Capsulodesis with internal brace augmentation for scapholunate ligament tears
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Tears of the scapholunate ligament are common wrist ligament injuries and can be partial or complete. Partial ligament tears can initially be treated nonoperatively, however operative treatment can be considered if symptoms persist.
Operative treatment may consist of arthroscopic debridement or open repair. Complete tears of the scapholunate (SL) ligament require surgical repair or reconstruction, depending on the chronicity of the injury. Acute tears are defined as being within 6 weeks of injury. Tears that are repaired acutely demonstrate more favorable outcomes than chronic tears. In chronic cases, fixed deformities of the scaphoid and lunate obviate repair or reconstruction and can lead to early arthritis. In these cases, a salvage procedure, such as a proximal row carpectomy or partial wrist fusion, is indicated.
Source: Steven S. Shin, MD, MMSc
Many different surgical techniques have been described for treating the acute and subacute SL ligament tears without fixed deformity, including direct ligament repair using drill holes or anchors, pinning, capsulodesis, screw fixation, bone-retinaculum-bone or bone-ligament-bone autograft and reconstruction through various techniques using a tendon transfer or free tendon autograft. None of these techniques have been shown to be universally superior. In this article, we present a novel technique utilizing the “internal brace” concept of scapholunate capsulodesis with internal brace augmentation.
Surgical technique
After the affected upper extremity is prepped and draped, an 8-cm mid-dorsal longitudinal incision is made over the wrist. The subcutaneous tissues are spread and the extensor tendons are retracted. A distally based capsulotomy is made to reveal the underlying complete SL ligament tear and gapping at the SL joint (Figure 1). Care is taken to avoid further injury to the dorsal capsular scapholunate septum.
With fluoroscopic guidance, a guidewire for a 3.5-mm SwiveLock anchor (Arthrex) is inserted dorsally into the mid-body of the lunate and then over-drilled with a 3.0 cannulated drill bit. The drill bit and wire are removed and a 3.5-mm SwiveLock anchor is inserted into the lunate, securing the FiberTape (Arthrex) and 3-0 FiberWire (Arthrex) suture. Secure fixation of the anchor is confirmed by pulling tightly on the tape and suture tails. A second anchor is then inserted into the proximal scaphoid, securing one of the tails of the FiberTape and a second 3-mm FiberWire suture. The SL joint is manually reduced during insertion of this second anchor. Care is taken to leave at least 3 mm of bone intact between the hole and the most proximal aspect of the scaphoid. A third anchor is inserted into the distal pole of the scaphoid to secure the remaining tape tail, again having at least 3 mm of intact bone between the anchor and the most distal aspect of the scaphoid (Figure 2).
Capsulodesis, closure, rehabilitation
The capsulodesis is then performed by passing the sutures from the lunate and proximal scaphoid through the dorsal capsuloligamentous complex and tying these to each other, bringing down the tissue to the dorsal scapholunate joint and providing “biology” to the construct (Figures 3, 4). Final fluoroscopic images are taken to confirm closing of the SL joint space (Figure 5). The wound is closed in a layered fashion and a short-arm plaster splint is applied.
Sutures are removed 7 to 10 days following surgery. At that time, a cast or custom brace is applied for another 5 weeks. At 6 weeks postoperatively, therapy is initiated with a focus on range of motion. Gradual strengthening and eventual unrestricted return to activities is anticipated around 3 to 4 months postoperatively.
Technique rationale
This technique is based on the concept of the internal brace which underlies and supports the capsulodesis of the SL joint. Biomechanical studies by Il-Jung Park, MD, PhD, and colleagues in 2020 and by Gilbert R. Thompson, FRCP, and colleagues found that SL ligament repairs with internal brace augmentation are stronger than repairs alone. The stiffness of the tape we used compared with the tendon makes use of the tape appealing for reducing and maintaining the native SL joint space. A study from 2021 by Park and colleagues demonstrated the two-strand or “V” tape construct was the most resistant to gapping and rotation at the SL joint compared with single-strand constructs.
The goals of the capsulodesis are to maintain reduction and resist gapping at the SL joint. At the same time, extrinsic healing (scarring) around the SL joint is taking place, which we believe is the key to maintaining the joint reduced in the long term. This construct also improves the SL angle by producing an extension moment on the flexed scaphoid and a flexion moment on the extended lunate, recreating native carpal biomechanics. This technique has also demonstrated a higher biomechanical load to failure than repair alone.
Advantages of this technique include an all-dorsal approach, unicortical drill holes (which theoretically decrease the chance of fracture or avascular necrosis at the proximal scaphoid and lunate compared with bicortical drill holes), reproducibility with readily available materials and implants, and relative simplicity compared with other more involved techniques. Potential disadvantages of this technique are tape slippage, anchor loosening and osteolysis, which may be seen over time and possibly increase the chance of recurrent malalignment of the scaphoid and lunate. We are not aware of any reports of adverse reaction to the implants and materials used with this technique. Although we have seen a high level of success with this technique for acute and subacute complete SL ligament tears, further clinical studies are necessary to judge its superiority over other techniques.
- References:
- Chen RE, et al. J Hand Surg Glob Online. 2022;doi:10.1016/j.jhsg.2021.10.007.
- Harvey EJ, et al. J Hand Surg Am. 1999;doi:10.1053/jhsu.1999.0963.
- Park IJ, et al. J Clin Med. 2021;doi:10.3390/jcm10071482.
- Park IJ, et al. J Hand Surg Am. 2020;doi:10.1016/j.jhsa.2020.03.017.
- Rohman EM, et al. J Hand Surg Am. 2014;doi:10.1016/j.jhsa.2014.06.139.
- Shin SS, et al. J Hand Surg Am. 1998;doi:10.1016/S0363-5023(98)80116-0.
- Thompson RG, et al. J Hand Surg Am. 2021doi:10.1016/j.jhsa.2020.06.017.
- Weiss AP. J Hand Surg Am. 1998;doi:10.1016/S0363-5023(98)80115-9.
- For more information:
- Harin B. Parikh, MD, and Steven S. Shin, MD, MMSc, are in the department of orthopaedics at Cedars-Sinai Health System in Los Angeles. Parikh’s email: harin.parikh@cshs.org. Shin’s email: steven.shin@cshs.org.
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