72: Dorsal Capsulodesis for Scapholunate Instability Using Suture Anchors

Published on 17/04/2015 by admin

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Last modified 17/04/2015

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Procedure 72 Dorsal Capsulodesis for Scapholunate Instability Using Suture Anchors

Shimpei Ono, Sandeep J. Sebastin, Kevin C. Chung

See Video 53: Dorsal Capsulodesis for Scapholunate Ligament Injury

Indications

Static or dynamic dorsal intercalated segmental instability (DISI) deformity is found without a wide scapholunate (SL) gap.

We determine the treatment for SL instability based on clinical presentation, radiographic appearance, and arthroscopic and intraoperative findings. Our current algorithm for selection of appropriate procedure for SL instability is indicated in Table 72-1.

Table 72-1 Selection of Treatment

Examination/Imaging

Clinical Examination

Patients complain of radial-sided wrist pain especially with loading activities, weakness of grip, and swelling, along with discomfort at extremes of wrist extension and radial deviation.

Tenderness is found in the radial snuffbox or over the SL interval just distal to the Lister tubercle.

The following two provocative tests have been described for global assessment of wrist pain. These tests are useful in patients when the history and findings of examination do not match. However, they do not indicate the location or nature of the pathology.

• Carpal shake test: This involves grasping the patient’s distal forearm and passively shaking or passively extending and flexing the wrist. Lack of patient resistance or complaints suggests a low level of carpal disease.

• Sitting hand test: The patient is asked to support his or her weight off the chair while seated. This maneuver produces stress across the wrist, and patients with wrist disease find it difficult to perform this.

One or more of the following provocative tests may be positive depending on the degree of injury to the SL ligament and integrity of the secondary stabilizers.

• Scaphoid shift test (Watson): The examiner places four fingers behind the radius. The thumb is placed on the scaphoid tuberosity, and the other hand is used to move the wrist passively from ulnar to radial deviation. In ulnar deviation, the scaphoid is extended, whereas in radial deviation, the scaphoid is flexed. Pressure on the tuberosity while the wrist is moved from ulnar deviation to radial deviation prevents the scaphoid from flexing. In such circumstances, if the SL ligaments are completely insufficient or torn, the proximal pole subluxates dorsally out of the scaphoid fossa, inducing pain on the dorsoradial aspect of the wrist. When pressure is released, a typical clunk may occur, indicating an abrupt self-reduction of the scaphoid back into its normal position.

• Resisted long finger extension test: The patient is asked to extend the long finger against resistance with the wrist partially flexed. This compresses any areas of synovitis under the tendon and causes pain. If the pain occurs over the SL joint, it is suggestive of SL disease. This maneuver is very sensitive but not specific.

• SL ballottement test (shear test/lift test) (Dobyns): The lunate is firmly stabilized with the thumb and index finger of one hand, while the scaphoid, held with the other hand (thumb on the palmar tuberosity and index on the dorsal proximal pole), is displaced dorsally and palmarly with the other hand. A positive result elicits pain, crepitus, and excessive mobility of the scaphoid.

Imaging

Stress views, including the clenched-fist view, posteroanterior maximal radial deviation, and posteroanterior maximal ulnar deviation, are useful in the diagnosis of dynamic SL instability.

Arthroscopic examination has become the standard method of evaluation of interosseous ligamentous injuries. The arthroscopic classification of ligament injuries proposed by Geissler (Table 72-2) is useful in determining treatment options.

Table 72-2 Arthroscopic Grading of Scapholunate Ligament Injuries (Geissler)

Surgical Anatomy

The SL ligament is a C-shaped structure that connects the dorsal, proximal, and volar surfaces of the scaphoid and lunate. Partial SL ligament tears most often involve only the proximal and volar components of the SL interosseous ligament complex. The dorsal ligament is much stronger than its volar counterpart and may resist substantial traumatic torques without yielding.

The normal kinematics of the SL joint is governed by the SL ligament, a primary stabilizer, and by an envelope of surrounding extrinsic ligaments that act as secondary stabilizers, namely the radioscaphocapitate (RSC), the long and short radiolunate (LRL and SRL) ligaments on the volar side, and the dorsal radiocarpal (DRC) and dorsal intercarpal (DIC) ligaments on the dorsal side.

When the scaphoid has lost its connections to the lunate, the role of secondary stabilizers is particularly important. Their failure results in the static carpal malalignment.

Exposures

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