Chapter 25 Arthroscopic Dorsal Tendon Interposition in Stage II Scapholunate Advanced Collapse Wrists

10.1055/b-0035-121135

Chapter 25 Arthroscopic Dorsal Tendon Interposition in Stage II Scapholunate Advanced Collapse Wrists

Introduction

Scapholunate ligament ruptures result in scapholunate instability. The ensuing biomechanical disruptions cause flexion of the scaphoid, which gradually leads to osteo-arthritis at the scaphoid fossa of the radius. This osteo-arthritis is often limited to the cartilage in the posterior margin of the radius and proximal pole of the scaphoid ( Fig. 25.1 ). Surgical care consists of various palliative techniques, such as complete wrist denervation, proximal row carpectomy, and partial wrist fusion. To avoid these aggressive procedures, we propose performing arthroscopic dorsal tendon interposition arthroplasty, where the tendon is pulled tight between the dorsal side of the radius and the scaphoid, in combination with an expanded radial styloidectomy.

**Fig. 25.1** Lateral computed tomographic scan of a stage II scapholunate advanced collapse (SLAC II) wrist showing radioscaphoid osteoarthritis at the dorsal part of the radius.

Operative Technique (Levadoux)

Patient Preparation and Positioning

The procedure is performed on an outpatient basis under regional anesthesia. The patient is placed supine. A traction tower is used to hold the arm flat on the arm board with the elbow at 90° and 5 to 7 kg of traction applied to the hand.

Exploration of Radiocarpal and Midcarpal Joints

The 3–4 and 4–5 portals are used to inspect the entire radiocarpal joint. This allows the surgeon to determine the extent of cartilage erosion in the dorsal part of the scaphoid fossa and the proximal part of the scaphoid ( Fig. 25.2 ).

**Fig. 25.2** Arthroscopic radiocarpal view of the eroded cartilage in the proximal pole of the scaphoid and dorsolateral section of the radius.

Tendon Harvest

After releasing the hand traction, the palmaris longus (PL) tendon is harvested from the ipsilateral limb through a short horizontal incision on the anterior side of the wrist at the volar wrist crease, proximal to the carpal tunnel. A tendon stripper is used to harvest the tendon in a single step without any counterincisions. If the PL tendon is not available, half of the flexor carpi radialis tendon can be harvested percutaneously through two or three small horizontal incisions. The tendon graft is kept in a damp compress. The incisions used for tendon harvesting are sutured closed.

Expanded Styloidectomy

Traction is again placed on the arm for this arthroscopic step. A new incision is made for the 1–2 radiocarpal portal. The shaver and bur are introduced through this portal, and the scope is placed in the 3–4 or 4–5 portal. In the first step any hypertrophied synovial tissue that hampers visibility is removed. This allows the surgeon to isolate the radial styloid process and determine how much arthritic bone must be resected. A bur is used to perform a radial styloidectomy, which is extended to the section of the scaphoid fossa with eroded cartilage. The goal is to freshen the area until bleeding subchondral bone is exposed, which is necessary for the formation of fibrous interposition tissue. The resection must not go beyond the areas of eroded cartilage; intact cartilage must not be resected ( Fig. 25.3 ).

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