Rev. bras. ortop. vol.52 número6

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rev bras ortop.2017;52(6):676–684

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Original

article

Dorsal

capsulodesis

associated

with

arthoscopy-assisted

scapholunate

ligament

reconstruction

using

a

palmaris

longus

tendon

graft

夽

Victor

Bignatto

Carvalho

a

_,

_Carlos

_Henrique

_Vieira

_Ferreira

b

_,

Andresa

Ramires

Hoshino

b,∗

,

Viviane

Alves

Bernardo

b

,

Gustavo

Mantovani

Ruggiero

b

,

Márcio

Aurélio

Aita

b

a_Faculdade_de_Medicina_do_ABC,_Santo_André,_SP,_Brazil

b_Faculdade_de_Medicina_do_ABC,_Servic¸o_de_Ortopedia_e_{Traumatologia,}_Santo_André,_SP,_Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received24September2016 Accepted1November2016 Availableonline28October2017

Keywords:

Lunatebone Jointinstability Arthroscopy Ligaments Articular

a

b

s

t

r

a

c

t

Objectives:Tomeasurethequalityoflife,thetimetoworkreturn,andclinical,functional, andradiographicparametersofpatientstreatedwithdorsalcapsulodesisassociatedwith scapholunate(SL)reconstruction,assistedbyarthroscopy.

Methods:FromJanuary2015toSeptember2016,14adultpatientswithSLdissociation under-wentsurgicaltreatmentwiththeSLreconstructionprocedureassistedbyarthroscopy,using thenewtechniqueproposedinthisstudy.Allpatientswereassessedbytheoccupational therapydepartmentatregularintervalsaftersurgeryandperformedthesamesequenceof rehabilitation.Theparametersanalyzedwere:rangeofmotion(ROM),DisabilityoftheArm, Shoulder,andHand(DASH),visualanalogscale(VAS),andradiographicanalysisto visu-alizethepre-andpostoperativeSLgapandthepre-andpostoperativedorsalintercalated segmentinstability(DISI)deformitythe.Thecomplicationsandthetimetoreturntowork activitiesweredescribed.

Results:Thefollow-uptimewas12months(3–17).TheROMaveraged321◦_(96.9%_of_the

normalside).VASwas1.79/10(1–6).DASHwas6.50/100(1–30).Thetimetoworkreturnwork was4.42months(2–17).Asforcomplications,onepatientdevelopedSLAC,andunderwent four-cornerfusiononeyearafterligamentreconstruction.Currently,hehasexperienced painrelief,withafunctionalrangeofmotionofthewrist,andhasnot yetreturnedto professionalactivities.

ThepreoperativeSLgapwas4.29mm(2–7);inthepostoperativeperiod,itwas1.79mm (1–4).TheDISIdeformity waspresentinten patientswithSLangle>70◦ _{(preoperative)}

anditwascorrectedaftersurgery,inallpatients.SLACstageI_was_identified_in_a_patient.

Arthroscopywasperformedinallcases.TheSLinstabilitywasclassifiedasGeisslergrade

III_in_four_cases_and_as_gradeIV_in_ten_cases.

夽

StudyconductedattheFaculdadedeMedicinadoABC,Servic¸odeOrtopediaeTraumatologia,SantoAndré,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:[email protected](A.R.Hoshino). http://dx.doi.org/10.1016/j.rboe.2016.11.010

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Conclusion: The newapproach (dorsal capsulodesis associatedwith SLreconstruction, assistedbyarthroscopy)presentedinthisstudyissafeandeffectiveinthetreatmentofSL dissociation,sinceitofferssatisfactoryclinical,radiographicandfunctionalresults,showing lowratesofcomplications.Forpatients,itallowsthereturntotheirsocialandprofessional activities,andincreasestheirlifequality.

Capsulodese

dorsal

associada

à

reconstruc¸ão

assistida

por

artroscopia

do

ligamento

escafossemilunar

com

enxerto

do

tendão

do

músculo

palmar

longo

Palavras-chave:

Ossosemilunar Instabilidadearticular Artroscopia

Ligamentosarticulares

r

e

s

u

m

o

Objetivos: Mensuraraqualidadedevida,otempoderetornoaotrabalho,osresultados clínicos,funcionaiseradiográficosdospacientessubmetidosàcapsulodesedorsalassociada àreconstruc¸ãoligamentarescafossemilunarassistidaporartroscopia.

Métodos: Dejaneirode2015asetembrode2016,14pacientes,esqueleticamentemaduros, adultos,comdissociaçãoescafolunar(SL),foramsubmetidosaotratamentocirúrgicocom oprocedimentodereconstruçãodoligamentoescafossemilunarassistidoporartroscopia comanovatécnicapropostanesteestudo.Todosospacientesforamavaliadospelosetorde terapiaocupacionalemintervalosregularesdepós-operatórioefizeramamesmasequência dereabilitação.Osparâmetrosanalisadosforam:arcodemovimento(ADM),DisabilityArm, ShoulderandHand(Dash),escalavisualanalógica(EVA)eanáliseradiográficaprée pós-operatóriaparavisualizaroespaçoescafolunar(sinaldeTerry-Thomas)edeformidadeem

DorsalIntercalatedSegmentInstability(DISI)préepós-operatória.Descric¸ãodascomplicac¸ões eotempoderetornoaotrabalho.

Resultados:Otempodeseguimentofoide12meses[3-17].OADMfoiemmédia321,07◦_(96,9%

doladonormal).Ovalordaavaliaçãosubjetivadador(VAS)foi1,79/10[1-6].Amensuração daqualidadedevidapeloDashfoide6,50/100[1-30].Otempoderetornoaotrabalhofoide 4,42meses[2-17].Quantoàscomplicações,umapacienteevoluiucomSLACefoisubmetida àartrodesedosquatrocantosumanoapósareconstruçãoligamentar.Evoluiucom mel-horiadadoreestácomoADMdopunhofuncional,masaindanãoretornouàsatividades profissionais.OintervalodoSL(gap)pré-operatóriofoide4,29mm[2-7]eopós-operatório foide1,79mm[1-4].AdeformidadeDISIestavapresenteemdezpacientes,comumângulo SLacimade70◦_{(pré-operatório),}_e_foi_corrigida_após_a_cirurgia_em_todos_os_pacientes._SLAC

estágioI_foi_identificado_em_um_paciente._A_artroscopia_foi_feita_em_todos_os_casos._A

insta-bilidadeSLfoiclassificadacomoumgrauGeisslerIII_em_quatro_casos_e_grauIV_em_dez

casos.

Conclusão: Anovaabordagem(capsulodesedorsalassociadaàreconstruçãoligamentar escafossemilunarassistidaporartroscopia)apresentadanesteestudoéseguraeeficazno tratamentodadissociaçãoescafolunar,jáqueapresentaresultadosradiográficos,clínicos efuncionaissatisfatórios,demonstrabaixastaxasdecomplicações,permiteoretornoàs atividadessociaiseprofissionaiseaumentaaqualidadedevidadessespacientes.

Introduction

Thescapholunate (SL) dissociation,or lesion ofthe SL lig-ament, is the most common form of carpal instability1

(Fig.1).

Numerous surgical techniques have been described to restoreorimprovethestabilityoftheSLjoint,aimingtodelay

orpreventtheprogressionofosteoarthrosisbetweencarpal bones,knownasSLadvancedcollapse(SLAC).

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rev bras ortop.2017;52(6):676–684

Fig.1–Radiographicaspectsofwrist–PAview–showing thescapholunategaportheTerry-Thomassign.

However,suchreconstructionsalterthebiomechanicsof the wrist, since they form a vertical connection between Gilula’sarcs,whichcanalterthemobilityoftheradiocarpal ormidcarpaljoints.

Thepersistenceofthe Terry-Thomas sign(gap between thescaphoidandlunate),looseningofthetendongraft, tech-nicaldifficulty,limitationofwristmobilityandpalmargrip strength,andiatrogenicfracturesduringthecreationofthe scaphoidorlunatetunnelshavebeenreportedasthemain complications.2–11 _The_authors_believe _that_these _problems

canbeavoidedwiththedevelopmentofnewimplants,such asbio-tenodesisscrewsofspecificsizesforcarpalbones.

Furthermore,mostmethodsonlypromotethe reconstruc-tionofthedorsalanduniplanarportionoftheSLligament. Manystudies havehighlightedthe importanceofthe volar portionofthisligament.12–15

Thesearchfortheidealreconstruction(volaranddorsal portion)began with the biomechanicalstudy byYi et al.16

whousedatendongraftfromthelongpalmarismuscleand introducedit throughholesinthe anteroposteriorplaneof thescaphoidandlunate.TheSLgapwaseffectivelyreduced tonormal,andthe anatomicSLreductionwassignificantly improvedafterreconstruction.

Zderoetal.17_assessed₁₉_cadaver_wrists,_and_used_bovine

tendonspassedthroughdoublebonetunnelsofthescaphoid andlunate.Seventeenofthe19wristssubmittedtothis recon-structionpresented nodifference inmechanical properties whencomparedwiththenormalside.

Theresultsofthesestudiessupporttheclinicalapplication ofacombined SLligamentreconstruction technique(volar anddorsal).

Hoetal.18_published_a_clinical_study_of₁₇_patients,_all_with

chronicSLdissociation,whounderwentarthroscopy-assisted reconstructionwiththeuseofafreetendongraftfromthe longpalmarmuscle(LPM);13patientsreturnedtotheir pre-viousworkactivities,allweresatisfiedwiththeresult,four evolvedwithrecurrenceofdorsalintercalatedsegmentation instability(DISI),andoneevolvedwithasymptomaticnecrosis oftheproximalpoleofthescaphoid.

Hagert et al.19 _suggested _that _the _wrist _ligaments _vary

withregardtosensoryandbiomechanicalfunctions. Depend-ingonthestructuralcompositionandinnervation,thewrist ligamentspresentgreatermechanical(denselypacked colla-genbundleswithlimitedinnervation)orsensorialrelevance (richlyinnervated,althoughlessdenseintheconnective tis-sue composition).Itisbelievedthat thedorsalcapsuleand theintrinsicligamentsofthewrist,includingtheSL,havean importantroleintheproprioceptionofthewrist.Thus,the authorssuggestthatsurgicalreconstructionshouldbe imme-diateatdiagnosisandthatthetreatmentmethodemployed shouldhaveaminimalimpactonthedorsalcapsuleofthe wrist.19–21

Overstraetenetal.22_described_the_presence_of_a_distinct

structure,whichconnectstheSLligamenttothedorsal cap-sule,termeddorsalcapsulo-scapholunateseptum(DCSS).The authorsbelievethattheDCSSisasecondarystabilizeroftheSL joint,andthatitmayhavetherapeuticandprognostic impli-cations.Thecapsulodesistechniquesdescribedthusfarfavor this“reconnection”ofthedorsalcapsulewiththeSLligament. Wolfeetal.23_conducted_a_kinematic_analysis_of_the_wrist

andshowedthattheproximalcarpalrowisalmoststationary duringthedartthrowmotion(DTM),whichisbelievedto pro-videastableplatformforthegenerationofforceandprecision duringcertainfunctionalactivities,suchaspalmar prehen-sion.Inordertoimprovetherehabilitationofpatientswho underwentwristligamentreconstruction,theauthorsbelieve thatDTMcanbeusedearlyinthefirstpostoperativeweeks, as itavoidsmuscular stiffnessand atrophyinthe affected limb,stimulatesproprioception,anddoesnotinterfereinthe healingofthereconstructedintrinsicligament.

Inthepresentstudy,anewapproachtothetreatmentof SLdissociationwillbedescribed,inordertoimprove clinical-functional outcomes,time-lapseforreturningtosocialand professional activities, surgical management, postoperative rehabilitation,andqualityoflifeofthesepatients.

Thisstudy isalsoaimedatassessingthequality oflife, returntowork,theclinical-functionalandradiographicresults of patients who underwent dorsal capsulodesis associated witharthroscopy-assistedSLligamentreconstruction.

Methods

From January2015toSeptember2016,14skeletallymature adultpatientswithSLdissociation,evaluatedattheoutpatient surgicalclinic,andwho underwentarthroscopy-assistedSL ligamentreconstructionwiththenewtechniqueproposedin thisstudy,wereassessed.

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679

Identification Age Follow-up Normal

ROM

Final ROM

Final DASH

Final VAS

Watson test

Geissler type

DISI SLgap

pre

SLgap

post

Return

towork

Complications Profession Associated

lesions

I ₃₃ ₁₇ ₃₁₅ ₃₁₅ ₆ ₁ ₊ ₄ _Yes ₆ ₂ _3rd_month _No _Engineer _No

II ₃₆ ₁₆ ₃₄₅ ₃₄₅ ₆ ₁ ₊ ₄ _Yes ₇ ₄ _3rd_month _No _Nurse _No

III ₂₅ ₁₃ ₃₄₅ ₃₄₅ ₆ ₁ ₊ ₃ _N ₃ ₁ _2nd_month _No _Student _Distal_radius

fracture

IV ₅₀ ₁₃ ₃₃₅ ₃₃₅ ₆ ₁ ₊ ₄ _Yes ₄ ₁ _3rd_month _No _Homemaker _Distal_radius

fracture

V ₂₃ ₁₅ ₃₄₅ ₃₄₅ ₆ ₁ ₊ ₄ _Yes ₅ ₁ _3rd_month _No _Student _No

VI ₅₂ ₁₅ ₃₁₆ ₂₃₀ ₃₀ ₆ _– ₄ _Yes ₅ ₄ _No _SLAC _Homemaker _No

VII ₆₀ ₁₄ ₃₃₅ ₃₃₅ ₆ ₂ ₊ ₄ _Yes ₅ ₁ _6th_month _No _Factory_worker _Distal_radius

fracture

VIII ₅₈ ₁₅ ₂₉₅ ₂₇₀ ₁₈ ₁ ₊ ₄ _Yes ₅ ₂ _6th_month _No _Factory_worker _No

IX ₂₈ ₁₂ ₃₂₅ ₃₂₅ ₁ ₁ ₊ ₃ _Yes ₄ ₂ _4th_month _No _Factory_worker _No

X ₁₉ ₇ ₃₄₅ ₃₄₅ ₁ ₁ ₊ ₄ _Yes ₄ ₁ _2nd_month _No _Student _Distal_radius

fracture

XI ₄₂ ₈ ₃₃₀ ₃₁₀ ₁ ₂ ₊ ₄ _No ₃ ₂ _2nd_month _No _TI _No

XII ₃₀ ₉ ₃₄₅ ₃₄₅ ₁ ₁ _– ₂ _No ₂ ₁ _2nd_month _No _Athlete _No

XIII ₅₂ ₆ ₃₁₅ ₃₁₅ ₁ ₁ ₊ ₂ _No ₃ ₁ _3rd_month _No _Homemaker _No

XIV ₂₃ ₃ ₃₄₀ ₃₃₅ ₂ ₁ ₊ ₃ _Yes ₄ ₂ _3rd_month _No _TI _No

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rev bras ortop.2017;52(6):676–684

andeighthadsubjectivelossofstrengthandinstabilitywith apainfulclick.Inallpatients,physicalexaminationindicated painatpalpationattheSLgapsite.TheWatsontestwas pos-itivein12of14cases.

Allpatients were evaluatedbytheoccupationaltherapy sectoratregularpostoperativeintervalsandunderwentthe same rehabilitationsequence,followingthe same protocol, andwere evaluatedintwoand sixweeks,sixmonths,and oneyearpostoperatively(Table1).

Theassessedparameterswere:

- Range ofmotion(ROM),assessingthe goniometryofthe ROMwiththemeasurementindegrees.

- DisabilityArm,Shoulder,andHand(DASH)Questionnaire– qualityoflife.

- Visualanalogscale(VAS)–subjectivepainassessment. - Radiographicanalysis tovisualizepre-and postoperative

SLspace(Terry-Thomassign)andSLangle(normalvalues rangefrom30to60◦_;_DISI_deformity_was_assessed_when_the

anglewashigherthan70◦_).

- Descriptionofthecomplicationsthataroseaftersurgical treatment.

- Returntowork.

Description

of

the

surgical

technique

Diagnosticarthroscopyis animportanttooltoidentifythe cause ofwristpainin caseswhereSLdissociationmay be associatedwithotherpathologies.

Thesurgerywasperformedundergeneralanesthesiaor locoregional blockade. The patient was placed in a dorsal recumbent position, withthe arm suspendedin a specific wristtractiontower,under10–13lboftraction.Atourniquet wasinflatedorpassed.Continuousirrigationwithsaline solu-tionwasachievedwithapumpandspecificequipmentunder theactionofgravity.

Aninventoryofthe radiocarpaljoint wasmadeinitially throughportals3–4,4–5,and6Uforthesalinesolutionexit; themidcarpaljointwasassessedthroughtheradial(MCR)and ulnar (MCU)portals. Small transverse incisions weremade alongtheskinfoldsforabetterscarappearance.Arthroscopes measuring1.9mmor2.7mmwereused.Thejointwas system-aticallyinspectedandthe resultsweredocumented. When necessary, radialsynovectomywas performed atthe same time,with2-mmand 2.9-mmshaverblades.Intra-articular fibrosiswasremovedtoimprovewristmobilityandto pro-motegapreductionand SLalignment,aswellastocorrect DISIdeformity.

Therebuildingstepwasinitiatedwitha2cmtransverse incisionalongtheproximaltransversefoldofthewrist(Fig.2) toidentifytheinsertionofthepalmarislongustendonandof theflexorcarpiradialistendon.Thepalmarislongusgraftwas extractedwithorwithouttheuseofatendonstripper.A2mm proximalincisionwasmadeinthefasciaoftheanterior fore-armtoidentifythemyotendinoustransitionofthepalmaris longus,inordertoexciseit.Bothdorsalandvolarjoint cap-suleswerepreserved,unaltered.Atthatmoment,the wrist wasreadyforthepreparationofthebonetunnels.

Fig.2–Preoperativeclinicalaspect:incisioninthe

transversepalmarfoldofthewristtolocatetheinsertionof thepalmarislongustendon.

Fluoroscopywasusedtoassessthewrist.IfaDISI defor-mity wasobserved, theextendedlunateposition wouldbe correctedbyflexionofthewristtorestorethenormal radioul-narangleandtheradioulnarjoint,withfixationornotwith a1.6-mmKirschnerwireinsertedpercutaneously.Thewrist wasthenpassivelyextendedtocorrecttheflexiondeformity ofthescaphoidandrestoreanormalSLangle.Ifthese cor-rectionswerenotachieved,additionalarthroscopicreleaseof thefibrosisaroundthescaphoidandlunatewasperformed.If itwasstillimpossibletoreducetheDISIdeformity,then lig-amentreconstructionwouldbeabandoned;fortunately,this didnotoccurinthisstudy.Throughthedorsalportals4–5or 6R,MCR,orMCU,a1.1-mmguidewirewasplacedinsidea soft-tissueprotector(drillguide)onthelunateandscaphoidunder fluoroscopicguidance.Whentheradiusandlunatewerewell alignedwiththeguidewire,thedirectionoftheradiusshould be perpendicular tothe long axisofthe lunate; i.e., paral-leltothelinejoiningthetipofvolaranddorsallipsofthe lunate(lateralview). Theguide wirewasadvanced2–3mm fromthebonemarginandthentowardthevolarcortex.With theflexortendonsandmediannerve,includingthepalmar cutaneousbranch,carefullymovedtotheulnarside,theexitof thiswirewasidentified.Anotherguidewirewastheninserted intothescaphoidthroughthe3–4dorsalportal.Itwasplaced paralleltothelunateguidewire,providedthattheSLangle hadbeencorrected.Otherwise,itsentranceshouldbeslightly moredistalthan thatofthelunateguidewire;it shouldbe movedtowardthepalmarandproximaldirectiontoprovide abettercorrectionofthescaphoidrotationandflexion.With theflexorcarpiradialistendonradiallymoved,thescaphoid wirewasadvancedthroughthevolarface.Bothtunnels(Fig.3) were sequentiallyenlargedwith2.0-,2.7-,or 3-mm cannu-lateddrills,dependingonthethicknessofthepalmarislongus graft.Thedrillofsmallestpossiblediametershouldbeused toensureasmoothpassageofthegraftandavoidiatrogenic fractureoravascularnecrosisofthesebones.

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Fig.3–Intraoperativefluoroscopy:preparationofthe lunatebonetunnel.

Fig.4–Intraoperativeaspect–preparationofthepalmaris longustendongraft(Krackowsuture).

Fig.5–Intraoperativeclinicalaspect:preparationofthe scaphoidbonetunnel.

(grooved)needlesorwiresfromthepalmartothedorsalsideof thescaphoid(Figs.5and6)andfromthedorsaltothepalmar aspectofthelunate.Thetendongraftwaspassedoutsidethe

Fig.6–Intraoperativeclinicalaspect:thetendongraftis passedthroughthescaphoidbonetunnel(inapalmarto dorsaldirection),exitingtheskinthroughthedorsal arthroscopicportal3–4.

dorsalcapsule,sothatitwasreinsertedlinearlyundertheSL gap(linearcapsulodesis).

Thefixationofthegraft inthebonetunnelswitha bio-tenodesisscrew,measuring3mmindiameterand 8mmin length,alsocalled3/8mm(Bio-Tenodesisscrew,ArthrexInc., FL,USA)wasperformed.Thefinalpartofthegraftwassutured atthe same siteofthe graft entrypointinto the scaphoid (reconstructionofthepalmarportionoftheSLligament).The Kirschner wirewaspassedbetweenthe scaphoidand cap-itatebonesforstabilizationoftheligament reconstruction. Themidcarpaljoint wasonce againinspectedthrough the MCRorMCUportal.TheSLgapwasonceagaininspectedwith probetweezers,asdescribedbyGeissler(Fig.7).Thisinterval shouldbeclosed.AnytissueinterpositionintheSLgap pre-ventingacompletereduction,wasarthroscopicallyremoved. SLstabilitywasconfirmedbyarthroscopyandfluoroscopy.

Thelayerswere cleanedandsutured,and aplastercast wasplaced.Twoweekspostoperatively,theplastercastand the Kirschnerwiresthat maintainedtheSLreductionwere removedfromthecarpalbones;allpatientsstarted rehabili-tationinoccupationaltherapy.

Results

Thefollow-uptimewas12months(3–17).ThemeanROMwas 321.07◦_(96.9%_of_the_normal_side)._The_mean_subjective_pain

assessment(VAS)was1.79/10 (1–6).ThemeanDASHscore, whichassessesqualityoflife,was6.50/100(1–30).

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rev bras ortop.2017;52(6):676–684

Lunate

Scaphoid

Fig.7–Intraoperativeaspectofwristarthroscopy:the probeisplacedintheSLgap,andtheclosureofthe scapholunategapisverified,asdescribedbyGeissler.

functionalwristROM,buthasnotyetreturnedtoprofessional activities.

Inthepreoperativeperiod,themeanSLgapwas4.29mm (2–7), vs.1.79mm(1–4) postoperatively.DISI deformitywas observed in ten patients, with an SL angle of more than 70◦_,_prior_to_the_procedure,_and _was_corrected_after_surgery

inall patients. SLAC stageI _was _identified _in _one_patient.

Arthroscopywas performed inall cases. SLinstabilitywas classifiedas aGeisslergradeIII _in_four_cases_and _gradeIV

intencases.Otherarthroscopyfindingswereradial synovi-tisin11patients,degenerationoftheradialstyloidcartilage inone,chondrallesioninthescaphoidfossaoftheradiusin two,proximalscaphoidchondraldefectinone,and triangu-larfibrocartilagecomplexlesion(TFCC)intwo.Concomitant procedures were performed in six cases, including TFCC debridementinone,radiusosteosynthesisinfour,andTFCC repairinone.Nocasesofinfectionorneurovascular compli-cationswereobservedinthepresentseries.

Results

Forstatistical analyses,ap-valueof5%(0.050) was consid-eredassignificantfortheapplicationofthestatisticaltests (Table2).

MS-Excelspreadsheet,initsversionfromMS-Office2013, wasusedtoorganizethedata.Thestatisticalpackage Statisti-calPackageforSocialSciences(SPSS),version23.0,wasusedto applytheWilcoxonsignaledranktest,inordertoverify pos-sibledifferencesbetweenthetwomomentsstudied,forthe variablesofinterest.

Discussion

Theideaofreconstructingthisligamentisnotnew.In1975, Dobynsetal.24_used_a_strip_of_tendon_and_passed_it_through

anteroposterior bone tunnels at the proximal pole of the

scaphoidandlunatetorebuildtheSLligament.Stabilitywas achievedbyloopingthetendongraftthroughoutthescaphoid and lunate. However, the open creation of bone tunnels compromised theirvascularization andresulted in avascu-larnecrosisand fractures.Thisapproachwassubsequently abandoned.Thepresentarthroscopicseriesdidnotrequire dissectionofthejointcapsuleandthuspreservedthe vascu-larsupplyandproprioceptionofthecarpus.21_This_minimally

invasivetechniquehelpstominimizesoft tissuedissection anddecreasestheriskofavascularnecrosis,promoteshealing ofthereconstructedSLligament,andacceleratesthe postop-erativerehabilitation.

Theresultsofthepresentstudydemonstratedan improve-mentinwristmobility,witha96.9%recoveryofROMwhen comparedwiththenormalside.Thepresentresultsare sim-ilar to those by Ho et al.18 _However, _the _present _authors

disagree with those authors. Ho et al. stated that dorsal capsulodesis decreases flexionofthe wrist,which wasnot demonstrated in the present study. The present authors believethatthelinearcapsulodesisperformedinthepresent study,limitedtotheSLgap,didnotinterfereinthemobility ofthemidcarpaljoint.

Wahegaonkaretal.25_stated_that_the_dorsal_portion_of_the

SLligament(DCSS)isparamountforSLstability,largelydueto itsattachmenttothedorsalcapsule.Theseauthorsconducted amulticenteranatomicalstudywithinternational collabora-tionanddemonstratedthecriticalimportanceofDCSS.The arthroscopiccapsule-ligamentrepairtechniqueprovided reli-able resultsand avoidedpostoperativestiffness.Theglobal resultsover amean follow-upperiodofovertwoyears are encouraging.Theauthorsbelievethatthecapsulodesis per-formedinthepresentstudyallowedcontinuityoftheligament withthedorsalcapsule,aswellasDCSSreconstruction.

Thechoiceofthepalmarislongustendongraft,usedinthis andotherpublishedstudies,offerssomeadvantages:

- the diameter of the bone tunnels can be minimal; it avoidscomplicationssuchasiatrogenicfracturesor vascu-larlesionsofcarpalbones;

- italsopreservestheflexorcarpiradialis,whichtheauthors believetobeanimportantsecondarystabilizerofthewrist, helpingtheuseofDTMintherehabilitationstages.23

The recurrence of the SL gap (Terry-Thomas sign) is commonly cited inthe literature,3 _and _the _present _results

demonstrated a maintenance of the SL gap reduction of 1.79mm(Fig.8).

Replacingaligamentwithatendonmaynotactually repro-ducetheoriginalanatomyoftheSLcomplex.However,the authorsbelieveinthe“ligamentization”ofthesegrafts,since theenvironmentinwhichtheyarefoundmayfavorthis mech-anism,similarlytowhatisobservedinpatientswhoundergo anteriorcruciateligament(ACL)reconstruction.26

Whenrebuildingboththevolaranddorsalportionsofthis ligament,greaterstabilityandefficacycanbeexpectedwhen comparedwiththemorecommondorsalreconstructions.

Many cadaveric studies support 360◦ _{reconstruction}

around the carpal bones, with favorable biomechanical results.15–17 _Other _clinical _studies _have _shown _promising

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Table2–Statisticalresultsoftheanalyzedclinical-functionalvariables.

Pairofvariables n Mean Standard

deviation

Minimum Maximum 25th

percentile

50th percentile

(median)

75th percentile

Significance

(p)

NormalROM 14 330.79 15.60 295.00 345.00 315.75 335.00 345.00 [1,0]

0.068

FinalROM 14 321.07 33.47 230.00 345.00 313.75 335.00 345.00

NormalDASH 14 1.00 0.00 1.00 1.00 1.00 1.00 1.00 [1,0]

0.006

FinalDASH 14 6.50 8.12 1.00 30.00 1.00 6.00 6.00

NormalVAS 14 1.00 0.00 1.00 1.00 1.00 1.00 1.00 [1,0]

0.102

FinalVAS 14 1.50 1.34 1.00 6.00 1.00 1.00 1.25

Source:MedicalStatisticalFileService.

Fig.8–Pre-andpostoperativeradiographicviewsthat demonstratethemaintenanceofSLgapreduction.

dorsalandpalmarreconstructionandobtainedgoodclinical results,whichwerealsodemonstratedinthepresentstudy.27

TheidealtreatmentforSLdissociationhasnotyetbeen established.Theauthors believe thatthe reconstruction of bothportionsoftheSLligament,associatedwithlinear dor-salcapsulodesis,graftfixationwithspecificscrews,andthe useoftheDTMduringimmediatepostoperativerehabilitation decreasestheperiodofimmobilization(ofonlytwoweeksin thispresentstudy)andtheratesofcomplication,allowingan earlyreturntosocialandprofessionalactivities.

Conclusion

The new approach (dorsal capsulodesis associated with arthroscopic-assistedSLligamentreconstruction)presented inthisstudyissafeandeffectiveinthetreatmentofSL dis-sociation,sinceitpresentssatisfactoryradiographic,clinical, andfunctionalresults,aswellaslowratesofcomplications, allowingthereturntosocialandprofessionalactivitiesand increasingthequalityoflifeofthesepatients.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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