Patent Publication Number: US-2009234396-A1

Title: Method and apparatus for articular scapholunate reconstruction

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application claims the benefit of U.S. provisional application No. 61/032,515, filed Feb. 29, 2008, the entirety of which is hereby incorporated by reference. 
    
    
     BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     The invention relates, in general, to reconstruction following injury to the scapholunate joint of the human hand and, more particularly, to methods and surgical instruments for reconstructing the scapholunate joint. 
     2. Description of Related Art 
     The human wrist is a complex articulation that allows motion in multiple planes. The wrist is actually a composite of multiple joint surfaces present between the distal end of the radius and ulna and the eight intrinsic carpal bones. On the proximal side of the joint are the broad joint surfaces formed from the distal end of the radius and ulna. Within the center of the wrist are two rows of small carpal bones, a proximal carpal row formed by the lunate, triquetrum, and pisiform and a distal carpal row formed by the trapezium, trapezoid, capitate, and hamate. Linking the two rows on the radial side of the carpus is the eighth carpal bone, the scaphoid. All of these bone elements are connected by a complex organization of multiple ligaments that provide stability of the multiple joint surfaces yet allow controlled motion to occur between the various osseous elements. 
     The joint that is formed between the base of the scaphoid and the lunate is particularly important. The lunate is a crescent shaped bone that is one of the main areas of load transfer between the proximal carpal row of the wrist and the distal radius. The scaphoid is an oblong bone that acts as a linkage between the proximal carpal row and the distal carpal row. Proximally, the scaphoid has a relatively flat surface where it articulates with an adjacent flat surface on the radial side of the lunate. The base of the scaphoid and lunate are anchored to each other by a group of ligaments known collectively as the scapholunate interosseous ligaments. These ligaments form a C-shaped connection between the base of the scaphoid and lunate, extending from the dorsal surface of this joint, continuing as a flat connecting ligament along the curved proximal edge where the two bones come together and ending in a palmar connection volarly. 
     Under normal conditions, the ligaments that connect the base of the scaphoid to the lunate function to coordinate motion between these bones. This prevents gapping between the scaphoid and lunate, prevents rotation of the scaphoid along its long axis (pronation or supination in relation to the lunate), and allows only slight dorsal or palmar translation of the base of the scaphoid in relation to the lunate. The C-shaped scapholunate interosseous ligament that extends from the dorsal edge back along the curved proximal edge of the articular surface between the two bones and ending at the distal palmar edge is a functional constraint that prevents step-off of the articular surface across the two bones. In effect, one role of these ligaments is to maintain a smooth articular surface between the base of the scaphoid and the proximal surface of the lunate so that abnormal wear of the distal radius is prevented. However, the inventor has observed that normally these ligaments function to allow the scaphoid to flex in relation to the lunate along a nearly circular arc of motion of the base of the scaphoid in relation to the lunate. These requirements of maintaining a congruent proximal articular surface between the scaphoid and lunate, yet simultaneously allowing flexion/extension movements of the scaphoid in relation to the lunate, is necessary to normal function of the wrist joint. 
     The C-shaped structure of the scapholunate interosseous ligaments is important in allowing flexion/extension while preventing translation or rotation of the scaphoid along its long axis. The C-shaped form results in a nearly transverse axis of rotation that is essentially perpendicular to the plane of the scapholunate joint at the center of the base of the scaphoid in relation to the lunate so that the base of the scaphoid can only displace slightly dorsally or palmarly with flexion/extension of the wrist. In addition, these ligaments constrain translational movements. It is the inventor&#39;s belief that the entire scapholunate interosseous complex is necessary for normal motion of the scaphoid. 
     The prevalent current teaching, though one that the inventor does not necessarily agree with, is that the dorsal edge of the scapholunate interosseous ligament is the main stabilizer of the scapholunate joint, and reconstruction of this portion of the ligament is all that is needed to restore normal or nearly normal joint function. If the only ligamentous attachment between the scaphoid and lunate were at the dorsal margin, the axis of rotation of the scaphoid with flexion and extension would be changed and shifted dorsally, resulting in dorsal translation of the base of the scaphoid as it flexes in relation to the base of the lunate. This would be expected to result in abnormal kinematics or movement of the scaphoid that contribute to osteoarthritis of the joint. In fact, in cases of chronic scapholunate disruption, accelerated osteoarthritis of the wrist ensues, and is usually first apparent at the articulation between the scaphoid and the distal articular surface of the radius. In these cases, the scaphoid can be noted to be translated dorsally and in a hyperflexed position, resulting in an incongruent joint with force concentration at the dorsal rim of the radius. This abnormal position is a result of the abnormal dorsal translation of the base of the scaphoid that occurs with this ligament injury. 
     As might be expected from the preceding description, injuries that result in rupture of the scapholunate interosseous ligament often lead to marked disability and arthritis of the wrist. In this context, the connection between the base of the scaphoid and the lunate is disrupted, allowing asynchronous motion to occur between these two small carpal bones. Typically, this results in separation of the base of the scaphoid away from the lunate, and migration of the capitate between these two bones. In this situation, the base of the scaphoid is no longer constrained to maintain congruency with the proximal articular surface of the lunate, but can displace dorsally resulting in significant offset of the articular surface and causing it to ride up against the dorsal edge of the articular surface of the radius. In addition, the scaphoid becomes uncoupled rotationally, resulting in pronation of the base and further incongruity of the radiocarpal joint. These abnormalities result in altered kinematics of the wrist and lead to an inexorable progression of pain, limited motion, decreased function, and arthritis. 
     Typically, significant rupture of the scapholunate interosseous ligament can result in subtle but consistent abnormalities of the relative positions of the carpal bones that can be identified on regular X-rays. The finding of an extended lunate in combination with a flexed scaphoid on the lateral film are suggestive of a scapholunate interosseous ligament tear. In addition, the finding of a gap between the scaphoid and lunate, sometimes only noted on a clenched fist view to load the wrist, can occur with this injury. Since rupture of the scapholunate interosseous ligament results in loss of the scaphoid linkage between the proximal carpal row and the distal carpal row resulting in a dorsiflexed attitude of the lunate, this condition has been also described as a dorsal intercalated segmental instability pattern, or DISI. 
     Many attempts to restore stability to the scapholunate joint have been tried over the years. One approach has been attempts at simple repair. Unfortunately, these ligaments are extremely short, often only a millimeter or two in length, and are usually shredded beyond repair. Furthermore, these bones are small and mostly covered by articular cartilage; it is technically difficult to place sutures directly into the small non-articular regions of bone. Sutures into the remaining ligament are tenuous and often rip out of the tiny ligament remnant that remains. Because fixation is tenuous, it must be supplemented with immobilization of the carpal bones with multiple pins for several weeks. Typically, this approach results in residual instability of the scapholunate joint and loss of movement. 
     A different approach has been reconstruction of the scapholunate joint with fully extramedullary placement of a tendon or ligament from another source. Tendons from the flexor carpi radialis, palmaris longus, and even bone-ligament-bone preparations that are harvested from the carpal-metacarpal joints of the hand or tarsal-metatarsal joints of the foot have been tried. In addition, allograft preparations (from a cadaveric human donor) have been tried. In general, these techniques have only reconstructed the dorsal scapholunate ligament by positioning and fixing the graft to the dorsal non-articular surface of the scaphoid and the lunate (or sometimes triquetrum). However, the available bone in this area is extremely small, compromising fixation by providing only a very limited area of ligament attachment and making this procedure technically difficult. In addition, since only the dorsal ligament is reconstructed, the rotational axis of the scaphoid in relation to the lunate is altered and moved dorsally, resulting in abnormal motion that causes the base of the scaphoid to shift dorsally as it flexes. In addition, the scaphoid and lunate remain uncoupled from rotational movement in pronation/supination. Again, since fixation of the tendon grafts to the bone elements is tenuous, fixation must be supplemented with temporary pins across the joints and prolonged immobilization that can result in stiffness. These issues often result in residual dysfunction, progression of arthritis, and a suboptimal result. 
     More recently, an approach to DISI instability caused by scapholunate ligament tears has been advocated which is characterized by inserting a screw across the scaphoid into the lunate. This so called RASL (‘reduction anatomic of the scapho-lunate’) procedure uses the screw to reduce and constrain the gap between the two bones. The screw is a rigid connection between the scaphoid and lunate. However, since the scaphoid “wants to flex” in relation to the lunate during normal motion, this procedure destroys the normal kinematics between these two bones. Because the screw is rigid, normal movements load the screw to create ‘windshield wiper’ movements in the scaphoid from the torque on the screw; this can result in significant bone loss. If the screw is not placed precisely in the correct axis of rotation, motion is restricted. In addition, if the scaphoid is allowed to move in relation to the lunate, some motion between the screw and the bone must occur. This often leads to destruction of the bone by movement against the screw and can lead to migration into the joint, fracture, arthritis, or breakage of hardware. Although more recently, screws have been introduced that attempt to allow some degree of rotation between the proximal and distal section of the screw in order to avoid these problems, this requires small moving parts that are subject to breakage with hardware that is more difficult to insert. In addition, since most implants are susceptible to fatigue and eventual failure, it is not a long term solution, particular for the younger patient population in whom this injury is commonly seen. 
     The present invention is intended to overcome these problems, and seeks to restore nearly normal kinematics to the scapholunate joint. One object of the present invention is to create a ligament reconstruction that limits dorsal/palmar translation of the base of the scaphoid in relation to the lunate, prevents separation or gapping of the scapholunate articulation, limits rotational movement of the scaphoid along its long axis (into pronation/supination relative to the lunate), yet allows near normal flexion/extension of the scaphoid relative to the lunate and this arc of motion along a physiologic transverse axis of rotation. 
     Another object of the present invention is to provide a means for a stable ligament reconstruction that is strong enough to allow early rehabilitation without require pinning of the carpus or prolonged periods of immobilization. Another object of the present invention is to provide a means to achieve strong fixation of a ligament reconstruction in a bone that is extremely small and predominantly articular. Another object of the present invention is to get a very strong repair in these very small bones, one that hopefully does not require pinning of the joint or immobilization; this is very difficult to do with techniques that simply apply a graft to the dorsal edges of these bones. 
     Another object of the present invention is to create a reconstruction that restores stability to prevent dorsal subluxation of the base of the scaphoid, which may well be the predominant cause of arthritis in injuries to the scapholunate joint. Another object of the present invention is to prevent gapping between the scaphoid and lunate, and to prevent abnormal rotation of the scaphoid along its long axis (pronation/supination), while at the same time allowing the normal physiologic flexion/extension of the scaphoid in relation to the lunate. Another object of the present invention is to restore the normal axis of rotation of the scaphoid for flexion/extension in relation to the lunate. Another objective of the present invention is a ligament reconstruction that has the ability to develop into a living, vascularized ligament that is not prone to implant failure with long term use. 
     These and other objects and features of the present invention will become apparent in view of the present specification, drawings and claims. 
     BRIEF SUMMARY OF THE INVENTION 
     The present invention includes methods for performing articular scapholunate ligament reconstruction using a tendon graft, as well as implements and instruments, including guides, screws, and suture anchors in the form of button-shaped and bead-shaped anchors, for facilitating a surgeon&#39;s performance of the various methods of the present invention. Moreover, the button-shaped and bead-shaped suture anchors of the present application are considered to have relatively broad surgical application, apart from scapholunate reconstruction. The present invention further includes kits comprising combinations of several of these implements and instruments. 
     In one method of the present invention, a tendon graft is harvested from the palmar longus or another suitable tendon. After exposing the carpus to the degree required, the scapholunate joint is reduced; if needed the reduction is temporarily held with pins. A guide pin is passed from the radial surface of the scaphoid, transversely through this entire carpal bone, across the scapholunate joint, and partially into the adjacent lunate. A cannulated drill is then extended along the guide pin to drill a 2 mm to 5 mm tunnel through the scaphoid, scapholunate joint, and partially into the interior of the lunate. Ideally, the guide pin should be inserted in the vicinity of the central axis of rotation of between the scaphoid and lunate. Preferably, the insertion site for the guide pin is nearly centered between the dorsal and palmar margin of the scaphoid. 
     Next, a guide, preferably E-shaped, is used to create a second hole entirely through the lunate, extending from the dorsal side to the palmar side, perpendicular to the first tunnel and intersecting the tunnel at its endpoint, to create a T-shaped channel within the lunate. This E-shaped guide can include a U-shaped member and central arm. The U-shaped member is preferably made of a radiolucent material to overcome the problem of obscuring the position of the central arm of the guide on X-ray, with collinear guide holes proximate the ends of opposing dorsal and palmar arms. The central arm includes a slotted eyelet which is collinear to the dorsal and palmar guide holes. This central arm preferably is made of a non-radiolucent material, facilitating the use of X-ray imaging to verify its proper positioning. 
     The E-shaped guide is positioned by inserting the central arm through the scaphoid, through the scapholunate joint, and into the lunate, and its accurate positioning is then confirmed by X-ray. First and second guide sleeves are then inserted into the opposing guide holes of the dorsal and palmar arms of the E-shaped guide, respectively. Next, a 2.0 mm drill is employed to create the second, vertical hole entirely through lunate, by extending the drill through the first guide sleeve, the dorsal arm, the slotted eyelet of the central arm, the palmar arm, and the second guide sleeve. Alternatively, the drill may be passed from palmar to dorsal. 
     A rigid pin and trailing tendon wire is next passed entirely through this second hole, by passing the pin and a portion of the tendon wire through all three collinear holes of the E-shaped guide. This pin and wire combination includes a rigid pin having one end swedged over or otherwise attached to a flexible wire, which may be manufactured from monofilament nylon (i.e., fishing line), braided wire, or nickel-titanium (nitinol) wire. Preferably, this tendon wire has a second rigid pin of smaller diameter swedged on or otherwise attached to the trailing portion of the flexible wire, and may have an optional wire loop attached to its trailing end. The guide sleeves are then removed, and the central arm of the E-shaped guide is withdrawn from the tunnel, pulling with it a looped, flexible central portion of the tendon wire out of the opening in the scaphoid. 
     Next, the tendon graft is looped about the tendon wire, and the ends of the tendon may be sutured together if desired. A pushing instrument is then used to guide the central loop of the tendon through the scaphoid, across the scapholunate joint and fully into the hole in the lunate. In a preferred embodiment, this pushing instrument is forked to guide the loop of the tendon graft into the hole. Alternatively, the two ends of the tendon wire are drawn apart, drawing the looped end of the graft through the scaphoid, scapholunate joint, and into the lunate. The tendon wire is withdrawn, pulling the larger diameter leading guide pin of the tendon wire back through the central loop of the graft in order to dilate it. Next, the tendon wire is advanced until the smaller diameter trailing guide pin engages the loop of the tendon graft; this smaller guide pin is sized to fit the central cannulation of the tendon screw. 
     A threaded, cannulated tendon screw is then extended over the tendon wire, through the dorsal opening of the lunate, through the loop of the graft, and towards the palmar opening in the lunate. In a preferred embodiment, the top and bottom portion of the screw are threaded with a smooth region therebetween in the area where the graft loop will be retained. Preferably, the bottom or leading thread is slightly smaller and rounder in order to avoid wrapping of the tendon by the screw as it is inserted. In another embodiment, only the top portion is threaded. 
     In another embodiment, a flexible line is passed through the second, vertical hole in the lunate. The central loop of this flexible line is withdrawn out the tunnel in the scaphoid and lunate and a tendon graft is looped through the loop of the flexible line. The graft is then positioned into the tunnel and the flexible line pulled taut. A cannulated guide pin is then threaded over the flexible line through the loop of the tendon graft. The threaded cannulated lunate screw is then directed over the guide pin, securing the loop of tendon in the lunate. 
     Next, the two arms of the graft, opposite the looped side, are pulled tightly away from the scaphoid, drawing the scaphoid and lunate together and shortening the gap between them. An optional interference screw or bone graft may be inserted if desired into the hole in the scaphoid to retain the graft between the sidewall of the hole and the screw. A bioabsorbable interference screw may alternatively be used to retain the graft at the scaphoid opening. Alternatively, no bone graft or interference screw is used but the graft is secured to the superficial surface of the scaphoid and/or lunate. 
     The tails of the graft extending out of the scaphoid hole are then looped around to the dorsal lip of the proximal scaphoid and secured in this region either with a suture anchor or with suture through drill holes in the bone. The remaining arm of the graft is then directed over the scapholunate joint, and on top of the dorsal surface of the lunate. These free arms are secured to the dorsal surface of the lunate. The graft may be secured with a suture that is placed through the cannulation of the lunate tendon screw and anchored on the palmar surface, with a suture extending through drill holes, in bone or with a suture anchor. This adds an additional layer of reconstruction and serves to further inhibit undesirable pronation and supination movement of the scapholunate joint. Optionally, the surgeon can add further reinforcement by continuing the graft over to the triquetrum and adding additional sutures or suture anchors to secure the end of the graft. 
     For this method, suture anchors in the general shape of screws, expandable anchors, buttons or beads may be used instead or in addition to affix an end of a suture proximate the lunate screw, towards securing the distal arms of the graft to the lunate. Alternatively, a looped end of the suture can be secured on the palmar surface of the lunate screw simply by tying a knot around the loop with a second heavier suture that is sized to be too large to pass through the cannulation in the screw. 
    
    
     
       BRIEF DESCRIPTION OF THE SEVERAL VIEWS OF THE DRAWINGS 
         FIG. 1A  of the drawings is a dorsal view of the carpal bones of the human hand, showing a dorsal view of the entire hand in an inset thereof; 
         FIG. 1B  is a palmar view of the carpal bones of the human hand, showing a palmar view of the entire hand in an inset thereof; 
         FIG. 1C  is a proximal view, looking distally, of the carpal bones of the human hand; 
         FIG. 2  is a simplified schematic, sectional view of the scaphoid and lunate and showing, in particular, an implanted lunate screw securing a looped end of an intramedullary tendon graft; 
         FIG. 3A  is a perspective view of the E-shaped guide; 
         FIG. 3B  is a rear view of the E-shaped guide; 
         FIG. 3C  is a sectional view of the E-shaped guide, taken generally along lines  3 C- 3 C of  FIG. 3B ; 
         FIG. 4A  is a top perspective view of the guide pin drill guide and associated referencing arm; 
         FIG. 4B  is a bottom perspective view of the guide pin drill guide and associated referencing arm; 
         FIG. 4C  is a front view of the guide pin drill guide and associated referencing arm; 
         FIG. 5  is a front view of the cannulated drill; 
         FIG. 6A  is a side view of the lunate screw; 
         FIG. 6B  is a top plan view of the lunate screw; 
         FIG. 6C  is a sectional view of the lunate screw, taken generally along lines  6 C- 6 C of  FIG. 6A ; 
         FIG. 7A  is a side view of the optional interference screw; 
         FIG. 7B  is a top plan view of the optional interference screw; 
         FIG. 7C  is a sectional view of the optional interference screw, taken generally along lines  7 C- 7 C of  FIG. 7A ; 
         FIG. 8  is a perspective view of the graft pusher; 
         FIG. 9  is a top plan view of the scapholunate reconstruction system kit; 
         FIG. 10  is a simplified palmar view of the carpal bones of the human hand and showing, in particular, the reduction of the scapholunate gap; 
         FIG. 11  is a simplified palmar view of the carpal bones of the human hand and showing, in particular, the insertion and orientation of the guide pin from a palmar vantage point; 
         FIG. 12  is a simplified proximal view, looking distally, of the carpal bones of the human hand and showing, in particular, the insertion and orientation of the guide pin from a proximal vantage point. 
         FIG. 13  is a palmar view of the carpal bones of the human hand and showing, in particular, the drilling of the trans-scaphoid/lunate hole; 
         FIG. 14  is an X-ray of the E-shaped guide with the central arm positioned within the scaphoid and lunate and showing, in particular, use of the radiolucent nature of a portion of the E-shaped guide to confirm proper placement of the central arm within the trans-scaphoid/lunate hole; 
         FIG. 15  is a proximal view, looking distally, of the carpal bones of the human hand and showing, in particular, the insertion of the drill sleeves through associated apertures of the E-shaped guide; 
         FIG. 16  is a simplified a proximal view, looking distally, of the carpal bones of the human hand and a simplified schematic view of the E-shaped guide and associated drill sleeves and showing, in particular, the drilling of the vertical lunate hole; 
         FIG. 17  is a proximal view, looking distally, of the carpal bones of the human hand and showing, in particular, the placement of the tendon wire through the vertical lunate hole and through portions of the E-shaped guide; 
         FIG. 18  is a proximal view, looking distally, of the carpal bones of the human hand and showing, in particular, the removal of the central arm of the E-shaped guide from the trans-scaphoid/lunate hole to draw a loop of the tendon wire out of the scaphoid; 
         FIG. 19  is a proximal view, looking distally, of the carpal bones of the human hand and showing, in particular, the looping of the tendon graft through a loop of the tendon wire; 
         FIG. 20  s a proximal view, looking distally, of the carpal bones of the human hand and showing, in particular, the loop of the tendon graft seated within the lunate; 
         FIG. 21  is a simplified schematic, sectional view of a combination of the scaphoid and lunate and showing, in particular, the use of the graft pusher to insert the tendon graft into the scaphoid and lunate; 
         FIG. 22  is a proximal view, looking distally, of the carpal bones of the human hand and showing, in particular, the insertion of the lunate screw; 
         FIG. 23  is a proximal view, looking distally, of the carpal bones of the human hand and showing, in particular, the dorsal reflection of the distal arms of the tendon graft; 
         FIG. 24A  is a side view of a suture loop for securing the distal arms of the tendon graft; 
         FIG. 24B  is a side view of the suture loop of  FIG. 8A  and showing, in particular, the preparation of the suture loop for placement about the button-shaped suture anchor; 
         FIG. 24C  is a side view of the button-shaped suture anchor; 
         FIG. 24D  is a side view of the suture loop secured to the button-shaped suture anchor using a Lark&#39;s Head knot; 
         FIG. 25A  is a side view of suture loop in preparation for insertion through the bead-shaped suture anchor; 
         FIG. 25B  is a side view of the suture loop and showing, in particular, the preparation of the suture loop for placement about the bead-shaped suture anchor; 
         FIG. 25C  is a side view of the suture loop secured to the bead-shaped suture anchor using a Lark&#39;s Head knot; and 
         FIG. 26A  is a side view of another embodiment of a suture anchor; 
         FIG. 26B  is a side view of yet another embodiment of a suture anchor; and 
         FIG. 27  is a proximal view, looking distally, of the carpal bones of the human hand and showing, in particular, the dorsal reflection of the distal arms of the tendon graft. 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION  
     While several different embodiments of the present invention are described herein and shown in the various figures, common reference numerals in the figures denote similar or analogous elements or structure amongst the various embodiments. 
     The carpal bones of a human right hand are shown in  FIGS. 1A-1C  as comprising the triquetrum  1 , pisiform  2 , trapezium  3 , trapezoid  4 , capitate  5 , hamate  6 , scaphoid  10  and lunate  20 . One aspect of the current invention is a method, and associated instruments, for performing scapholunate ligament reconstruction—i.e., repairing injury to the group of scapholunate interosseous ligaments, proximate the scapholunate joint. 
     The methods of the present invention perform ligament reconstruction using a tendon graft to create a replacement for the function of the scapholunate ligaments. The graft is placed in the vicinity of the center axis of rotation at the base of the scaphoid. The result of this reconstruction is shown in a simplified, schematic form in  FIG. 2 . A suitable tendon graft  40  of the palmar longus or other similar tendon and of suitable length is harvested, using tendon stripper  310  of scapholunate reconstruction system kit  300 , shown in  FIG. 9 . 
     Next, exposure of the carpus is done as needed. Typically, this will include dorsal exposure of the carpus with a skin incision radial to Lister&#39;s tubercle. A skin flap is elevated radially to an interval between the first and second compartment distal to the tip of the styloid, with the styloid tip being removed, if necessary. A skin flap is also elevated ulnarly to the triquetrum. The fourth compartment retinaculum is typically incised and, from within the fourth compartment, the radial septum is incised to the third compartment. The dorsal wrist capsule is typically incised transversely from the radial border of the second compartment to the mid-portion of the dorsal radiocarpal ligament, continuing obliquely to triquetrum. 
     Following exposure, the scapholunate joint is reduced, as shown in  FIG. 10 . In particular, as shown by the arrows of  FIG. 10 , scaphoid  10  is supinated to correct pronation, the capitate is pushed palmarly, and the scapholunate gap is closed. Specifically, the wrist is placed in approximately 20° of ulnar deviation, to expose the entry site of scaphoid  10 . Capitate  5  is translated palmarly to over correct lunate  20  flexion as much as possible. A heavy pin is placed from the ulnar side of the dorsal radius through the radiocarpal joint to engage and stabilize lunate  20 . This pin should be placed ulnarly to avoid instrumentation in the rest of the present procedure. If necessary, a tenaculum may be employed to close the scapholunate gap and pin scaphoid  10  to capitate  5  in a manner distal enough to avoid instrumentation in the rest of the procedure. 
     Next, as shown in  FIGS. 11 and 12 , a guide pin, such as Kirschner or K-wire  320 , is passed from radial surface  11  of scaphoid  10 , transversely across scaphoid  10 , across scapholunate joint  30  and partially into lunate  20 . The inventor has observed that the normal axis of rotation of the scaphoid in relation to the lunate is along an axis that is directed into the central part of the lunate between the dorsal/palmar surfaces, and is positioned as close to the distal surface of the lunate as possible. This corresponds to the center of a circle that is drawn around the base of the lunate and appears to be the primary transverse rotation axis of the scaphoid. 
     Guide pin  320  is preferably positioned along an axis  393  that is normal to the plane of the scapholunate joint  392  as shown in  FIG. 11 . In general, when the hand is in neutral position with the third metacarpal aligned with the long axis of the forearm  391 , the plane of the scapholunate joint  392  is inclined approximately 17 degrees to axis  391 . Moreover, as shown by dashed  391  coordinate axis of  FIG. 12 , guide pin  320  is preferably positioned at an angle of approximately five degrees supination. 
     A point of entry is selected for the guide pin that is approximately halfway between the dorsal/palmar surface of the scaphoid. The guide pin is inserted along the rotational center of the scaphoid (relative to the lunate), and across the scapholunate joint. In general, the guide pin should enter the lunate near its distal margin and is inclined proximally towards the triquetrum. 
     Placement of guide pin  320  may be facilitated with the use of guide pin drill guide  330 , shown in  FIGS. 4A through 4C  as comprising elongated central body  331 , first arm  332 , and second arm  333  at opposing ends of central body  331 . First arm  332  includes an aperture through which first drill guide sleeve  334  is inserted, and second arm  333  includes an aperture through which second drill guide sleeve  335  is inserted. In an embodiment of the present invention, first drill guide sleeve  334  includes a channel extending from top aperture  336  to bottom aperture  338  of approximately 1.6 millimeters in diameter. Second guide sleeve  335  includes a channel extending from top aperture  337  to bottom aperture  339  of approximately 4.0 millimeters in diameter, sized to accommodate a 3.6 millimeter cannulated drill. Bottom apertures  338  and  339  both have chamfered and serrated openings, serving to inhibit unwanted slippage of the drill guide sleeve upon placement adjacent a targeted region of bone. As shown in  FIG. 4C , first arm  332  and second arm  333  are each set at an angle  340  of approximately thirty degrees, relative to longitudinal axis  341  of elongated central body  331 . 
     As shown in  FIGS. 4A through 4C , drill guide locator sleeve  350  is releasably attachable to first drill guide sleeve  334 . The use of a detachable drill guide locator sleeve permits the option of selecting from amongst a plurality of locator sleeves having referencing arms of different, predetermined sizes to center the insertion site in order to accommodate a range of differently sized scaphoids that may be encountered. Preferably, a selected referencing arm places the entry site approximately five millimeters dorsal to the palmar surface of the proximal scaphoid. 
     Drill guide locator sleeve  350  includes cylindrical top portion  351  having top aperture  352  and four vertical slots  353 , equally spaced at ninety degree intervals about the circumference of top portion  351  and permitting top portion  351  to flex to facilitate secure yet releasable attachment of drill guide locator sleeve  350  about first drill guide sleeve  334 . Drill guide locator sleeve  350  further includes referencing arm  354 , having an upper curved region  355  proximate cylindrical top portion  351 . 
     In an embodiment of the present invention, a drill guide locator sleeve  350  is provided wherein cylindrical top portion  351  and referencing arm  354  are each approximately 0.500 millimeters in length, and curved region  354  provides an offset of approximately 0.197 inches of referencing arm  354  relative to a central longitudinal axis of cylindrical top portion  351 . 
     With drill guide locator sleeve  350  attached to first drill guide sleeve  334 , referencing arm  354  is placed under the scaphoid, palmarly. This serves to position guide pin  320  approximately 5 millimeters from the volar surface, and aligns guide pin  320  as it is advanced through first drill guide sleeve  334  in order to center the entry site of guide pin  320  as it is further advanced between the dorsal and palmar surfaces of the proximal pole of the scaphoid. 
     Next, as shown in  FIG. 13 , a cannulated drill bit, such as drill bit  360  of  FIG. 5 , is then drilled over guide pin  320 , through scaphoid  10 , across scapholunate joint  30  and partially into lunate  20 , creating tunnel  12  through scaphoid  10  and tunnel  22 , partially through lunate  20 . Drill bit  360  is shown in  FIG. 5  as comprising elongated shaft  361  having proximal handle attachment region  362  and distal cutting region  363 . Proximal handle attachment region  362  includes ball detent  364  and planar surface portion  365 , facilitating attachment of cannulated drill bit  360  to a “quick-change” type of drill. Elongated shaft  361  includes a plurality of graduated drill depth markings, including those  366  with bands only alternating with those  367  having both bands and numeric indicia. While a 3.6 mm cannulated drill is typically employed, any drill size between 3 mm and 5 mm may be used. 
     Prior to drilling, a depth gauge, such as pin depth gauge  380  of  FIG. 9 , is preferably employed to measure the depth of insertion of guide pin  320  to ascertain the required depth of the transverse scapholunate hole, using a second guide pin alongside to further confirm the required depth, and using a C-arm to check the depth of drill  360 . The targeted position of the drill hole in lunate  20  is slightly over halfway between the scapholunate and lunotriquetral joints. The direction of the scapholunate hole tends to angle proximally in lunate  20  as it approaches the lunotriquetral joint. If the transverse hole is drilled too deeply in lunate  20  (i.e., too close to lunotriquetral joint), the vertical hole will end up too far proximal/ulnar on lunate  20 . 
     If an optional interference screw, such as interference screw  120  of  FIGS. 7A through 7C , is to be employed in securing the graft to the scaphoid, a tap, such as  4 . 0  millimeter tap  390  of  FIG. 9 , may be employed to prepare the entry region of scaphoid hole to receive optional interference screw  120 . 
     Once tunnels  12  and  22  are drilled through scaphoid  10 , across the scapholunate articulation, and partially into lunate  20 , a guide, such as E-shaped guide  50 , shown in  FIGS. 3A through 3C , is then used to position a secondary, vertical lunate hole  23  (as shown in  FIG. 2 ) to be drilled through lunate  20 , intersecting and orthogonal to tunnel  22  proximate an endpoint of tunnel  22  (though, as shown in  FIG. 2 , tunnel  22  may extend beyond hole  23  to include region  172  to facilitate graft placement), extending from dorsal side  21  to palmar side  24  of lunate  20 . 
     Referring to  FIGS. 3A-3C , E-shaped guide  50  includes central arm  51  that is sized for insertion into the scapholunate tunnel comprising substantially collinear scaphoid tunnel  12  and lunate tunnel  22 . Central arm  51  has a central end with a substantially hook-shaped opening  52  creating an associated eyelet, and may be attached to U-shaped member  53  by cross pin  54 . U-shaped member  53  includes dorsal arm  55  and palmar arm  60 . Dorsal arm  55  includes slotted dorsal aperture  56 . Palmar arm  60  includes slotted palmar aperture  61 . As best seen in  FIG. 3C , slotted dorsal aperture  56 , hook-shaped opening  52 , and palmar aperture  61  are substantially collinear to each other. E-shaped guide  50  may optionally include cross-angled apertures  57 ,  58 ,  62  and  63  extending through dorsal arm  55  and palmar arm  60 , permitting the insertion of K-wires therethough to assist in maintaining E-shaped guide  50  in position as lunate hole  23  is drilled. 
     Central arm  51  is inserted through scaphoid tunnel  12  and into lunate tunnel  22 , until hooked end  52  of central arm  51  is proximate or abuts an endpoint of lunate tunnel  22 . Slotted dorsal aperture  56  of dorsal arm  55  is preferably positioned proximate the center or just past the radial/ulnar mid-line of the lunate from the anterior posterior view. Placement too far ulnar may result in placement of a lunate screw too proximal in the lunate. The position of the volar arm of E-shaped guide  50  is used to make a volar incision, ulnar to the median nerve. Dissection is performed bluntly to the palmar capsule. Once so positioned, dorsal arm  55  and palmar arm  60  of E-shaped guide  50  are disposed above and below the wrist, permitting secondary lunate hole  23  be created from palmar side  24  to dorsal side  21  of lunate  20  (or dorsal to palmar). 
     Once central arm  51  of E-shaped guide is inserted through scaphoid tunnel  12  and positioned within lunate tunnel  22 , the accurate desired positioning of central arm  51  is preferably confirmed via X-ray. As demonstrated in  FIG. 14 , U-shaped member  53  of E-shaped guide  50  is preferably constructed of a substantially radiolucent material, leaving only central arm  51  and cross pin  54  visible in the X-ray, facilitating the determination of the accurate positioning of central arm  51 . 
     Next, referring to  FIG. 15 , dorsal drill guide sleeve  80  is then inserted through slotted dorsal aperture  56  of E-shaped guide  50  until seated against the dorsal surface of lunate  20 , and an identically configured palmar drill guide sleeve  81  is inserted through slotted palmar aperture  61  until seated against the palmar surface of the lunate. Each guide sleeve  80 ,  81  is sized to form a friction fit with its associated aperture  56 ,  61  of E-shaped guide  50 . 
     Next, referring to  FIG. 16 , as drill guide sleeves  80  and  81  are held against lunate  20 , a drill, such as 2.0 mm drill  90 , is then placed from palmar to dorsal, or alternatively from dorsal to palmar, passing through guide sleeve  80 , through slotted dorsal aperture  56 , the aperture of hooked end  52  of central arm  51 , and exiting through palmar guide sleeve  81  and slotted palmar aperture  61 . Palmar arm  60  of E-shaped guide  50 , in conjunction with palmar guide sleeve  81 , ensures that drill  90  does not damage or sever the important nerves, arteries, and tendons on the palmar side as the tip of drill  90  exits palmar side  24  of lunate  20 . Moreover, drilling from palmar to dorsal is preferred, as the drill guide sleeve ensures that important nerves, arteries, and tendons are not wrapped or injured by the drill, and drilling in this direction lessens the risk of drilling the median nerve, should drill  90  somehow to miss the far drill guide sleeve upon exit. 
     Since lunate  20  is relatively small in size, the use of a two-armed drill guide and associated sleeves serves to satisfy the significant physical accuracy constraints imposed by the small size of lunate  20 , relative to the placement of transverse secondary lunate hole  23 . However, a substantially C-shaped, single-armed drill guide, having a central arm and a single dorsal or palmar outer arm, of similar construction to the dorsal and palmar arms of E-shaped guide  50 , may alternatively be employed. 
     Next, as shown in  FIG. 17 , once drill  90  has been placed, it is removed and flexible guide wire  100  is placed through the newly formed vertical secondary lunate hole  23  which, together with lunate tunnel  22 , forms a substantially T-shaped intramedullary channel within lunate  20 . Several different embodiments of the tendon wire  100  are contemplated. In most of the contemplated embodiments, a length of flexible material is attached to a rigid pin by swedging or otherwise attaching the flexible material onto the pin. The rigid pin is constructed of a material stiff enough to enable it to easily pass through dorsal guide sleeve  80 , through the eyelet of hooked end  52  of central arm  51  of E-shaped guide  50 , and out of palmar guide sleeve  81 . Meanwhile, the flexible material must be flexible enough to allow a loop of the flexible material to be pulled out through lunate tunnel  22  and scaphoid tunnel  12 , as will be described in detail, infra. Moreover, both the rigid pin and the flexible material must be small enough to pass through the 2 mm diameter of secondary lunate hole  23 . 
     In a first embodiment of the tendon wire  100 , a length of monofilament nylon is attached to a trailing end of the rigid pin. In a second embodiment of the tendon wire  100 , a length of braided wire is attached to a trailing end of the rigid pin. In a third embodiment of the tendon wire  100 , a length of a NITINOL (NIckel TItanium Naval Ordnance Laboratory) wire, a relatively stiff wire that can be bent but retains a ‘memory’ and straightens out spontaneously when the bending for is released, is attached to a trailing end of the rigid pin. In another embodiment, the tendon wire is simply a flexible piece of cable, wire or suture. In this embodiment, a stiff pin with a central cannulation is then thread over the flexible wire to guide the insertion of the lunate screw. In another embodiment, the tendon wire is of a form of two guide pins that are connected by an intermediate flexible wire, cable, or the like. The leading pin is of a diameter that is large enough to go through the vertical hole in the lunate and can be used to dilate the loop of tendon graft when it is in place. The trailing pin is sized to pass through the cannulation in the lunate screw in order to direct the screw through the graft loop after it has been dilated. In addition, a small trailing loop of wire or suture at the back end of the second pin allows a loop of suture to be shuttled through the center cannulation of the lunate screw as a means of anchoring the suture. 
     The leading rigid pin portion of the tendon wire  100  is passed through dorsal guide sleeve  80  and slotted dorsal aperture  56 , into secondary lunate hole  23 , through the eyelet of hooked end  52  of central arm  51 , further across secondary lunate hole  23 , through palmar guide sleeve  81  and slotted palmar aperture  61 , and out of palmar surface  24  of lunate  20 . The rigid pin is pulled completely out of lunate  20 , leaving the trailing wire traversing the entirety of transverse secondary hole  23 . Of course, alternatively, the tendon wire can be passed from palmar to dorsal. 
     Next, as shown in  FIG. 17 , dorsal guide sleeve  80  and palmar guide sleeve  81  are removed by sliding them in opposing directions along tendon wire  100 . Tendon wire  100  is then uncoupled from dorsal arm  55  and palmar arm  60  of E-shaped guide  50  by pulling portions of the tendon wire  100  through the slots of slotted dorsal aperture  56  and slotted palmar aperture  61 . 
     Referring to  FIG. 18 , central arm  51  of E-shaped guide  50  is then pulled out of lunate tunnel  22  and scaphoid tunnel  12 , bringing with it a central portion of the tendon wire  100  that is engaged by hooked end  52  of central arm  51 . Next, as shown in  FIG. 19 , central portion  43  of graft  40  is then looped around the central loop of the tendon wire  100 , and a strong running suture may optionally be used to sew distal arms  41 ,  42  of graft  40  together, starting approximately five millimeters away from the central loop of the tendon wire  100  and continuing down toward the distal free end arms  41  and  42  of graft  40 . 
     Next, as shown in  FIG. 20 , the two free ends of tendon wire  100 , exiting the distal and palmar openings of vertical secondary hole  23 , respectively, are pulled apart from each other until the portion of tendon wire  100  therebetween becomes taut. This, in turn, pulls the central loop of tendon wire  100 , together with the looped end  43  of graft  40  looped about the central loop of tendon wire  100 , into the opening of scaphoid tunnel  12  adjacent radial surface  11  of scaphoid  10 , through the entirety of scaphoid tunnel  12 , across scapholunate articulation, or joint  30 , and into lunate tunnel  22 , until looped end  43  of graft  40  reaches the juncture of lunate tunnel  22  and vertical secondary lunate hole  23 . Optionally, tendon wire  100  is then withdrawn until the larger pin is drawn back up into the vertical lunate hole  22 , through the loop  43  in graft  40  and out the top of the lunate  20 , in order to dilate the opening of the loop  43  in graft  40  and ensure that it is not adherent to tendon wire  100 . Optionally, tendon wire  100  may be pulled back and forth through secondary lunate hole  23  several times in an oscillating manner, to ensure that graft  40  slides freely over tendon wire  100  and that looped end  43  is completed seated in transverse lunate hole  23 . Tendon wire  100  is then advanced until its trailing pin is seated fully in vertical hole  23  in lunate  20 , including passing through loop  43  in tendon graft  40 . 
     Alternative methods of positioning and seating looped end  43  of graft  40  at the junction of lunate tunnel  22  and vertical secondary lunate hole  23  are also contemplated. For example, in  FIG. 21 , scaphoid  10 , lunate  20 , and scapholunate articulation  30  are shown in combined, simplified schematic form, viewed from the dorsal side, and are identified by reference numeral  170 . Moreover, scaphoid tunnel  12  and lunate tunnel  22  are shown in combined, simplified schematic form, viewed from the dorsal side and with the scapholunate gap omitted, and are identified by reference numeral  171 . 
     In this alternative method, the scaphoid and lunate tunnels, as well as vertical lunate hole  23 , are prepared in the manner previously described. Moreover, in the manner previously described, tendon wire  100  is passed through lunate hole  23  and hooked end  52  of central arm  51  of E-shaped guide  50 , and central arm  51  is withdrawn from the scaphoid and lunate tunnels, pulling a central loop of the tendon wire  100  out of the radial side of the scaphoid. Furthermore, in the manner previously described, graft  40  is looped around the central loop of tendon wire  100  to form graft loop  43 , and distal arms  41  and  42  of graft  40  may be sewn together, preferably with a strong running suture. Next, as shown in  FIG. 21 , a forked implement, such as graft pusher  180 , shown in simplified form in this figure, is employed to engage graft loop  43 , and to push graft loop  43  through the scaphoid and lunate tunnels  171  until graft loop  43  is seated at or beyond the junction of the scaphoid and lunate tunnels  171  and transverse lunate hole  23 . Graft pusher  180  includes handle region  181 , elongated shaft  182 , and forked end  183 , having two tines. Looped end  43  of graft  40  is engaged between the tines of graft pusher  180 , and is then pushed by graft pusher  180  fully through the scaphoid tunnel until it is fully seated at the end of the lunate tunnel, proximate the juncture of the lunate tunnel with transverse secondary lunate hole  23 . Next, graft pusher  180  is removed from the scaphoid and lunate tunnels  171 , leaving looped end  43  of graft  40  in place. The use of graft pusher  180  is considered to be a more gentle method of seating graft  40  within lunate  20 , reducing the risk of abrasion or other damage to graft  40 . 
     Graft pusher  180  is shown in further detail in  FIG. 8  as comprising elongated shaft  185 , having a proximal end including handle  181 , and a distal, forked end  183  including tines  186  and  188 , separated by concave region  187 , providing a smooth, arcuate surface for engaging looped end  43  of graft  40 . 
     In a variation of this alternative method of positioning and seating looped end  43  of graft  40  at the junction of lunate tunnel  22  and vertical secondary lunate hole  23 , vertical lunate hole  23  is not formed at the very end of lunate tunnel  22 , but is instead formed to intersect lunate tunnel somewhat towards the radial side of its internal endpoint, further towards scapholunate articulation  30 . This, in turn, creates an extended region  172  of the lunate tunnel, as shown in  FIGS. 2 and 21 . Referring to  FIG. 21 , in this variation, forked implement  180  is used to push looped end  43  of graft  40  completely into extended region  172  of the lunate tunnel, beyond the intersection of the lunate tunnel with transverse secondary lunate hole  23  so as to prevent wrapping of the loop of the graft around the tip of the lunate screw as it is advanced into the hole. Next, as shown in  FIG. 22 , regardless of how looped end  43  of graft  40  is seated within lunate  20 , cannulated lunate screw  110  is then passed over the end of the trailing pin of the tendon wire  100  extending out of the dorsal side aperture of vertical lunate hole  23 , and is then threaded down into lunate hole  23 , typically using a cannulated hexagonal screwdriver, such as hex driver  480  in combination with handle  370  of  FIG. 9 . Alternatively, a cnanulated guide pin may be threaded over a simple flexible tendon wire  100  to guide cannulated screw  110 . Tendon wire  100  thus guides cannulated lunate screw  110  down through vertical lunate hole  23 , and through looped end  43  of graft  40 , fixing looped end  43  in place, intramedullary to lunate  20  and disposed about smooth central region  112  of cannulated lunate screw  110 . Once lunate screw  110  has been so placed, the distal end of graft  40  is tugged away from the scaphoid hole to insure graft  40  is well secured by lunate screw  110 . Lunate screw  110  may be made out of any biocompatible material, such as metal or metal alloy, plastic, ceramics, or bioaborbable material. 
     A first embodiment of cannulated lunate screw  110  is shown in  FIGS. 6A through 6C  as comprising a generally cylindrical body having first threaded region  111  for threadably engaging lunate hole  23  proximate dorsal side  21 , substantially smooth central region  112  for engaging looped end  43  of graft  40 , and second threaded region  113  for threadably engaging lunate hole  23  proximate palmar side  24 . Tapered end  116  facilitates the passage of cannulated lunate screw  110  through looped end  43  of graft  40 , reducing the likelihood that the graft will be damaged by the passage of the lunate screw therethough. Tapered end  116  may be either substantially conical in shape, as shown in  FIGS. 6A and 6C , or substantially hemispherical in shape. Elongated channel  115  communicates with hexagonal driver accepting region  114  to provide a contiguous passage extending through the entire length of cannulated lunate screw  110 . In one embodiment, threaded region  113  is smaller in diameter than threaded region  111  and may include threads that are not as sharp to reduce the likelihood of damaging the graft as the screw is passed. 
     In another embodiment of cannulated lunate screw  110 , second threaded region  113  is omitted, and substantially smooth central region  112  extends from first threaded region  111  to tapered end  116 . The omission of second threaded region  113  eliminates the possibility of a threaded region of cannulated lunate screw  110  damaging looped end  43  of graft  40  as cannulated lunate screw  110  is guided along tendon wire  100  and through the aperture of looped end  43 . In either embodiment of cannulated lunate screw  110 , other configurations of driver accepting region  114 , such as configurations accepting Phillips or TORX drivers, rather than hexagonal drivers, may alternatively be used. 
     In another embodiment of the present invention, a retaining member in the form of a cannulated screw is not employed. Instead, a retaining member in the form of a cannulated, generally cylindrical peg, having a plurality of ridges extending outwardly from the arcuate outer surface of the peg, is provided, and may be hammered into place, dorsally to palmary, within transverse secondary lunate hole  23 . 
     Once cannulated lunate screw  110  has been threaded dorsally to palmary into transverse secondary lunate hole  23 , loop  43  of graft  40  is fixed rigidly within lunate  20 . Next, distal arms  41  and  42  of graft  40  are pulled tightly out of radial end  11  of scaphoid  10 , closing the gap between scaphoid  10  and lunate  20  at scapholunate articulation  30 . 
     In one embodiment, fixation of the tendon graft  40  within the scaphoid tunnel  12  is done with an interference screw  120  which is then inserted into a previously tapped region of scaphoid tunnel  12  at radial end  11 , alongside graft  40 , fixing a portion of graft  40  in place against the sidewall of scaphoid tunnel  12 . As a result of the foregoing method, a relatively large tendon graft  40  is rigidly secured in both the scaphoid  10  and the lunate  20 . The gap  30  between scaphoid  10  and lunate  20  is securely closed and dorsal migration of scaphoid  10  in relation to lunate  20  is prevented by graft  40 , since it is disposed transversely across scapholunate joint  30 . Furthermore, since graft  40  is flexible in a manner similar to a normal ligament, relative flexing or movement between scaphoid  10  and lunate  20  is permitted, without significant risk of hardware failure, loss of fixation, or bone destruction of the scaphoid, as may occur in a prior art RASL procedure. Use of an interference screw is not necessarily a preferred method if securing the distal arms of the tendon graft, however, due to concerns of fracturing the scaphoid as a result of hoop stress. 
     Sounds, such as plug pins  400 ,  410  and  420  of  FIG. 9 , may be used to confirm that sufficient room exists for placement of an interference screw of a desired size. In a preferred embodiment, plug pins  400 ,  410  and  420  are 3.0 mm, 3.4 mm and 3.8 mm in size, respectively. Plug pin  410 , for example, ensures sufficient room for a 3.5 mm interference screw. 
     Interference screw  120  is shown in  FIGS. 7A through 7C  as comprising a substantially cylindrical body having threaded region  121 , tapered end  126 , and hexagonal driver accepting region  124 . Other configurations of driver accepting region  124 , such as configurations accepting Phillips or TORX drivers, rather than hexagonal drivers, may alternatively be used. 
     Interference screw  120  is preferably provided with a relatively rounded head region  127 , as it is placed through a hole that enters a relatively oblique area of scaphoid  10 . In one embodiment of the present invention, interference screw  120  is constructed of a bio-absorbable material. In another embodiment of the present invention, interference screw is constructed of PEEK (polyether-etherketone), a relatively hard, radiolucent non-absorbable plastic. Alternatively, the portion of the graft in the scaphoid hole  12  may be secured with osseous sutures, suture anchors, plugs, bone graft or bone dowels, or similar options well known in the art. 
     Another method of graft fixation via scaphoid interference is the use of a bone plug. Again, plug pins  400 ,  410  and  420  may be used as sounds to determine an appropriately sized bone plug to place in the scaphoid hole. Using an appropriately size hollow mill, such as hollow drill  430 ,  440 , and  450  of  FIG. 9 , a plug of bone is removed from the radius. In a preferred embodiment, hollow drills  430 ,  440  and  450  are 3.0 mm, 3.4 mm and 3.8 mm drills, respectively. One of plug pin  400 ,  410  or  420  may be used to remove the bone plug from the hollow mill. 
     A further improvement of the fixation of the scapholunate reconstruction may be obtained by adding an additional step to the foregoing procedure, in an alternative method of the present invention. In this embodiment, an interference screw may or may not be used to secure a portion of graft  40  adjacent a sidewall of scaphoid tunnel  12 . As shown in  FIG. 23 , distal arms  41  and  42  of graft  40 , extending out of scaphoid tunnel  12  at its aperture at radial surface  11  of scaphoid  10 , are taken and looped around the peripheral surface of scaphoid  10 , up across the dorsal surface of scaphoid  10 , across scapholunate joint  30 , to the dorsal surface of lunate  20 . Distal arms  41  and  42  of graft  40  are again pulled taught to close scapholunate gap  30 , and are then secured to the dorsal surface of scaphoid  10  and/or the dorsal surface of lunate  20 , using suture through drill holes, or a conventional suture anchor. 
     This alternative method of the present invention adds a second layer of reconstruction of the dorsal portion of the scapholunate ligament, and results in a distal sling portion of graft  40  that rigidly holds the base of scaphoid  10  to lunate  20 , with one arm of the sling portion fixed in a more dorsal position and one arm in a more palmar position. This adds additional constraint to scapholunate joint  30 , and adds additional stability to restrict axial rotation (i.e., pronation/supination movement) of scaphoid  10 . With the two limbs of ligament reconstruction thus created, one through scapholunate joint  30  and one dorsally, there are two limbs of fixation present, separated by a distance, yielding improved resistance to torque and abnormal rotation of scaphoid  10  about its long axis. Moreover, this alternative method of the present invention restores significant stability to scapholunate joint  30 , allows nearly normal flexion/extension of scaphoid  10  to occur in relation to lunate  20 , while constraining any large dorsal translation of the base of scaphoid  10  and inhibiting gapping between scaphoid  10  and lunate  20 . In addition, the fixation is secure enough to allow early mobilization of scapholunate joint  30  with rigid fixation of a sizeable graft  40  between two very small carpal bones. 
     An alternative method and associated apparatus for securing a suture tied to distal arms  41  and  42  of graft  40  adjacent dorsal surface of lunate  20 , which may be used with or without a supplemental suture anchor, will now be described. In particular, a generally button-shaped suture anchor of the present invention is provided for use in cooperation with cannulated lunate screw  110 . 
     After threading cannulated lunate screw  110  into transverse secondary lunate hole  23 , a pin is passed palmary to dorsally through the central hole of the lunate screw. This pin has a small loop of suture attached to a dorsal end thereof. Alternatively, the tendon wire used in the previous step to guide the lunate screw can be produced with a small loop of suture on the trailing portion to accomplish the same purpose. Referring to  FIGS. 24A through 24D , a double armed suture  130  (i.e., a suture with a needle on each distal end  132 ) is passed through the loop of suture or wire attached to the pin. The pin is then withdrawn out palmar side  24  of lunate  20 , pulling central loop  131  of double armed suture  130  through the central hole of cannulated lunate screw  110 . On palmar side  24  of lunate  20 , central loop  131  is retrieved. The loop attached to the end of the pin is then cut, freeing the loop of double armed suture  131 . A second piece of heavy suture which is too large to pass through the central hole of the lunate screw  110  is then tied around the loop to anchor it on the palmar side when the arms of the suture  130  are sutured into the tendon graft dorsally, tightened and tied together. Alternatively, the suture can be folded back on itself as shown in  FIG. 24B  and then locked around a suture button  140 . as shown in  FIG. 24D . 
     As shown in  FIG. 24C , a substantially hemispherical, button-shaped suture anchor  140  is provided. A central hemispherical groove  141  is provided to maintain an associated suture proximate an apex of suture anchor  140 , and to keep the associated suture from sliding off in either direction from central groove  141 . In a preferred embodiment, button-shaped suture anchor  140  is constructed of a biocompatible material such as metal, metal alloy, bioabsorbable material, PEEK, or other plastic material. Alternatively, this button could be spherical, flat, disc shaped, or other shapes. 
     Next, as shown in  FIG. 24D , double armed suture  130  is fixed about button-shaped suture anchor  140 , buy passing both loops of suture  130  about central groove  141  and then through central loop  131 , with suture anchor  140  locked in place as distal ends  132  of suture  130  are tightened, thus forming a Lark&#39;s Head knot with suture  130  about suture anchor  140 . 
     Distal ends  132  of suture  130  are then pulled taut through the dorsal side of lunate screw  110 , anchoring suture anchor  140  and, in turn, central loop  131  against palmar surface  24  of lunate  20  (or the palmar end of lunate screw  110 , if it is extending out beyond palmar surface  24  of lunate  20 ). The distal needles of suture  130  are then sewed into graft  40 , tightened and tied to lock the distal arms  41  and  42  of graft  40  down against dorsal surface  21  of lunate  20 . 
     Yet another alternative method and associated apparatus for securing a suture tied to distal arms  41  and  42  of graft  40  to the dorsal surface of lunate  20 , which may be used with or without a supplemental suture anchor, will now be described. In particular, a generally bead-shaped suture anchor of the present invention is provided for use in conjunction with cannulated lunate screw  110 . 
     Referring to  FIGS. 25A , central loop  131  of double armed suture  130  is passed first dorsal to palmar through the central channel of the lunate screw to exit palmarly, and then threaded through vertical channel  151  extending through bead-shaped suture button  150 . Next, as shown in  FIG. 25B , central loop  131  is widened to enable it to be pulled down around the exterior of bead-shaped suture button  150 . Next, as shown in  FIG. 25C , loop  131  is passed around the back of the button  150  and free ends  132  are pulled taut, forming a Lark&#39;s Head knot and securing suture  130  to bead-shaped suture button  150 . In a preferred embodiment, bead-shaped suture anchor  150  is constructed of a biocompatible material such as metal, metal alloy, bioabsorbable material, PEEK, or other plastic material. 
     Distal ends  132  of double-armed suture  130  are then tightened and pulled taut from the dorsal side, anchoring suture anchor  150  and, in turn, central loop  131  against palmar surface  24  of lunate  20  (or the palmar end of lunate screw  110 , if it is extending out beyond the palmar surface  24  of lunate  20 ). The distal needles of suture  130  are then sewed into graft  40 , tightened and tied to lock the distal arms  41  and  42  of graft  40  down against the surface of lunate  20 . 
     Additional alternative suture anchors  460  and  470  are shown in  FIGS. 26A and 26B . Though slightly different in size and shape, suture anchors  460  and  470  share the same basic construction, having disc-shaped heads  461  and  461 , arcuate bottom loops  463  and  473 , and apertures  462  and  472 , respectively. Suture anchor  460  is shown in  FIG. 27 , positioned with bottom loop  463  drawn into to the palmar side of vertical lunate hole  23  by a suture extending through the hole and sewn into distal arms  41  and  42  of graft  40  to secure graft  40  in place at the dorsal side of vertical lunate hole  23 . 
     As an alternative to a suture button, a heavy strand of Ethibond® or other suitable suture may be tied securely to the loop of suture in the palmar incision to create a knot that is sized to be unable to pass through vertical lunate hole  23  or the cannulated channel  115  in lunate screw  110 . Such polyester sutures are considered to be of sufficient strength to go up the lunate hole. 
     The present invention also includes kits of components, comprising combinations of several of the previously described implements. For example, any permutation or combination of two or more of any of the above-identified elements may be combined in kit form. Specific or assorted sizes of cannulated and non-cannulated drills, hexagonal or other form of drivers, and associated standard or quick-change handles may likewise further be included in any of these kit combinations. 
     By way of example, scapholunate reconstruction system kit  300  is shown in  FIG. 9  as comprising tray  301 , having a plurality of indentations for retaining implements and implants employed to perform the scapholunate reconstruction of the present invention. In particular, tray  301  holds, amongst other items, E-shaped guide  50 ; drill guide sleeves  80 ,  81 ; 2.0 mm drill  90 ; K-wires/guide pins  100 ; lunate screws  110 ; interference screws  120 ; suture beads  150 ; graft pusher  180 ; tendon stripper  310 ; tendon wire  320 ; guide pin drill guide  330 ; drill guide locator sleeve  350 ; cannulated drill  360 ; handle  370 ; pin depth gauge  380 ; tap  390 ; plug pins  400 ,  410  and  420 ; hollow drills  430 ,  440  and  450 ; and hex driver  480 . 
     The preceding description and drawings merely explain the invention and the invention is not limited thereto, as those of ordinary skill in the art who have the present disclosure before them will be able to make changes and variations thereto without departing from the scope of the present invention.