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INTRODUCTION

The dorsal radiocarpal ligament (DRCL) is a capsular ligament that originates adjacent to Lister’s tubercle and travels distally and ulnarly to insert on the dorsal tubercle of the triquetrum. The DRCL has been shown to be important in maintaining carpal stability. The DRCL and the dorsal intercarpal (DIC) ligament function like a dorsal radioscaphoid ligament that provides stability to the scaphoid throughout the full arc of wrist motion. Tears of the DRCL have been linked to the development of both volar intercalated segmental instability (VISI) and dorsal intercalated segmental instability (DISI) and may be implicated in the development of midcarpal instability.

In most series, the DRCL is overlooked during the arthroscopic examination of the wrist. It is hard to visualize the DRCL through the standard dorsal wrist arthroscopy portals. The torn edge of the DRCL tends to float up against the arthroscope while viewing through the 3-4 portal, which makes both identification and repair of the DRCL tear cumbersome. The DRCL tear can be seen obliquely through the 1-2 or 6U portal, but visualization of the DRCL across the radiocarpal joint may be laborious in a tight or small wrist, especially if synovitis is present. The DRCL is best viewed through the volar radial (VR) portal because of the straight line of sight.

INDICATIONS FOR REPAIR

An arthroscopic repair is indicated for isolated DRCL tears owing to the favorable outcomes that can be achieved. DRCL tears are commonly associated with scapholunate interosseous ligament (SLIL) tears and/or instability. In cases in which the SLIL tear is debrided and/or pinned, an arthroscopic DRCL repair should be performed. DRCL repairs should also be considered when associated ulnar-sided pathology is present, including lunotriquetral ligament tears and triangular fibrocartilage complex (TFCC) tears. The results of these combined repairs, however, appear to be strongly influenced by the results of treatment of the coexisting wrist pathology, which can lead to a mixed clinical result.

CONTRAINDICATIONS

When treatment of an SLIL tear or dynamic scapholunate instability includes some type of dorsal capsulodesis, the dorsal incision followed by the creation of a dorsal capsular checkrein to restrain palmar flexion of the scaphoid renders any separate treatment of the DRCL tear infeasible. When the DRCL tear is seen in association with palmar midcarpal instability (MCI), a soft tissue repair of the dorsal ligaments will not by itself correct the midcarpal instability.

Contraindications to a DRCL repair also include those that preclude wrist arthroscopy in general, such as any cause of marked swelling, which distorts the topographic anatomy; large capsular tears, which can lead to extravasation of irrigation fluid; neurovascular compromise; bleeding disorders; or infection. Lack of familiarity with the regional anatomy is a relative contraindication to DRCL repair.

EQUIPMENT AND IMPLANTS

SURGICAL TECHNIQUE

The patient’s arm is suspended in a traction tower with 10 lb of countertraction under tourniquet control. The standard dorsal portals are established in the usual fashion, including the 3-4, 4-5,6R, and 6U portals and a radial and ulnar midcarpal portal. A VR portal is established by making a 2-cm longitudinal incision in the proximal wrist crease, exposing the flexor carpi radialis (FCR) tendon sheath. The sheath is divided and the flexor carpi radialis tendon retracted ulnarly. The radiocarpal joint space is identified with a 22-gauge needle, and the joint is inflated with saline. A blunt trocar and cannula are introduced through the floor of the flexor carpi radialis sheath, which overlies the interligamentous sulcus between the radioscaphocapitate (RSC) ligament and the long radiolunate ligament. A 2.7-mm 30 degree arthroscope is inserted through the cannula, and a hook probe is placed in the 3-4 portal.

The DRCL is visualized just ulnar to the 3-4 portal underneath the lunate. Fluid irrigation and use of the hook probe reveal the torn edge of the ligament. The torn edge may appear rounded in longstanding cases, which should not be confused with a redundant dorsal capsule ( Fig. 46-1 ). A 2-0 absorbable suture is passed through a curved spinal needle that is introduced through the 4-5 portal. The end of the suture is retrieved with a grasper in the 3-4 portal. After both ends of the suture are withdrawn, dorsal traction can be seen to pull the torn edge of the DRCL up against the dorsal capsule ( Fig. 46-2 A and B). One suture is usually sufficient. A curved hemostat is used to pull either end of the suture underneath the extensor tendons, and the knot is tied at either the 3-4 or 4-5 portal after the wrist traction has been released ( Fig. 46-2 C)>. The repair is augmented with thermal shrinkage if the DRCL is voluminous and still protrudes into the joint after the suture is tied ( Fig. 46-2 D–F).

Chronic dorsal radiocarpal ligament tear from the volar radial portal. Note the rounded edges ( ^{∗ ∗ ∗} ). L, lunate; R, radius.

(Copyright, David Slutsky, MD, 2010.)

Outside-in dorsal radiocarpal ligament (DRCL) repair technique. A, Arthroscopic view of DRCL tear from the VR (volar radial) portal. B, Diagram of a DRCL tear showing its separation from the dorsal capsular tissue. C , A suture is placed through the 4-5 portal and retrieved through the 3-4 portal. D, Diagram of suture placement. E, Completed repair. Note how the DRCL has been plicated to the dorsal capsule. F, Diagram of the repair. L, lunate; S, scaphoid; T, triquetrum.

(From Slutsky, DJ. Dorsal radiocarpal ligament repair. In Slutsky DJ, Nagle D [eds]: Techniques in Wrist and Hand Arthroscopy. Philadelphia: Elsevier, 2007, pp. 118–123, with permission.)

REHABILITATION

After the repair, the patient is placed in a below-elbow splint with the wrist in neutral rotation. Finger motion and edema control are instituted immediately. At the first postoperative visit, the sutures are removed and the patient is placed in a below-elbow cast for a total immobilization time of 6 weeks. Wrist motion with use of a removable splint for comfort is instituted after cast removal. Gradual strengthening exercises are added after 8 weeks. Dynamic wrist splinting is instituted at 10 weeks, if needed.

RESULTS

In the author’s personal series from 1998 to 2007, 64 patients underwent diagnostic wrist arthroscopy for chronic wrist pain or carpal instability. DRCL tears were found at the time of arthroscopy in 35 patients, or 55%. None of these tears could be identified preoperatively, either by examination or imaging studies. In five patients, the DRCL tear was the first manifestation of carpal instability and was the sole cause of wrist pain. Fourteen patients in this series had SLIL instability and/or tear; 8 of the 14 also had a DRCL tear. Seven patients had a lunotriquetral interosseous ligament (LTIL) instability and/or tear; 2 of the 7 also had a DRCL tear. A DRCL tear was found in one of two patients with a capitohamate (CH) ligament tear. Nine patients had both a DRCL tear and a TFCC tear. Two or more lesions were present in 23 patients; DRCL tears were present in 12 of these 23 patients.

The patients with isolated DRCL tears had pain for a median time of 36 months (range 12 to 60), whereas the group with associated intracarpal pathology had pain for a median of 12 months (range 4 to 60). Conservative measures including wrist immobilization, cortisone injections, and activity modification were ineffective in this series of patients. An arthroscopic DRCL repair was performed in most patients except for 11 with SLIL instability, who were primarily treated with a dorsal capsulodesis. Four patients with SLIL instability were treated with debridement and/or thermal shrinkage and/or pinning. All the LTIL tears and the capitohamate tear were treated with debridement or pinning or both. The TFCC tears were repaired in five patients and debrided in the rest. There were two concomitant wafer resections and one ulnar shortening. At an average follow-up of 15.8 months, all five patients with an isolated DRCL tear had an excellent result with no or mild pain after the arthroscopic repair. When there were other intercarpal derangements, the results were mixed and largely dependent on the treatment of the associated pathology. The outcomes and procedures are summarized in Table 46-1 .

TABLE 46-1

Procedures/Outcomes

Patient	DRCL Tear	SLIL Tear/Instability	LTIL Tear	TFC Tear	CHIL Tear	Other	Pain
1. MR	Repair + shrinkage						None
2. ND	Repair + shrinkage					CTR	None
3. DA	Repair					CTR	None
4. MA	Repair						Occ, mild
5. CB	Repair					Loose body removal	Occ, mild
6. AF	Repair	Shrinkage					Lost to f/u
7. VA	Repair	Shrinkage					None
8. MSA		Capsulodesis					Lost to f/u
9. DL		Capsulodesis					Occ, mild
10. MJ		Capsulodesis				CTR	Occ, mild
11. BL		Capsulodesis					None
12. VB		Capsulodesis				1st extensor release	Chronic, moderate
13. CE		Capsulodesis				1st extensor release	Chronic, moderate
14. BM		SLIL repair Capsulodesis					Chronic, severe
15. MB		Capsulodesis	Debrided				Chronic, moderate
16. SC		Capsulodesis		Debrided			Chronic, moderate
17. KS		Capsulodesis		Debrided			Chronic, moderate
18. MS		Capsulodesis		Repair			Chronic, moderate
19. DS	Shrinkage	Debrided + pinned	Debrided + pinned				Chronic, moderate
20. HS	Repair		Debrided + pinned			CTR	Chronic, moderate
21. AS				Repair			Chronic, moderate
22. ML	Repair			Repair		CTR	Chronic, moderate
23. EC	Repair			Debrided			None
24. MM	Repair			Repair			Occ, mild
25. DG	Repair			Debrided + wafer			None
26. MRO	Shrinkage			Debrided + wafer		Cubital tunnel release	None
27. KS	Repair		Debrided	Debrided + wafer			None
28. MG			Debrided	Debrided + wafer			Chronic, moderate
29. AD	Repair + shrinkage		Debrided	Repair			Lost to f/u
30. JP	Repair		Debrided + pinned	Debrided			Occ, mild
31. GJ	Repair + shrinkage		Debrided	Debrided + ulnar shortening			Chronic, moderate
32. YB	Shrinkage			Debrided			Chronic, moderate
33. GN	Repair
34. RF	Repair + shrinkage		Pinned				Chronic, moderate
35. SCI	Repair					Ulnar styloid excision	None

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