Internal Brace Augmentation for Scapholunate Interosseous Ligament Injuries Is Supported by Limited Evidence and Is Associated With Early Failures: A Systematic Review.

BACKGROUND: Internal brace augmentation, a recently introduced technique using synthetic suture tape, has emerged as an adjunct to scapholunate ligament repair or reconstruction that provides immediate biomechanical stability and may facilitate earlier rehabilitation. Although early case reports have demonstrated rapid pain relief and functional recovery, recent mid- to long-term studies have raised concerns regarding perianchor osteolysis and late structural failure. To date, no systematic review of which we are aware has evaluated the discrepancy between favorable short-term clinical outcomes and emerging long-term concerns (perianchor osteolysis and structural failure).

QUESTIONS/PURPOSES: (1) Does internal brace augmentation improve pain, function, and disability in patients with scapholunate interosseous ligament (SLIL) injury? (2) Does internal brace augmentation achieve durable radiographic correction of carpal alignment? (3) What proportion of patients had perianchor osteolysis and structural failure?

METHODS: We performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines and registered the protocol in PROSPERO (CRD420261355353). PubMed, Embase, Web of Science Core Collection, the Cochrane Central Register of Controlled Trials, and Google Scholar were searched from inception through April 3, 2026. We included studies reporting clinical or radiographic outcomes of internal brace augmentation for SLIL injury in adults, with at least five patients and a minimum follow-up of 12 months, and excluded cadaver studies, technique descriptions without patient outcomes, review articles, and case reports with fewer than five patients. Methodological quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS). Owing to clinical and methodological heterogeneity, no meta-analysis was performed; results were synthesized narratively. Eleven studies (161 wrists, 160 patients) were included. Of these, two were comparative studies and nine were single-arm series; four studies assessed perianchor osteolysis and seven did not. Follow-up ranged from 12 to 50 months.

RESULTS: In the two comparative studies, adding the internal brace did not improve pain, function, or disability compared with reconstruction or fixation without it. Across the single-arm series, pain and function consistently improved (preoperative VAS pain of 6 to 8 improved to 0 to 4; grip strength 62% to 98% of the contralateral side). Radiographically, the scapholunate gap decreased from 4 to 6 mm preoperatively to 2 to 3 mm at most recent follow-up, and the scapholunate angle improved from a preoperative range of 65° to 84° to a postoperative range of 52° to 67°. However, the longest follow-up study (mean 50 months, n = 18) reported structural failure (loss of reduction or attritional rupture of the construct) in 44% of patients. Among the studies that assessed osteolysis, the proportion of patients with perianchor osteolysis was 47% at 14 months, 36% at 16 months, and 59% at 50 months, whereas a single all-arthroscopic study reported 0% at 16 months. One comparative study reported osteolysis in 36% of the internal brace cohort versus 0% in the reduction and association of the scaphoid and lunate (RASL) control group, suggesting that this complication may be related to the internal brace construct. Most studies had short and often incomplete follow-up, less rigorous (unblinded, nonindependent) outcome assessment, and probable selection bias. These limitations most likely overestimated the apparent benefit and underestimated the harm of the technique.

CONCLUSION: Most of the included studies lacked suitable comparator groups, did not assess key endpoints such as patient-reported outcomes and structural failure (including osteolysis), or did not follow patients long enough to detect all relevant harms; the apparent benefits of internal brace augmentation are therefore likely overstated. In the only study with follow-up beyond 4 years, structural failure of the anchor construct occurred in nearly one-half of patients, and osteolysis was already evident, both of which are concerning. Surgeons should counsel patients about the risks of late structural failure and perianchor osteolysis. Prospective studies with regular radiographic surveillance and a minimum follow-up of 5 years are needed before this technique is routinely adopted.

LEVEL OF EVIDENCE: Level IV, therapeutic study.