONS
  These biomechanical data suggest that a tunnel exiting in the distal pole of the scaphoid results in better correction of scaphoid flexion when performing the modified Brunelli procedure.
authors.affiliation: Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA 98195-4743, USA. jhowlet@u.washington.edu
authors.forename: John P C
authors.initials: JP
authors.lastname: Howlett
authors.forename: H James
authors.initials: HJ
authors.lastname: Pfaeffle
authors.forename: Thanapong
authors.initials: T
authors.lastname: Waitayawinyu
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Trumble
mesh_terms: D000368:Aged; D002102:Cadaver; D050824:Carpal Joints; D005260:Female; D006801:Humans; D007593:Joint Instability / Q000000981:diagnostic imaging / Q000601:surgery*; D008023:Ligaments, Articular / Q000601:surgery; D012667:Lunate Bone; D008297:Male; D008875:Middle Aged; D011859:Radiography; D016059:Range of Motion, Articular; D021361:Scaphoid Bone; D053656:Tenodesis / Q000379:methods*; D016474:Weight-Bearing