72: Dorsal Capsulodesis for Scapholunate Instability Using Suture Anchors

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Procedure 72 Dorsal Capsulodesis for Scapholunate Instability Using Suture Anchors

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

imageSee Video 53: Dorsal Capsulodesis for Scapholunate Ligament Injury

Indications

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

image 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

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Examination/Imaging

Clinical Examination

image 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.

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

image 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.

image 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

image 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.

image 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)

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Surgical Anatomy

image 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.

image 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.

image 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

image A 6-cm dorsal longitudinal incision centered over the radiocarpal joint in line with the long finger metacarpal is made (Fig. 72-1). Sharp dissection is carried down to the extensor retinaculum. Skin and subcutaneous tissue flaps are raised on both sides. The third dorsal compartment is identified and does not need to be opened along its entire length. The wrist capsule is opened longitudinally and dissection performed to elevate the second and fourth compartments, such that the second and fourth compartment tendons are maintained within the compartment (Fig. 72-2). This exposes the scaphoid and lunate.

image Figure 72-3 shows a Freer elevator within the SL interval demonstrating a partial rupture of the SL dorsal ligament.

image

FIGURE 72-1

image

FIGURE 72-2

image

FIGURE 72-3

Pitfalls

Care is taken not to injure both branches of the radial sensory nerve.

Avoid dissection along the dorsal ridge portion of the scaphoid to prevent compromise to the blood supply to the proximal pole of the scaphoid.

Procedure

Step 1: Reduction of Scaphoid and Lunate

image Two 0.045-inch K-wires are placed dorsally into the scaphoid and lunate, respectively, to act as joysticks for reduction of these two bones (Fig. 72-4).

image

FIGURE 72-4

Step 1 Pearls

The scaphoid needs to be extended, and the lunate needs to be flexed. This is done using the joystick K-wires. Directing the scaphoid K-wire proximally and the lunate K-wire distally makes correction of the deformity easier.

Step 2: Maintenance of SL Reduction

image While an assistant maintains the scaphoid and lunate in their corrected positions, two K-wires are drilled percutaneously from the radial side of the wrist through the scaphoid into the lunate.

image Remove the joystick K-wires.

Step 2 Pearls

Anatomic reduction should be confirmed fluoroscopically and by direct inspection, with careful evaluation of the SL angle as well as the contours of the radioscaphoid and midcarpal articulations.

Step 3: Make a Drill Hole in the Scaphoid, and Insert a Bone Anchor

image Make a drill hole at the most distal part of the scaphoid (Fig. 72-5).

image A 1.8-mm bone anchor suture (Mitek Mini QuickAnchor or similar) is placed in the drill hole (Fig. 72-6).

image

FIGURE 72-5

image

FIGURE 72-6

Step 3 Pearls

A drill hole should be prepared on the dorsal surface of the distal pole of the scaphoid, adjacent to the scaphotrapezial joint, well distal to the scaphoid axis of rotation.

Step 3 Pitfalls

Care is taken not to injure the vascular pedicle entering the scaphoid at its dorsal ridge (Fig. 72-7).

image

FIGURE 72-7

Step 4: Secure the Dorsal Capsule to the Scaphoid

image The anchor suture is passed through the dorsal capsule and tied securely to prevent the scaphoid from flexing (Fig. 72-8).

image

FIGURE 72-8

Step 5: Assess Final Fixation

image A final fluoroscopic examination is done to confirm that the lunate is in neutral position and the carpal bones are aligned correctly (Fig. 72-9).

image

FIGURE 72-9

Step 6: Dorsal Capsular Repair

image The dorsal capsule is repaired using 3-0 Ethibond suture.

Step 7: Closure

image The tourniquet is released, and hemostasis is obtained.

image The extensor retinaculum is then closed using 3-0 Ethibond suture.

image Finally, the skin is closed using 4-0 monocryl suture (Fig. 72-10).

image

FIGURE 72-10

Postoperative Care and Expected Outcomes

image Following surgery, the patient is placed in a volar wrist splint for 8 weeks.

image Ten days after the operation, the wound is examined and sutures are removed.

image The K-wires are removed 6 to 8 weeks after the surgery. The K-wires are often cut under the skin to avoid pin tract infection, which is common when the K-wires are left outside the skin for more than 3 weeks.

image Eight weeks after the surgery, the patient is transitioned to a removable volar splint for an additional 4 weeks, and gentle active wrist range of motion commences.

image Although the wrist’s range of motion decreases about 20%, most patients have significant improvement in pain after this procedure.

Evidence

Gajendran VK, Peterson B, Slater RRJr, Szabo RM. Long-term outcomes of dorsal intercarpal ligament capsulodesis for chronic scapholunate dissociation. J Hand Surg [Am]. 2007;32:1323-1333.

The authors reviewed the patients undergoing dorsal intercarpal ligament capsulodesis (DILC) for chronic (>6 weeks), flexible, static SLD. Only patients with follow-up evaluation of greater than 60 months were included. Physical examination, radiographs, and validated outcome instruments were used to evaluate the patients. Twenty-one patients (22 wrists) met the inclusion criteria. Fifteen of 21 patients (16 wrists) were available for follow-up evaluation. Average follow-up period was 86 months. Physical examination revealed average wrist flexion and extension of 50 degrees and 55 degrees, respectively; radial and ulnar deviation of 17 degrees and 36 degrees, respectively; and grip strength of 43 kg. Disabilities of the Arm, Shoulder and Hand; Short Form-12; and Mayo wrist scores averaged 19, 78, and 78, respectively. Radiographs revealed an average SL angle and gap of 62 degrees and 3.5 mm, respectively. Eight of the 16 wrists in the study demonstrated arthritic changes on radiographs. The authors concluded that the DILC does not consistently prevent radiographic deterioration and the development of arthrosis in the long term; however, the level of functionality and patient satisfaction remained relatively high in 58% of their patients, suggesting a lack of correlation between the radiographic findings and development of arthrosis and the functional outcomes and patient satisfaction. (Level IV evidence)

Moran SL, Cooney WP, Berger RA, Strickland J. Capsulodesis for the treatment of chronic scapholunate instability. J Hand Surg [Am]. 2005;30:16-23.

The authors reviewed retrospectively the intermediate-term results of dorsal capsulodesis for cases of chronic SLD. Patients had to have a minimum follow-up period of 2 years for inclusion in the study. Thirty-one patients were identified with isolated chronic SLD. Of the 31 patients, 18 had dynamic carpal instability, and 13 had static carpal instability. The time from injury to surgery averaged 20 months. The follow-up period averaged 54 months (range, 24 to 96). All patients underwent a dorsal capsulodesis procedure using either a Blatt or Mayo technique. Results were reviewed clinically and radiologically. Static and dynamic groups were compared with a Student t test. Results showed a 20% decrease in wrist motion after capsulodesis and no improvement in grip strength after surgery. Most patients had improvement in pain, but only two patients were completely pain free. Radiographically, the SL gap and SL angle increased over time. There was no statistical difference in overall wrist motion, grip strength, or wrist score between the dynamic and static groups. The time to surgery and age had no significant effect on overall outcome. The authors concluded that the dorsal capsulodesis provided pain relief for patients with both dynamic and static SL instability. Although pain was improved, it was not completely resolved in most cases. From a radiographic perspective, dorsal capsulodesis did not provide maintenance of carpal alignment in cases of chronic SL dissociation. (Level IV evidence)

Wintman BI, Gelberman RH, Katz JN. Dynamic scapholunate instability: results of operative treatment with dorsal capsulodesis. J Hand Surg [Am]. 1995;20:971-979.

The authors presented 19 patients who underwent 20 dorsal capsulodesis procedures for dynamic SL instability. Seventeen patients (18 wrists) were evaluated by a questionnaire and physical examination after a mean postoperative follow-up period of 34 months. The diagnosis was based on a combination of characteristic symptoms of SL instability and physical findings consisting of dorsal wrist tenderness at the SL interval and a positive scaphoid shift test. Following surgery, a significant decrease was noted in symptoms of pain and clunking. Functional status was improved postoperatively; the most significant gains were seen in opening jars, sweeping, shoveling, and throwing. Fifteen of 17 patients returned to their original occupations, although 7 of those who returned to their original occupations did so with some restrictions. Objective evaluation by physical examination revealed a significant improvement in wrist stability as determined by the scaphoid shift test, and an average loss of 12 degrees of flexion. Fifteen of 17 patients (16 of 18 wrists) stated that they would undergo the surgery again if faced with the same choice. The authors concluded that dorsal radioscaphoid capsulodesis of the wrist in patients with dynamic SL instability provides substantial improvement over preoperative status. (Level IV evidence)

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