Challenges and complications of trans-osseous carpal tenodesis for scapholunate ligament tears

Scapholunate (SL) instability remains a challenging condition with significant possibility of implications for wrist function and long-term outcomes. This review explores the limitations and complications of current trans-osseous scapholunate ligament (SLL) reconstruction techniques, focusing on isometric reconstruction challenges and complications, for example osteonecrosis, tunnel fractures, graft failure, and iatrogenic extrinsic ligament injuries. Through biomechanical analysis and clinical case reviews, we demonstrate that the conventional three-ligament tenodesis (3LT) scaphoid tunnel has high risk of resulting in a non-isometric volar scapho-trapezial (vST) ligament reconstruction, potentially exacerbating carpal instability. Additionally, trans-osseous techniques have risk of osteonecrosis and fracture, which can accelerate degenerative changes and necessitating salvage procedures. This paper will additionally highlight concerns regarding tendon graft viability, anchor failure, and the critical role of extrinsic ligaments in SL stability. It will also be shown that modular arthroscopic approaches, which focus on selective ligament repair, may provide better outcomes with fewer complications and lower morbidity compared to traditional reconstructions. Future advancements probably should prioritise preserving bone vascularity and minimising iatrogenic injury, guiding surgeons toward safer and more effective treatment strategies.