Surgical Management

Dorsal Capsulodesis

After exsanguination of the extremity and elevation of a tourniquet, a dorsal longitudinal incision was made centered over the radiocarpal joint (Fig. 65—2A). Careful dissection through the subcutaneous tissues was performed, and the extensor retinaculum was identified. The extensor pollicis longus was released from its compartment, and the dorsal capsule was exposed through a longitudinal incision between the third and fourth compartments. The wrist extensors were retracted radially and the finger extensors ulnarly.

At this point in the operation, the wrist was taken through its range of motion and the midcarpal clunk was easily reproduced. By grasping the dorsal capsule with

Dorsal CapsulodesisDorsal CapsulodesisDorsal Capsulodesis Surgery

Figure 65—2. (A) Dorsal capsulodesis for midcarpal instability. A longitudinal incision is made through the skin on the dorsum of the hand, centered over the radiocarpal joint. (B) The extensor pollicis longus (EPL) is released from its compartment, and the dorsal capsule is exposed between the third and fourth compartments. The wrist extensors are retracted radially while the finger extensors are retracted ulnarly, and a 2.5-cm transverse incision is made in the capsule between the radius and the proximal carpal row. (C) The dorsal capsule is imbricated using two rows ofTicron mattress sutures, eliminating the clunk.

Figure 65—2. (A) Dorsal capsulodesis for midcarpal instability. A longitudinal incision is made through the skin on the dorsum of the hand, centered over the radiocarpal joint. (B) The extensor pollicis longus (EPL) is released from its compartment, and the dorsal capsule is exposed between the third and fourth compartments. The wrist extensors are retracted radially while the finger extensors are retracted ulnarly, and a 2.5-cm transverse incision is made in the capsule between the radius and the proximal carpal row. (C) The dorsal capsule is imbricated using two rows ofTicron mattress sutures, eliminating the clunk.

a Kocher clamp and tightening the dorsal capsular radiotriquetral ligaments, the clunk could be eliminated.

A 2.5-cm transverse incision was then made in the capsule between the radius and the proximal carpal row (Fig. 65—2B). The joint was explored, and although in the previous arthroscopy a tear of the triquetrolunate ligament was identified and lightly debrided, this joint was stable. The scapholunate ligament was found to be intact. The articular cartilage ofthe radiocarpal joint was normal in appearance, but there was some degree of synovitis within the dorsal wrist capsule.

At this point, the tourniquet was deflated and good hemostasis was achieved. The distal segment of the posterior interosseous nerve was identified and excised, and the arm was then reexsanguinated and the tourniquet re-inflated. The dorsal capsule was then imbricated using two rows of mattress sutures (Ticron) (Fig. 65—2C), and the wrist was taken again through a range of motion while visualizing the bony structures through fluoroscopy. All of the carpal relationships appeared normal, and the clunk was eliminated.

The dorsal retinaculum was repaired over the second and fourth compartments, and the third compartment was left open. A layered closure of the more superficial tissues was performed, and a bulky physiologic dressing with sugar-tong splint was applied to hold the wrist in neutral, leaving the thumb and fingers free to move. During application of the postoperative splint, dorsally directed pressure was applied to the distal carpus and metacarpals to maintain the midcarpal joint in its reduced position.

Postoperative Management

A sugar-tong splint was placed postoperatively to hold the wrist in neutral, and this was converted to a short-arm cast at 2 weeks. At 10 weeks following surgery, the cast was removed, and the patient was allowed to begin gentle active range-of-motion exercises. He began a work hardening program at 3 months postoperatively, and resumed all other activities at 4 months following surgery. The midcarpal clunk did not return.

Alternative Methods of Management

Most patients respond to conservative treatment. This includes nonsteroidal anti-inflammatories, avoidance of aggravating activities such as extreme ulnar deviation of the wrist with axial loading, special splints that push dorsally on the pisiform reducing the VISI sag, and physical therapy. Occasionally, the patient can be taught to activate the hypothenar muscles and/or the extensor carpi ulnaris muscle tendon unit prior to ulnar deviation, thereby pre-reducing the wrist and midcarpal joints as the wrist begins its movement into ulnar deviation, preventing the painful clunk.

Alternative surgical treatment includes reconstruction at the triquetrohamate joint with interosseous tendon grafts, advancement of the ulnar arm of the volar arcuate ligament, and midcarpal (capitate-lunate-triquetrum-hamate) arthrodesis. A comparison between volar ligament repair and midcarpal arthrodesis demonstrated a higher patient satisfaction level with arthrodesis.

No long-term studies are available that compare dorsal capsulodesis with arthrodesis for midcarpal instability. In the senior author's experience, however, dorsal cap-sulodesis is an acceptable alternative for mild to moderate cases failing conservative treatment. Failing soft tissue repair, an arthrodesis can be performed. It is important, however, to inform the patient of the possible need for a follow-up procedure.

Complications

The surgical complications involved in treating midcarpal instability include stretching out of the imbricated capsule, advanced ligaments, or tendon grafts, thereby allowing recurrence of the clunk. Patients may also develop a significant reduction in wrist range of motion, and the change in biomechanics may theoretically result in greater incidence of ulnocarpal or radiocarpal arthritis.

Suggested Readings

Alexander CE, Lichtman DM. Ulnar carpal instabilities. Orthop Clin NothAm 1984; 15:307-320.

Ambrose L, Posner MA. Lunate-triquetral and midcarpal joint instability. Hand Clin 1992;8:653-668.

Brown DE, Lichtman DM. Midcarpal instability. Hand Clin 1987;3:135-140.

Cooney WP III, Garcia-Elias M, Dobyns JH, et al. Anatomy and mechanics of carpal instability. Surg Rounds Orthop 1989;9:15-24.

Feinstein WK, Lichtman DM. Recognizing and treating midcarpal instability. Sports Med Arthroscopic Rev 1998;6:270-277.

Lichtman DM. Midcarpal instability. In: McGinty JB, ed. Operative Arthroscopy. New York: Raven Press; 1991:647-650.

Lichtman DM, Bruckner JD, Culp RW, Alexander CE. Palmar midcarpal instability: results of surgical reconstruction. J Hand Surg [Am] 1993;18A:307-315.

Lichtman DM, Gaenslen ES, Pollock GR. Midcarpal and proximal carpal instabilities. In: Lichtman DM, Alexander AH, eds. The Wrist and Its Disorders, 2nd ed. Philadelphia: WB Saunders; 1997:316-328.

Lichtman DM, Schneider J, Swafford A, Mack G. Ulnar midcarpal instability— clinical and laboratory analysis. J Hand Surg [Am] 1981;6:515-523.

Linscheid R, Dobyns J, Beabout J, Bryan R. Traumatic instability of the wrist. J Bone Joint Surg [Am] 1972;54A:1612-1632.

Palmer A, Dobyns J, Linscheid R. Management of posttraumatic instability of the wrist secondary to ligament rupture. J Hand Surg [Am] 1978;3:507-532.

Ruby LK, Cooney WP III, Linscheid RL, Chao EYS. Relative motion of selected carpal bones: a kinematic analysis of the normal wrist. J Hand Surg [Am] 1988;13A: 1-10.

Sebald J, Dobyns J, Linscheid R. The natural history of collapse deformities of the wrist. Clin Orthop 1974;104:140-148.

Taleisnik J. Pain on the ulnar side of the wrist. Hand Clin 1987;3:51-68.

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