Dorsal Capsulodesis

Indication

Scapholunate instability

Three possible procedures

Surgical technique - Blatt

Skin incision

Dorsoradial longitudinal incision

Superficial dissection

Dissect between the 3rd and 4th extensor compartments, exposing the dorsal wrist capsule.
 

Deep dissection

• Raise a proximally based, 1 cm wide flap of dorsal capsule, which includes part of the dorsal radiocarpal ligament.

• Confirm the scapholunate injury.

• Reduce scapholunate interval using  two Kirschner wires as joysticks.

• The lunate is flexed, and placing pressure on the scaphoid tubercle while ulnarly deviating the wrist extends the scaphoid.

• The scapholunate interval is pinned with two to three 0.045 inch diameter Kirschner wires.

• A Kirschner wire is passed across the scaphoid capitate interval as well.

• Identify the area of the dorsal distal scaphoid that is devoid of articular surface. Make a notch in this surface that is proximal to the articular surface of the distal scaphoid but distal to the midaxis of rotation.

• Drill a hole from dorsal to volar, exiting the scaphoid tubercle. The capsular flap is sutured to the dorsal scaphoid using a pull-out suture placed through the drill hole and tied over a button on the scaphoid tuberosity volarly.

• An alternative method of fixation includes a suture anchor placed in the dorsal distal pole of the scaphoid.

Post operatively

• Splint the wrist for approximately 2 to 3 months, at which time the Kirschner wires are removed and a range of motion program started.

Modification of dorsal capsulodesis - Slater et al

Dorsal intercarpal ligament capsulodesis (DILC)

The dorsal intercarpal ligament, based ulnarly on the triquetrum, is elevated off the trapezoid and sutured to the distal aspect of the scaphoid.

DILC compared with dorsal capsulodesis described by Blatt:

The scapholunate angle reduces equally with both procedures, although the DILC has been found to decrease the scapholunate gap better than the Blatt capsulodesis.

It has been proposed that DILC has certain theoretical advantages.

The DILC links the scaphoid and triquetrum directly, keeping the proximal carpal row linked together as a functional unit, which may account for the decreased diastasis.

It has been hypothesized that the reduction of the scapholunate angle is related in part to the position of the dorsal intercarpal ligament. It uses the capitate as a pulley for the ligament to prevent flexion of the distal pole of the scaphoid. In addition, since the dorsal intercarpal ligament does not tether the scaphoid to the distal radius, improved wrist flexion may be expected clinically.

Another indirect soft tissue tether ECRL

A distally based split extensor carpi radialis longus (ECRL) tendon is sutured to the dorsal scaphoid.

Dagum et al. compared the Blatt dorsal capsulodesis to the split ECRL tendon reconstruction using a cadaveric model of static scapholunate dissociation.

They showed that both procedures reduced the scapholunate gap and scapholunate angle.

The carpal row index (C/R index) also was increased with both reconstructions.

References

Page created by: Lee Van Rensburg

Last updated 11/09/2015