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Renata Bayer Battistotti 15 October 2013 Dorsal Capsulodesis for Wrist Instability

Dorsal Capsulodesis is a procedure that aims to stabilize the wrist and to relievethe symptoms associated with the wrist instability. It is an option of ligamentreconstruction to prevents abnormal flexion of the scaphoid. Currently it is one ofthe less invasive soft tissue procedures for scapholunate dissociation [1], which isthe commonest cause of wrist instability [2]. Since it does not anatomicallyreconstruct the scapholunate ligament, it causes some limitation of wrist flexion.

When Blatt described the technique in 1987 he considered it useful for twoconditions that caused impairment of wrist function: scapholunate dissociationand caput ulnae syndrome. Blatt found it useful in patients with symptomaticdynamic instability and a static deformity. [3]

The indications to this procedure depends on multiple factors, includingchronicity, reducibility of the scapholunate interval, integrity of the ligament,arthritic changes, and others patient- related factors. [4] Blatt stated as a singlecriterion for the procedure the ability to anatomically reduce the scaphoid at thetime of surgery. [3] It means that if a scaphonulate ligament repair is not feasible,as often is the case with chronic injuries, and there is a reducible scapholunateinterval, the dorsal capsulodesis can be done.

The contraindications are degenerative changes in the midcarpal orradiocarpal joints, as arthritic changes. Also it should not be done in patients witha fixed dorsal intercalated segment instability carpal collapse deformity. [4]

The method consists in a longitudinal incision made dorsoradialy aboutthe wrist. The wrist and finger extensors are retracted, laterally and mediallyrespectively. A proximally based, 1 cm wide flap of dorsal capsule is developed.

[4] The scapholunate ligament injury is confirmed inspecting the interosseous anddorsal scapholunate ligaments, ascertaining their rupture and irreparability. [1]The scapholunate interval is reduced using two Kirschner wires as joysticks. Thelunate is fixed, and pacing pressure on the scaphoid tubercle while ulnardeviation of the wrist extends the scaphoid. The scapholunate interval is pinnedwith two to three wires. [4] A wire is passed across the scaphoid capitate interval,as well. A notch is made in the dorsum of the distal pole of the scaphoid proximalto the distal articular surface and distal to the midaxis of rotation of the scaphoid.[4] The capsular flap is sutured to the dorsal scaphoid using a 4-0 stainless steelpull-out wire suture placed through the drill hole and tied over a button on thescaphoid tuberosity volarly. [3] The wrist is splinted for approximately 2 to 3

months at which time the wires are removed and a range of motion programstarted. [4] The main complications are a significant reduction of wrist movement and

grip strength, and a high failure rate in patients who are not operated on withintwo years of injury. [1]

The results of the procedure reported in the literature are conflicting. Itappears to provide the best results in patients with less significant staticradiographic abnormalities such as in a dynamic instability. At this time, dorsalcapsulodesis is a reasonable procedure for dynamic scapholunate instabilityusing the appropriate selection criteria. [4]

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Bibliography

1. Konduru R.S., Scott I., Mehdi R., et al, 2006. Dorsal Capsulodesis forscapholunate instability - Effect on patient disability and wrist pain. Journal ofHand Surgery , 31B(3), pp.311 316.

2. Deshmukh S.C., Givissis P., Belloso D. et al., 1999. Blatts capsulodesis forchronic scapholunate dissociation. Journal of Hand Surgery , 24(2), pp.215 220.

3. Campbell, Willis C, Canale, S. Terry, Beaty,James H. 2008, Campbell'soperative orthopaedics, Mosby Elsevier, Philadelphia, Pa.

4. Bozentka, D.J., 2000. Is dorsal capsulodesis a good operation for dynamicscapholunate dissociation? Current Opinion in Orthopedics , 11(4), pp.238 242.

5. Luchetti, R. et al., 2010. Dorsal intercarpal ligament capsulodesis forpredynamic and dynamic scapholunate instability. The Journal of handsurgery, European volume , 35(1), pp.32 7.

6. Stephan, C., Prommersberger, K.-J. & van Schoonhoven, J., 2009. Dorsalcapsulodesis for the treatment of scapholunate instability. OperativeOrthopdie und Traumatologie , 21(4-5), pp.405 15.