Dorsal intercarpal ligament capsulodesis (DILC) has a role in the treatment of dynamic scapholunate instability and flexible chronic static scapholunate dissociation in the absence of arthritic changes. The procedure is also useful as an augmentation for patients with an acute perilunate dislocation undergoing open reduction and repair of the scapholunate interosseous ligament (SLIL).

With regard to age range, the procedure has no limitations. It is our preferred choice in skeletally immature individuals with scapholunate instability since growth should not be disturbed. DILC can be done in the acute setting, as raising the dorsal intercarpal ligament based ulnarly provides a good exposure to repair the SLIL if needed. DILC can be done anytime in the chronic setting. There are no time limits for the procedure. The presence of radiographic or arthritic changes in asymptomatic patients with scapholunate dissociation is not an indication for use of DILC as a preventative measure to stop the progression of arthritis. Symptomatic patients without destructive arthritic changes are likely to benefit from the procedure.

Scapholunate dissociation is the most frequently diagnosed pattern of carpal instability (1). If left untreated, it will lead to scapholunate advanced collapse and progressive painful arthritis of the wrist (2). Treatment for scapholunate dissociation remains controversial and has varied from limited wrist arthrodeses (3,4,5,6) to soft-tissue procedures including dorsal capsulodesis (7,8,9,10,11) and SLIL reconstruction using tendon graft (12,13,14).

Soft-tissue reconstructions have several theoretical advantages that make them attractive alternatives to other procedures. In contrast to arthrodeses, soft-tissue reconstructions preserve more intercarpal motion including scaphoid flexion and extension with radial and ulnar wrist deviation, respectively. Arthrodeses limit motion. The scaphotrapeziotrapezoid limited arthrodesis results in a loss of 16% to 45% wrist flexion, 25% wrist extension, and 45% radial deviation (3,4,5,6). Scaphocapitate arthrodesis, also advocated for scapholunate dissociations, has been shown to produce similar reductions in wrist range of motion and on relative intercarpal motion to scaphotrapeziotrapezoid arthrodesis (15). There has been a renewed interest in tendon reconstructions (12,14); however, historically, early results, while promising, have not stood the test of time (13).

A dorsal capsulodesis procedure has the advantage because as a soft-tissue procedure rather than an arthrodesis, greater intercarpal motion is preserved, including scaphoid flexion and extension with radial and ulnar wrist deviation, respectively. Blatt (7) popularized the capsulodesis using a radius-based flap of wrist capsule inserted into the distal pole of the scaphoid. That procedure, however, has been reported to result in a significant decrease in wrist flexion by some investigators, including Blatt, who reported a mean loss of 20 degrees of flexion (7,16). While it corrects the flexed posture of the scaphoid by crossing the radiocarpal joint and tethering the scaphoid, it nevertheless fails to correct the diastasis between the scaphoid and lunate seen radiographically.

The DILC was developed to reconstruct the scapholunate association with local ligamentous tissue that does not cross the radiocarpal joint. The DILC has been tested with good results biomechanically, and it has also demonstrated good to excellent functional outcomes clinically in short-term follow-up
and for many patients in the long-term also (10,17). In cadavers, the reconstruction prevents volar rotation of the scaphoid and preserves a normal scapholunate interval. Additionally, the vector of pull of the DILC may help prevent pronation of the scaphoid that occurs along with flexion in scapholunate dissociation.

Absolute contraindications are patients with irreducible (inflexible) chronic static scapholunate dissociation or patients with any arthritic changes indicative of a scapholunate advanced collapse SLAC wrist. This procedure is not indicated for patients with chronic, static scapholunate gaps of 1 cm or greater.

A relative contraindication may be patients who require high demand of wrist strength judged by physician and patient. Those patients may best be served by a scaphocapitate or scaphotrapeziotrapezoid arthrodesis, although those procedures have also not provided a predictable solution to this problem (3,4).

A longitudinal skin incision is made dorsally over the patient’s wrist, centered over Lister’s tubercle. The superficial soft tissues are dissected off the extensor retinaculum, being careful to avoid injuring the cutaneous branches of the ulnar and radial nerves. The extensor pollicis longus (EPL) is unroofed by incising the retinaculum over the third extensor compartment in a step-cut fashion to facilitate subsequent closure, and the tendon is retracted radially. A surgical sponge is used to wipe the dorsal ligamentous and capsular structures clean so that the interval between the dorsal radiocarpal and dorsal intercarpal ligament can be identified in line with the long finger. An umbilical tape is passed around the dorsal intercarpal ligament, which is dissected out as it traverses the operative field (Fig. 21-3). It is then divided off its insertion on the trapezoid and trapezium (Fig. 21-4). A 5-mm-wide strip of the ligament is harvested and reflected ulnarly, exposing the scaphocapitate

and scaphotrapeziotrapezoid joints (Fig. 21-5). Care is taken not to injure the vascular pedicle entering the scaphoid at its dorsal ridge. Next, the dorsal wrist capsule is incised longitudinally over the joint, and the dissection continued proximally and subperiosteally beneath the second and fourth extensor compartments as necessary to allow adequate exposure.