Chapter 15 Dorsal Capsuloligamentous Repair of the Scapholunate Ligament Tear

10.1055/b-0035-121125

Chapter 15 Dorsal Capsuloligamentous Repair of the Scapholunate Ligament Tear

Introduction

Scapholunate interosseous ligament (SLIL) tears are one of the most serious injuries associated with wrist trauma. Although open surgical repair can be performed, it is not indicated in the initial stages because of the resulting joint stiffness.

Wrist arthroscopy has changed how these injuries are diagnosed and treated. The injury can be evaluated in its initial stage, before the ligament is completely torn and the scaphoid becomes horizontal. The dorsal portion of the scapholunate (SL) ligament and its attachment to the dorsal capsule through a dorsal capsuloscapholunate septum (DCSS) are the keys to SL stability. This dorsal complex can be repaired arthroscopically using capsule-to-ligament suturing, thereby preventing the stiffness typically observed with open procedures.1

Operative Technique

Patient Preparation and Positioning

The procedure is performed on an outpatient basis under regional anesthesia. The patient is placed supine, with the arm resting on an arm board with an attached tourniquet. Upward traction of 5–7 kg is applied to the hand.

Radiocarpal Exploration

The arthroscope and sheath are inserted through the 3–4 radiocarpal portal to visualize the SLIL. However, the dorsal portion of SLIL can be seen only with the scope in the 6R portal.

A shaver is introduced into the 6R portal to clean out the joint and perform a synovectomy. The shaver and arthroscope are reversed to finish the synovectomy, particularly at the dorsal recess. A probe is used to assess the nature of the SL ligament injury (Chapter 14). The scope can be used to follow the volar portion of the SLIL to its dorsal insertion. Usually the SLIL is avulsed from the scaphoid. The ligament stump that is attached to the lunate can easily be lifted with the probe. The dorsal portion of the SLIL and the DCSS are then evaluated at the dorsal recess. More often than not, the ligament is torn, with ligament stumps remaining attached to the scaphoid and lunate ( Fig. 15.1 ). This technique can be performed only under these circumstances.

**Fig. 15.1** Drawing of a torn scapholunate ligament. The probe indicates a positive push test with a torn DCSS. The red arrow shows the movement initiated by the probe from proximal to distal passing from RC joint to MC joint, because of the rupture of DCSS. The repair can be performed only if the scapholunate interosseous ligament remnants are attached to the lunate and scaphoid.

A push test is performed to assess the DCSS, which is an anatomical structure located between the dorsal intercarpal (DIC) ligament and the dorsal portion of the SL ligament. The probe is placed in the dorsal recess under scope guidance, using the angulation and triangulation effects. If the DCSS is intact, it will be completely visible, and the probe will not be able to advance. If the DCSS is not intact, the probe can subsequently move into the midcarpal joint without being hindered by the DCSS (positive push test) (Chapter 14).

Exploration of the Midcarpal Joint

The arthroscope and sheath are introduced through the ulnar midcarpal (MCU) portal. The shaver is introduced through the radial midcarpal (MCR) portal to carry out a synovectomy. In cases of dorsal intercalated segment instability (DISI), there will be a step-off between the scaphoid and lunate. The probe is inserted between the scaphoid and lunate to determine the dissociation stage (Chapter 14).