Does midcarpal arthroscopy affect Geissler grade and treatment recommendations for suspected scapholunate ligament pathology?

Scapholunate instability is the most common form of carpal instability and is the result of a rupture of the scapholunate interosseous ligament (SLIL). The SLIL is a ligament connecting the dorsal volar and proximal lunate to the scaphoid. When patients have a complete rupture of the SLIL, they can experience episodic pain related to SLIL insufficiency or persistent pain related to subsequent osteoarthritis caused by malalignment. The impact and importance of SLIL pathology that is not a complete rupture and is not associated with carpal malalignment is a subject of debate and results in a substantial variation in care.

Because combined clinical and radiological examinations are often inconclusive, diagnostic arthroscopy may be offered to patients with wrist pain and possibly SLIL pathology. Moreover, some surgeons consider diagnostic arthroscopy to be the reference standard in the evaluation of SLIL pathology.

However, a diagnostic wrist arthroscopy would only be worthwhile if there is high yield of pathology that can be effectively addressed. A recent review of diagnostic wrist arthroscopy reported a very low yield of diagnoses. In 78% of the patients no pathological findings or mild synovitis was found. Furthermore, many of the arthroscopic findings were debatable and some lesions were possibly iatrogenic. Subsequent surgery followed in only 12% of all patients and much of it had a questionable value.

To arthroscopically evaluate the entire scapholunate interosseous ligament, radiocarpal and midcarpal evaluation can be performed. To save time of surgery and limit harm to the patient, sometimes only radiocarpal view is performed.

This study will address the primary null hypothesis that there is no difference in inter-observer variability for the Geissler classification of SL pathology between surgeons that viewed only radiocarpal and those who viewed radiocarpal and midcarpal videos.
We will also address the following secondary hypothesis: There is no variation in recommended treatment for patients with suspected SL pathology between surgeons that viewed only radiocarpal and those who viewed radiocarpal and midcarpal videos, accounting for surgeon characteristics; There is no difference in inter-observer variability for the Geissler classification of SL pathology between surgeon characteristics; Neither viewing the radiocarpal arthroscopy, nor surgeon factors are associated with type of surgery recommended.

The data collection will take place between October 2018 and May 2019, depending on the length of the waiting list for the SOVG, which is a list for new SOVG studies which will go online in consecutive order. The statistical data analysis will be performed after data collection and will take 1-2 weeks. Writing of the manuscript will take 2-4 weeks.

Surgeon members of the Science Of Variation Group (SOVG) will be asked to review 15 arthroscopic wrist videos and indicate their treatment reccomendation. The participants will be divided in two groups. Half of the participants (group A) will be randomized to receive radiocarpal arthroscopic videos. The other half (group B) will also receive midcarpal wrist videos.