TECHNIQUE

Chronic Scapholunate Dissociation: Ligament Reconstruction Combining a New Extensor Carpi Radialis Longus Tenodesis and a Dorsal Intercarpal Ligament Capsulodesis

Pablo De Carli, MD, Agustin G. Donndorff, MD, Gerardo L. Gallucci, MD, Jorge G. Boretto, MD, and Vero´nica A. Alfie, MD

Abstract: Scapholunate dissociation (SLD) is the commonest cause of carpal instability and wrist osteoarthrosis. The value of early diagnosis and treatment of this injury is well established in the literature. When a partial or total rupture of the scapholunate ligament is treated with early anatomic reduction and repair, functional results may be good to excellent. However, if this ligament is not addressed acutely then an overall carpal malalignment may seem progressively as a result of failure of the secondary scaphoid stabilizers. Chronic SLD will lead to scapholunate advanced collapse and progressive painful arthritis of the wrist. Although most surgeons agree that operative intervention is indicated, no clear consensus exists on the best treatment for patients with chronic SLD. Several procedures have been described that include some sort of partial fusion, capsulodesis, tenodesis, or bone-ligament-bone graft. If there is no evidence for arthrosis, soft-tissue procedures using either capsulodesis or tenodesis may be carried out in an attempt to preserve radiocarpal and intercarpal motion whereas avoiding fusion. This article describes a scapholunate ligament reconstruction combining a new dorsal extensor carpi radialis longus tenodesis and a dorsal capsulodesis for the treatment of chronic SLD. Key Words: scapholunate dissociation, carpal instability, capsulodesis, tenodesis (Tech Hand Surg 2011;15: 6--11)

HISTORIC PERSPECTIVE Tenodesis and capsulodesis procedures have become a popular option for reconstructing the dysfunctional scapholunate ligament with a capsular/ligament strip or tendon graft in patients with reducible nonarthritic SLD. The primary goals of these soft-tissue procedures include pain relief, reestablish- ment, and maintenance of carpal alignment to prevent osteoarthritic changes, and preserve functional wrist mobility. Capsulodesis techniques varied with both radiocarpal and intercarpal capsulodesis. In 1987, Blatt proposed a capsulod- esis using a proximally based flap of dorsal wrist capsule inserted into the distal pole of the scaphoid tethering it to the radius to stabilize the forceful flexion of the scaphoid.1 Herbert modified this technique using the same reversed capsular flap reinserted proximally into the Lister tubercle.2 A similar

FIGURE 1. A, Tenodesis using a distally based strip of the ECRL Received for publication March 30, 2010; accepted May 3, 2010 fixed with 3 suture anchors to the proximal and distal pole of the From the Department of Hand Surgery and Upper Extremity, Hospital Italiano scaphoid and lunate. B, Dorsal capsulodesis with a proximal strip de Buenos Aires, ‘‘Carlos E. Ottolenghi’’ Institute, Buenos Aires, Argentina. Address correspondence and reprint requests to Pablo De Carli, MD, of the DICL. Gasco´n 450, Capital Federal, C1199 ACK, Buenos Aires, Argentina. E-mail: [email protected]. Copyright r 2011 by Lippincott Williams & Wilkins

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FIGURE 3. A dorsal capsulotomy after the DICL and RTqL as FIGURE 2. A 36-year-old woman with static scapholunate inst- described by Berger and Bishop is made. ability of her right wrist. S-shaped longitudinal incision of the skin. procedure is recommended by Linscheid and Dobyns3 with a Tendon grafts have been reported to replace a scapholu- proximally based strip of the dorsal intercarpal ligament nate ligament. From the first reported tendon reconstruction of (DICL). The problem with these procedures is that they fail to the SL ligament by Dobyns et al7 in 1975, the procedures have correct directly the SL gap and limit wrist motion, particularly considerably evolved. The original technique consisted of flexion, as the transferred capsule tethers the distal pole of the passing a strip of tendon graft through anteroposterior tunnels scaphoid to the distal radius. Thus, in 1999 Slater developed a in the proximal pole of the scaphoid and the lunate to recreate procedure including the DICL for scapholunate reinforce- the dorsal SL ligament. At that time, the procedure provided ment.4 In this capsulodesis, the DICL is elevated from its unsatisfactory results because the holes drilled into poorly insertion on the trapezium and trapezoid, rotated proximally, vascularized bone areas induced fractures or joint degenera- and secured to the distal pole of the scaphoid. So, the proximal tions. Sixteen years later Almquist et al8 described the use of carpal row is linked together (triquetrum to the distal pole of the so-called ‘‘four-bone ligament reconstruction’’. Through a the scaphoid) to decrease the SL diastasis and the scapholunate dorsal and palmar approach a distally based strip of the angle is corrected equally well. Schweizer and Steiger5 extensor carpi radialis brevis (ECRB) tendon was passed described another option that included the DICL, but inserting through the holes made in the capitate, scaphoid, and lunate, it into the proximal rather than into the distal part of the and finally fixed to the distal-palmar radius. The major scaphoid to fix the SL space in anatomic position, without problem of this method came from crossing both radiocarpal focusing on scaphoid flexion. In 2002, Walsh et al6 described and midcarpal joints, which provided wrist stiffness. Linscheid a technique that involved the use of a DICL strip detached and Dobyns9 proposed another option using a distally based from the ulnar insertion on the triquetrum, rotated proximally, strip of the extensor carpi radialis longus (ECRL) passed and reinserted into the dorsal lunate. This reconstruction through a hole made in the distal scaphoid to prevent flexion also included the ability to limit rotatory subluxation of the collapse and fixed to the dorsal lunotriquetral ligament to close scaphoid and at the same time stabilize the SL joint. In contrast the SL gap. In 1995, Brunelli and Brunelli10 advocated a to Blatt capsulodesis, none of the abovementioned methods procedure with a strip of FCR that was passed through a tunnel cross the radiocarpal joint. in the distal pole of the scaphoid, pulled dorsally reducing the The major advantage of dorsal capsulodesis compared scaphoid to its position, and sutured to the dorsal radius. Both with tenodesis is the technical ease of the procedure. However, methods based their effectiveness in the stabilization of the capsulodesis seem to have a tendency to stretch out over time. proximal and distal ends of the subluxating scaphoid. More- Sometimes the joint capsule, which had been attenuated by over, the holes were drilled far from the SL joint in which the repeated proximal pole subluxation, is too weak to resist the 2 bones are poorly vascularized. The Brunelli procedure was strong flexion forces acting on the scaphoid. first modified by Van Den Abbeele et al,11 who suggested not r 2011 Lippincott Williams & Wilkins www.techhandsurg.com | 7 De Carli et al Techniques in Hand & Upper Extremity Surgery  Volume 15, Number 1, March 2011

FIGURE 4. Once the proximal row is exposed the SL joint is FIGURE 5. Reducibility is checked by direct manipulation with 2 inspected and the presence of a complete nonrepairable rupture K-wires inserted into the scaphoid and lunate as joysticks. If all of the SL ligaments with intact cartilage is confirmed. C indicates cartilage is intact and good reducibility of the carpal capitate; L, lunate; S, scaphoid. malalignment is achieved, a combined dorsal tenodesis- capsulodesis is indicated. to cross the radiocarpal joint but to anchor the tendon onto the well-known capsulodesis (Walsh-technique)6 by the same dorsum of the lunate or onto the dorsal radiotriquetral ligament dorsal approach seeking more consistent and predictable (RTqL). By incorporating some features from these proce- prevention of radiographic deterioration without adding dures, Garcı´a-Elı´as et al12 described a new modification named increased morbidity. The purpose of this article is to describe ‘‘the 3-ligament tenodesis’’ or ‘‘3LT procedure’’ as this our preferred surgical option for the treatment of this tenodesis replicated the action of 3 ligaments (scaphotrape- challenging injury since the senior researcher (PDC) developed zial-trapezoidal, dorsal SL, dorsal radiotriquetral). Recently, this technique in 2003. Bleuler et al13 described a dynamic tenodesis through a minimally invasive dorsal approach fixing the ECRL just to the dorsal aspect of the distal scaphoid with a screw. However, INDICATIONS/CONTRAINDICATIONS this technique only controlled 1 aspect of the deformity When selecting treatment for chronic SLD one must first (flexion of the scaphoid). establish whether there is dynamic or static carpal instability. As Garcı´a Elı´as described, the ideal tenodesis should Patients with dynamic instability have normal radiographs, prevent rotary subluxation (flexion and pronation) of the and their diagnosis is made by physical examination with scaphoid and extension-ulnar translation of the lunate. tenderness over the scapholunate interval and a positive Although most modern techniques would include these scaphoid shift maneuver. Carpal malalignment can only be aspects, most types of these tendon reconstructions are seen by radiologic stress-views. Reviews of surgical treatment technically difficult to carry out with the need to drill several of dynamic carpal instability report equally high success rates carpal bones. On the basis of the similar concepts of tendon with both tenodesis as capsulodesis.11,12,14–16 Thus, in these stabilization, we developed a reconstructive technique that cases we prefer to carry out a dorsal capsulodesis as described uses a strip of the ECRL combined with a DICL capsulodesis by Walsh et al using the dorsal intercarpal ligament, which is (Fig. 1) by a unique dorsal approach. Our tendon reconstruc- technically simpler. In contrast, treatment of those patients tion technique may offer several advantages: (1) as a single with a static instability remains controversial. The long-term dorsal approach is needed and suture anchors are used, it is results are still unpredictable, with no optimal proce- technically simpler than other procedures; (2) tunnels through dure.14,17–19 As described by Garcı´a Elı´as et al,12 we believe the scaphoid are not required, and thus, the risk of fracture or that patients with static reducible scapholunate instability necrosis is avoided; (3) the tenodesis can be combined with a without arthritis represent the best candidates to carry out some

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FIGURE 7. A channel is carved over the dorsal aspect of FIGURE 6. Through the same dorsal approach a distally based the scaphoid and lunate to uncover cancellous bone. Once strip of the ECRL is harvested. the tendon strip has been passed under the dorsal capsule, the tendon strip is fixed on the distal and proximal poles of the scaphoid and lunate with 3 sutures anchors (stars) and finally type of tendon reconstruction to stabilize not only the proximal sutured to de RTqL. Care is taken not to detach the scaphoid SL joint but also the distal palmar component of the scaphoid. fibers of the DICL. Contraindications for some type of soft-tissue procedure include those cases in which it is impossible to make an checked under fluoroscopy control by direct manipulation with anatomic reduction of carpal bones (static irreducible instability) K-wires as joysticks (Fig. 5). At this stage the surgeon should or when radiocarpal osteoarthritic changes are already present. confirm that the scaphoid and lunate are reducible and that there are no cartilage changes. The 2 bones (scaphoid and lunate) are reduced and percutaneously stabilizated with two SURGICAL TECHNIQUE 1.5 mm K-wires across the SL joint, or 1 across the SL joint A 6 to 8 cm, S-shaped longitudinal incision of the skin and and another across the SC joint. After carpal reduction and subcutaneous tissue is made on the dorsal aspect of the wrist stabilization a distally based 5-cm long strip of ECRL is centered on Lister tubercle (Fig. 2). The dorsal-sensory obtained through the same dorsal approach (Fig. 6) and passed branches of the radial and ulnar nerve are identified and under the dorsal capsule. Pulled distally, the tendon strip is meticulously spared. The extensor retinaculum is divided fixed on the dorsal aspect of the distal scaphoid with an anchor along the third compartment and the extensor pollicis longus suture to augment the palmar-distal connections of the tendon is retracted radially. The retinacular septa between scaphoid and prevent rotary subluxation. A channel is carved compartments II and IV are sectioned and the 2 retinacular over the dorsal aspect of the scaphoid and lunate to uncover flaps are sharply separated from the wrist capsule, elevated, cancellous bone to facilitate the process of tendon to bone and retracted. Arthrotomy is carried out by a radially based incorporation. Then, without releasing the tendon tension the capsular flap as described by Berger et al20 after the dorsal rim strip is fixed on the proximal pole of the scaphoid and lunate of the radius, the radial border of the RTqL and the proximal with another 2 anchor sutures to reconstruct the dorsal SL edge of the DICL (Fig. 3). Care is taken to leave enough dorsal ligament (Fig. 7). The end of the tendon is finally sutured onto RTqL and DICL to facilitate later tensioning of the tendon the distal portion of the RTq ligament to reduce ulnar reconstruction and creation of the dorsal capsulodesis. Once translation and extension of the lunate. Once the tendon the proximal row is exposed the SL joint is inspected and the reconstruction is finished, reinforcement is made with a dorsal presence of a complete rupture of the SL ligaments with a capsulodesis as described by Walsh et al. A radially based strip static carpal instability is confirmed (Fig. 4). The scaphoid of the dorsal intercarpal ligament is rotated proximally and is seems subluxated in a rotary fashion whereas the lunate seems attached to the proximal pole of the scaphoid and lunate with abnormally ulnarly translated and extended. Reducibility is the same anchor sutures earlier used (Fig. 8). The capsular r 2011 Lippincott Williams & Wilkins www.techhandsurg.com | 9 De Carli et al Techniques in Hand & Upper Extremity Surgery  Volume 15, Number 1, March 2011

FIGURE 8. Reinforcement of the tenodesis is made with a proximal strip of the DICL attached to the proximal pole of the scaphoid and lunate with the same anchors. FIGURE 9. The capsular flap is then brought back to its original position and sutured. The extensor retinaculum is finally flap is then brought back to its original position and sutured reconstructed and the skin is closed. Immediate postoperative (Fig. 9). The extensor retinaculum is finally reconstructed and x-rays showing the restoration of carpal alignment are taken and the skin is closed. No drains are placed. Immediate post- a short-arm spica cast is placed for 8 weeks. operative x-rays showing the restoration of carpal alignment are taken and a short-arm spica cast is placed and maintained problems. No second surgeries have been necessary so far. As with the K-wires for 8 weeks. usual in this type of procedure, it is expected to find some limitation of mobility, especially wrist flexion. REHABILITATION Eight weeks after surgery, the K-wires and cast are removed. A RESULTS protective wrist splint must be worn for another 4 weeks and Sixteen patients (16 wrists) with a symptomatic chronic SLD a program of passive and active wrist range of motion under (Stage IV of Garcı´a Elı´as-classification) were surgically supervision is started. Patients are instructed to avoid forceful treated using this combined tenodesis-capsulodesis from axial loading of the wrist, particularly in extension as with September 2003 until November 2009. We recently reviewed weight lifting or push-ups, for 6 months. retrospectively the first 8 wrists in 8 patients (7 men, 1 woman; average age: 39 y, range: 30 to 52 y) with a flexible static SLD and a minimum 1 year of follow-up (average: 23 mo, range: COMPLICATIONS 12 to 58 mo). After surgery all patients noted pain relief. Potential complications include infection, chronic regional According to the visual analog scale (VAS: 0 to 10), the pain syndrome type I, radial neuroma, joint stiffness, and average postoperative pain was 3 (range: 1 to 5). The mean chondrolysis or osteolysis owing to the placement of the pins postoperative DASH score was 13 (range: 0.83 to 30). The and anchors. In our series, there were no instances of these mean postoperative Wrightington score was 73 (65 to 90).

TABLE 1. Radiographic Results

Immediate Final Preopertive Postoperative Evaluation Contralateral Scapholunate space 4.6 mm 2.1 mm 2.6 mm 1.8 mm Radioscaphoid 23 degrees 55 degrees 38 degrees 42 degrees angle Scapholunate angle 82 degrees 38 degrees 60 degrees 52 degrees

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Functional results were excellent in 2 cases and good in 6 9. Linscheid RL, Dobyns JH. Treatment of scapholunate dissociation. cases. As expected, it was radiologically observed in all cases Hand Clin. 1992;8:645–652. some loss of reduction initially obtained. However, none of 10. Burnelli GA, Brunelli GR. A new technique to correct carpal them had a recurrence of carpal collapse (Table 1). Our results instability with scaphoid rotary subluxation: a preliminary report. are comparable with other tendon reconstruction techniques J Hand Surg Am. 1995;20A:S82–S85. earlier described for static SLD. Therefore, we conclude that 11. Van Den Abeele KL, Loh YC, Stanley JK, et al. Early results of a this new ECRL tenodesis combined with a DICL capsulodesis modified Brunelli procedure for scapholunate instability. J Hand Surg represent a reliable option for chronic SLD with a static Br. 1998;23B:258–261. reducible carpal instability. 12. Garcı´a-Elı´as M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical REFERENCES technique. J Hand Surg Am. 2006;31A:125–134. 1. Blatt G. Capsulodesis in reconstructive hand surgery. Dorsal 13. Bleuler P, Shafighi M, Donati OF, et al. Dynamic repair of capsulodesis for the unstable scaphoid and volar capsulodesis scapholunate dissociation with dorsal extensor carpi radialis longus following excision of the distal ulna. Hand Clin. 1987;3:81–102. tenodesis. J Hand Surg. 2008;33A:281–284. 2. Herbert TJ, Hargreaves IC, Clarke AM. A new surgical technique 14. Moran SL, Cooney WP, Berger RA, et al. Capsulodesis for the for treating rotary instability of the scaphoid. Hand Surg. treatment of chronic scapholunate instability. J Hand Surg Am. 1996;1:75–77. 2005;30A:16–23. 3. Linscheid RL, Dobyns JH. Treatment of scapholunate dissociation. 15. Seradge H, Baer C, Dalsimer D, et al. Treatment of dynamic scaphoid Rotatory subluxation of the scaphoid. Hand Clin. 1992;8:645–652. instability. J Trauma. 2004;56:1253–1260. 4. Slater RR Jr, Szabo RM. Scapholunate dissociation: treatment with the 16. Wintman BI, Gelberman RH, Katz JN. Dynamic scapholunate dorsal intercarpal ligament capsulodesis. Tech Hand Upper Extrem instability: results of operative treatment with dorsal capsulodesis. Surg. 1999;3:222–228. J Hand Surg Am. 1995;20A:971–979. 5. Schweizer A, Steiger R. Long-term results after repair and 17. Deshmukh SC, Givissis P, Belloso D, et al. Blatt’s capsulodesis for augmentation ligamentoplasty of totatory subluxation of the scaphoid. chronic scapholunate dissociation. J Hand Surg Br. J Hand Surg. 2002;27A:674–684. 1999;24B:215–220. 6. Walsh JJ, Berger RA, Cooney WP. Current status of scapholunate 18. Gajendran VK, Peterson B, Slater RR, et al. Long-term outcomes interosseous ligament injuries. J Am Acad Orthop Surg. 2002; of dorsal intercarpal ligament capsulodesis for cronic scapholunate 10:32–42. dissociation. J Hand Surg Am. 2007;32A:1323–1333. 7. Dobyns JH, Linscheid RL, Chao EYS, et al. Traumatic instability of 19. Zarkadas PC, Gropper PT, White NJ, et al. A survey of the surgical the wrist. Instr Course Lect. 1975;24:189–199. management of acute and chronic scapholunate instability. J Hand 8. Almquist EE, Bach AW, Sack JT, et al. Four-bone ligament Surg Am. 2004;29A:848–857. reconstruction for treatment of chronic complete scapholunate 20. Berger RA, Bishop AT, Bettinger PC. New dorsal capsulotomy for the separation. J Hand Surg. 1991;16A:322–327. surgical exposure of the wrist. Ann Plast Surg. 1995;35:54–59.

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