Reply: Outcomes of All-Dorsal Augmented Intercarpal Ligament Reconstruction

We were intrigued to read the constructive response by Drs. de Villeneuve Bargemon, Gandolfi, and Lupon to our article published in Plastic and Reconstructive Surgery.1 Their feedback underscores the challenges of finding an optimal surgical solution for chronic scapholunate (SL) instability and concerns with early adoption of a new surgical technique. We are continuing to follow our cohort, and since the time of publication, 18 more patients have been enrolled in the study, and 25 patients are due for follow-up of 2 years or more. The importance of caution when applying new surgical techniques is highlighted by Scott’s parabola, which outlines the life cycle of new medical treatments that are adopted prematurely into standard care, only to be abandoned once evidence of inefficacy or harm emerges.2 The variability in pathology among patients with irreparable scapholunate interosseous ligament (SLIL) tears is vast, ranging from dynamic instability to static SL interval diastasis and dorsal translation of the scaphoid.3 Moreover, the distinction between the latter, severe type of SL dissociation and early SL advanced collapse (for which SLIL reconstruction is no longer indicated) is not clear-cut.4 This variability in pathology and surgical indications likely contributes to the relatively equivalent results among different reconstructive techniques. There is likely no “one size fits all” solution to SLIL reconstruction. It is possible that single-incision techniques are better suited for patients with dynamic instability, whereas more demanding anatomic reconstructions (or even salvage surgery) are superior for advanced instability with static radiographic changes. Comparative studies, likely through large-scale, sufficiently funded, multicenter efforts, are needed to define indications for specific reconstructive techniques. Recent studies have resurfaced concerns about osteolysis around polyetheretherketone (PEEK) anchors used in hand and wrist surgery.5,6 In our series, we did not observe perianchor osteolysis after 12 months. An early biologic reaction to PEEK material is exceedingly rare, and the appearance of perianchor lucencies and clinical symptoms in the early postoperative course could reflect technical errors during drilling or anchor insertion. Late osteolysis has been found to occur around metallic anchors and anchorless rotator cuff repairs as well. The clinical significance of this finding is not clear, as studies have failed to link osteolysis with clinical outcomes or even objective measurements of rotator cuff tendon retears.7,8 Nonetheless, the threat of reconstructive failure due to suture anchor osteolysis should not be taken lightly. Small bones in the hand and wrist may be particularly susceptible to catastrophic complications, such as fracture around the implant. Soft metaphyseal bone may also be predisposed to increased implant micromotion and osteolysis. The ideal biomaterial for ligament reconstruction in the hand and wrist is yet to be established. PEEK anchors carry advantages over metallic and biodegradable options. Compared with truly biocompatible repairs using tendon grafts, bone anchors with suture tape have marked advantages, including increased strength of initial fixation, lack of need for supplemental Kirschner wires, reduced graft creep, and technical ease. These technical implications need to be weighed against the prospect of construct failure and need for revision surgery. Much work has to be done to understand the optimal approach to SLIL reconstruction. DISCLOSURE Dr. Chung receives funding from the National Institutes of Health and book royalties from Wolters Kluwer and Elsevier. This study was an independent study without industry sponsorship. Both authors certify that there are no funding or commercial associations that might pose a conflict of interest in connection with the submitted communication in relation to the author or any immediate family members.