Palmar Capsuloligamentous Plication in Dorsal

TECHNIQUE

Palmar Capsuloligamentous Plication in Dorsal Capitolunate Instability: Technique and Preliminary Results Sebastian Farr, MD,* Florian Schachinger, MD,* and Werner Girsch, MD† Abstract: Midcarpal instability (MCI) is a form of the carpal instability nondissociative pattern and can be differentiated into dorsal, palmar, or extrinsic MCI. Dorsal MCI can frequently be observed in adolescent or adult patients due to trauma or hyperlaxity of the palmar intrinsic carpal ligaments. Clinical stress tests and cinematography are capable to depict the ligamentous instability centered around the capitolunate area. We describe a novel technique which aims to address palmar ligamentous hyperlaxity by plication of the radioscaphocapitate, radiolunotriquetral, and arcuate ligaments, thus closing the so-called space of Poirier. This palmar technique has been used in several cases in isolated form or in conjunction with other concomitant procedures. After the floor of the carpal tunnel and thus the palmar ligaments are exposed and the weak spot meticulously verified, 2 or rarely 3 deep FibreWire pulley sutures are used for capsuloligamentous plication. Among 11 patients, 4 cases (5 operated wrists) with isolated capitolunate capsuloligamentous plication were followed at an average of 2.6 years after surgery. The results were excellent with a mean postoperative Disabilities of the Arm, Shoulder and Hand Score of 9.7 (range, 6.9 to 15.0), mean numerical rating scale of 0 at rest and 1 (range, 0 to 2) during stress. All cases stated that they were very satisfied with the result and all would definitely elect to choose the surgery again. Palmar capsuloligamentous plication has been shown to be a quick, relatively easy and reliable procedure to reduce dorsal MCI in our patient cohort. Key Words: midcarpal instability, space of poirier, capitolunate instability, CL instability pattern, MCI, wrist instability (Tech Hand Surg 2018;00: 000–000)

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idcarpal instability (MCI) is a rare condition which may cause discomfort and pain in the patient’s wrist. The pathogenesis is various, but the symptoms are induced by an alteration of the ligamentous integrity of the wrist joint in most cases. This may be due to trauma or laxity of the intrinsic carpal ligaments.1–3 MCI is a form of the so-called carpal instability nondissociative (CIND) or carpal instability complex (CIC) pattern.4,5 Mouchet6 originally described the pathology of subluxation of the midcarpal joint in 1934. Lichtman et al1 later described midcarpal subluxation including clinical diagnosis and potential treatments in more detail. Latest findings have shown that MCI can be differentiated into dorsal MCI (DMCI), palmar MCI (PMCI), or extrinsic MCI.7

From the *Orthopedic Hospital Speising, Vienna; and †Department of Plastic Surgery, Medical University Graz, Graz, Austria. Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding. Address correspondence and reprint requests to Sebastian Farr, MD, Orthopedic Hospital Speising, Speisinger strasse 109, A-1130, Vienna, Austria. E-mail: [email protected]. Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website, www.techhandsurg.com. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Since then the knowledge about the pathogenesis has increased, but there is still no common consent for a “goldstandard” surgical procedure to treat patients with persistent symptoms.5 Although conservative methods have shown satisfactory short-term outcomes,8–10 long-term results have not been fully satisfying so far.3 No comparative studies have yet been published to show the superiority of one particular technique. Previous studies have, however, shown that midcarpal arthrodesis is a suitable procedure for achieving a permanent pain-free wrist. Although soft tissue reconstruction has been shown to produce inferior outcomes compared with (partial) bone fusion in PMCI,11 arthrodeses may not be the ideal interventions for younger, adolescent patients with intact, minorly or even undamaged articular cartilage, and more specifically in DMCI.11 In this paper, we present a new technique to treat DMCI after failed conservative treatment.

ANATOMY The anatomy of the carpal ligaments is complex and diverse. Taleijsik et al have shown that the radioscaphocapitate (RSC), the radiolunotriquetral (RLT), and the arcuate ligament are responsible for palmar midcarpal stability.12 The arcuate ligament consists of a radial (scaphocapitate) and an ulnar part (triquetrohamate capitate). These structures (RSC, RLT, arcuate ligament) encircle the space of Poirier, which is considered a weak spot for subluxation of the capitolunate (CL) joint.13 Profound knowledge of the ligamentous anatomy is mandatory as the ligaments are tightly connected to the palmar wrist capsule and may be challenging to identify. In DMCI, the isolated midcarpal form of CIND, elongation of the intrinsic ligaments, particularly the RSC and dorsal intercarpal ligament, is present due to the recurrent dorsal dislocation of the capitate. DMCI may also be associated with radiocarpal instability (CIND-DISI) if the palmar radiolunate (RL) ligament is hyperlax.

INDICATIONS AND CONTRAINDICATIONS Patients with both acute and chronic wrist pain firstly undergo a standardized clinical, and if necessary, radiographic assessment at our hand clinic. Clinical testing (eg, range of motion, stability, tenderness) includes an evaluation of the radiocarpal, ulnocarpal, and midcarpal compartments, respectively. To our current personal experience, especially young adolescent female individuals during growth spurt often report diffuse, nonspecific wrist pain which warrants a particular examination of the midcarpal joint. Bilateral radiocarpal and midcarpal stress tests such as the palmar and dorsal drawer tests are performed to look for hyperlaxity or even instability as a possible pain origin. In case that patients report discomfort and/or a high index of suspicion for MCI is affirmed, further cinematographic evaluation is indicated. We therefore, follow a strict algorithm as published by Sulkers et al14 to look for abnormal carpal behavior in the anteroposterior and lateral planes. Stress tests, as mentioned before, are repeated under continuous cinematography to

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FIGURE 1. A, Preoperative cinematography demonstrates massive CL instability with marked dorsal subluxation of the proximal capitate pole (black arrow), who is only being prevented from complete dislocation by the dorsal lunate lip. B, The same examination of the contralateral hand, which was previously operated, reveals a stable situation with almost no CL shifting during the dorsal stress test (white arrow). CL indicates capitolunate.

verify any instability, in particular, CL instability pattern, a form of dorsal CIND (Fig. 1).8,15 As regards, dorsal stress maneuvers can clearly verify dorsal subluxation of the capitate from the lunate (see Video, Supplemental Digital Content 1, http://links. lww.com/BTH/A67 which demonstrates marked instability during passive midcarpal shifting) and rule out any associated radiocarpal instability (no widening of the anterior radiocarpal/ radiolunate joint space present) or PMCI. Whenever these examinations are positive, we prefer to initiate a minimum 3 to 6 months series of conservative treatment (wrist stability exercising, splinting) and activity modification. In severe cases or after failed conservative treatment, however, palmar capsuloligamentous plication is performed. Whenever necessary, our procedure can easily be combined with concomitant interventions for other associated pathologies (eg, arthroscopic triangular fibrocartilage complex repair, dorsal wrist ganglion excision, etc.). Our described technique may be deemed contraindicated in rare cases with a high likelihood for recurrence such as general, syndrome-related hyperlaxity, collagen disorders (Ehlers-Danlos) or voluntary habitual instability. In these

instances with markedly, pathologically elongated ligaments all over the wrist our technique may not be sufficient and thus longterm splint therapy or fusion techniques should be chosen.

TECHNIQUE Setup Palmar capsuloligamentous plication is conducted while the patient is lying supine and the operative hand is positioned in supination on a radiolucent arm table extension. Application of tourniquet around the upper arm is helpful. After general anesthesia induction, the hand is prepped and draped in a sterile manner. In adults but preferably not in adolescents, the surgery can alternatively be performed with regional anesthesia and sedation. The incision line is marked and basically resembles an extended curvilinear carpal tunnel approach, which crosses the wrist crease proximally in a zig-zag manner (Fig. 2). It is our preference to utilize an extended approach, however, an incision that does not cross the wrist crease can be utilized as well.

Superficial and Deep Exposure The skin is incised and the subcutaneous layer gently dissected with the knife. The palmar aponeurosis is then cut in the midline and the flexor retinaculum is cautiously divided. In rare cases, a present palmaris brevis muscle belly is divided using the bipolar cautery. The antebrachial fascial layer is dissected with the scissors and care is taken to ensure that the palmar branch of the median nerve, the median nerve itself and its motor branch are not violated. The perineural tissue and peritendineum should not be affected unless any hypertrophic or synovitic tissue is present. The median nerve is secured and gently retracted with Langenbeck retractors as are the superficial and deep flexor tendons. The easiest way to gain access to the midcarpal area is to retract parts of the flexors to the radial and to the ulnar side, respectively, without any need for dissecting the synovial layer. FIGURE 2. A clinical photograph showing the volar, extended carpal tunnel approach crossing the wrist crease in a zick-zag manner. We prefer this particular approach over a smaller incision in order to minimize pressure on the median nerve during dissection to reach the ligaments.

Reconstruction As the floor of the carpal tunnel and thus the palmar ligaments are exposed, meticulous localization of the space of Poirier is needed. A thin needle is introduced in the desired direction and correct positioning is verified under fluoroscopy. The needle

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Palmar Capsuloligamentous Plication

FIGURE 3. These images demonstrate the next intraoperative steps. A, The needle is inserted at the expected area representing the center of the capitolunate-joint line. B, Fluoroscopic confirmation of the correct position for soft tissue plication.

should aim directly into the midpoint of the CL joint space line (Fig. 3). In the vast majority of cases, hyperlax and softened ligaments can be found at this location and represent the desired area for the plication (Fig. 4). Thereafter, 2 (rarely 3) deep 2-loop pulley sutures are used for soft tissue plication of an area of 10 to 15×10 to 15 mm. We prefer #4-0 FibreWire sutures (Arthrex Inc., Naples) for this purpose. To our experience, the sutures cannot be overtighened. Postrepair clinical evaluation and fluoroscopy should confirm the stabilized situation by proving a firm stop without any subluxation on dorsal stress test (see Video, Supplemental Digital Content 2, http://links.lww. com/BTH/A68 which demonstrates restored midcarpal stability during passive shift test).

Closure After exact hemostasis and irrigation, the subcutaneous tissue in the forearm and skin are closed with 3-0 vicryl and 4-0 nylon sutures, respectively. A temporary drainage is inserted and to be removed at the first postoperative day. Then, a dorsal plaster cast is applied to allow for swelling and immediate active finger remobilization; this will be changed into a forearm cast for another 4 weeks at the time of suture removal (10 to 12 d postoperatively).

Rehabilitation Six weeks postoperatively the cast will eventually be removed and occupational therapy is prescribed. Moreover, a removable orthosis (zipper splint) is custom-made for the patient and is kept for 6 to 8 more weeks until the patient has regained

strength and motion. The patients are encouraged to resume sports participation not before 3 months postoperatively and they should avoid participation in any sports with heavy wrist loading for a total of 6 months.

EXPECTED OUTCOMES The advantage of the current technique is first of all its relatively easy approach to the structures of interest, hence, an extended carpal tunnel release incision is quick and sufficient to gain prompt access to the elongated palmar ligaments. The extended approach allows to decrease traction on the median nerve and facilitates inspection of the radiocarpal ligaments as well. Second, no fusion of carpalia is performed, which thus makes this technique very much appreciated in the treatment of adolescent patients. Within the last 6 years, we performed a total of 13 CL plication procedures in 11 patients with a mean age of 28 years (range, 14 to 52 y) at the time of surgery. Several of them received this kind of surgery in conjunction with other upper limb interventions and were thus excluded from our current analysis. Overall, 4 cases (5 operated wrists; mean age 18 y) with isolated CL capsuloligamentous plication were followed. The mean postoperative Disabilities of the Arm, Shoulder and Hand Score (DASH) at an average of 2.6 years follow-up (range, 1.0 to 4.5 y) was 9.7 (range, 6.9 to 15.0); the mean Numerical Rating Scale (NRS) was 0 at rest and 1 (range, 0 to 2) during stress. Patients were asked whether they are satisfied with the procedure (scale 0 to 10; 0 = not at all,

FIGURE 4. A and B, The photographs show the anatomic correlate of the elongated, hyperlax volarcapsuloligamentous structures that are being tightened. B, Clinical situation after setting of 2 FibreWire loop sutures at the area of hyperlaxity.

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Farr et al


10 = very satisfied) and whether they would undergo this surgery again (scale 0 to 6; 0 = definitely not, 6 = definitely yes). All cases stated that they were very satisfied with the result (10/10 points) and all would definitely elect to choose the surgery again (6/6 points). Overall, our results compare favorably with the few results published so far on this topic, and do in fact show excellent outcomes in isolated CL instability. The first comparison between partial arthrodesis and soft tissue reefing in palmar MCI was presented by Lichtman et al.11 The presented data showed a better outcome for the arthrodesis group. However, the results were biased due to sample size and materials used for the surgical procedure. Johnson and Carrera16 first described a collective of young patients who had suffered from a dorsiflexion injury of the wrist with subsequent chronic wrist pain. Patients were treated by sewing the proximal aspect of the RSC to the RLT ligament, thereby partially closing the space of Poirier, reefing the RSC ligament and stabilizing the lunate. Johnson and Carrera16 had 6 patients with excellent and 4 patients with good outcomes which the authors graded on their postoperative evaluation protocol. One particular patient who was a professional bowler had additional augmentation of the space of Poirier closure site with a palmaris longus graft. Nevertheless, the result was evaluated as “poor” and the continuous cartilage degeneration and concomitant symptoms required fusion of the wrist. The patient was able to return to professional bowling after the bone fusion. The high wrist load associated with professional bowling may be a contraindication for soft tissue repair. In total 7 patients reported a pain-free wrist after surgery and the postoperative procedure. Aspergis17 published a similar technique which extended Johnson’s approach by passing additional sutures through the capitotriquetral and lunotriquetral ligaments. Thus the space of Poirier was narrowed and, as opposed to Johnson’s technique, finally closed with further sutures. Apergis reported that 11 patients (12 patients with 14 affected limbs in total) scored at least 80 points in the Modified Mayo Wrist Score (MMWS) after surgical intervention and regained full range of motion after physical therapy. More specifically, 8 cases had an excellent and 5 cases had a good result. There was only 1 case with a fair result, affected by both CL and triquetrohamate instability, but was only treated for the former. In 4 patients partial denervation and additional palmar capsular reefing was performed. No complications were reported. Our approach is rather similar to Apergis’,17 but we prefer not to sacrifice the terminal branch of the anterior interosseus nerve. Although the role of the anterior interosseous nerve in wrist proprioception remains inconclusive, we feel that we therefore, may preserve at least some of the mechanoreceptive ability.18 Second, the use of FibreWire material ensures more stability than conventional absorbable sutures with less local tissue irritation. Moreover, our technique is different to Aspergis’ with regard to the plication itself since we (1) do not remove the “superficial” radiocarpal ligament and (2) we perform a focused closure of Poirier as opposed to Aspergis, who described a more extensive ligament plication including the radial (RSC to LRL ligaments) and ulnar (CT to LT ligaments) sides of Poirier. As opposed to Johnson’s technique, we aim for capsuloligamentous plication directly over the CL interval so as to completely close the space of Poirier. We believe that radical procedures like midcarpal fusion are not suited for the wrists of young patients with healthy bone and cartilage tissue. The intended effect of our presented procedure is the closure of the space of Poirier by approaching the mid portion of the RLT ligament to the attachment of the RSC ligament plus the ulnar

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and the radial arm of the arcuate ligament by using as little suture material as possible to prevent mechanical irritation. Through this process, a shrinkage of the joint capsule with a tightening effect is attempted. Up to now, a second (dorsal) incision has never been performed as the palmar plication was sufficient to avoid dorsal instability in all cases so far. In addition, this approach provides more local stability as the FibreWire is more tear resistant than conventionally used sutures.19,20 In our opinion bone fusions or carpectomies should only be performed after soft tissue reconstruction has failed and should be reserved for adult patients.

COMPLICATIONS Possible complications for this procedure theoretically include iatrogenic median nerve and flexor tendon injuries and, of course, recurrent instability, although we did not observe any of these complications until now. In order to avoid recurrent instability, we generally aim for a relatively long time in the cast (6 weeks) to achieve sufficient ligamentous healing and scarring. However, postoperative occupational therapy and activity modification are still necessary to counsel the (young) patients on how to actively stabilize their wrist and prevent further damage. According to the sparse current literature, only 2 patients had minor discomfort during strenuous activities which resolved at rest.16 Two patients suffered neurapraxia of the median nerve postoperatively which resolved after a few weeks without any further intervention.16 However, both Johnson and Carrera16 and Apergis17 reported no occurrence of severe complications. REFERENCES 1. Lichtman DM, Schneider JR, Swafford AR, et al. Ulnar midcarpal instabilityclinical and laboratory analysis. J Hand Surg Am. 1981;6:515–523. 2. Linscheid RL, Dobyns JH, Beabout JW, et al. Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. J Bone Joint Surg Am. 1972;54:1612–1632. 3. Ono H, Gilula LA, Evanoff BA, et al. Midcarpal instability: is capitolunate instability pattern a clinical condition? J Hand Surg Br. 1996;21:197–201. 4. Wright TW, Dobyns JH, Linscheid RL, et al. Carpal instability nondissociative. J Hand Surg Br. 1994;19:763–773. 5. Hargreaves DG. Midcarpal instability. J Hand Surg Eur Vol. 2016;41:86–93. 6. Mouchet ABJ. Poignet a’ressaut: subluxation mediocarpienne en avant. Bull Mem Soc Chir. 1934;60:1243–1244. 7. Niacaris T, Ming BW, Lichtman DM. Midcarpal Instability: a comprehensive review and update. Hand Clin. 2015;31:487–493. 8. Louis DS, Hankin FM, Greene TL, et al. Central carpal instabilitycapitate lunate instability pattern: diagnosis by dynamic displacement. Orthopedics. 1984;7:1693–1696. 9. Mulders MAM, Sulkers GSI, Videler AJ, et al. Long-term functional results of a wrist exercise program for patients with palmar midcarpal instability. J Wrist Surg. 2018;7:211–218. 10. Salva-Coll G, Garcia-Elias M, Hagert E. Scapholunate instability: proprioception and neuromuscular control. J Wrist Surg. 2013;2:136–140. 11. Lichtman DM, Bruckner JD, Culp RW, et al. Palmar midcarpal instability: results of surgical reconstruction. J Hand Surg Am. 1993;18:307–315. 12. Taleisnik J, Watson HK. Midcarpal instability caused by malunited fractures of the distal radius. J Hand Surg Am. 1984;9:350–357.

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13. Thompson JC. Forearm Joints. Netter’s Concise Orthopaedic Anatomy E-Book, Updated Edition. Elsevier Health Sciences; 2015:150.

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14. Sulkers GSI, Strackee SD, Schep NWL, et al. Wrist cineradiography: a protocol for diagnosing carpal instability. J Hand Surg Eur Vol. 2018;43:174–178.

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15. White SJ, Louis DS, Braunstein EM, et al. Capitate-lunate instability: recognition by manipulation under fluoroscopy. AJR Am J Roentgenol. 1984;143:361–364.

19. Brockardt CJ, Sullivan LG, Watkins BE, et al. Evaluation of simple and looped suture and new material for flexor tendon repair. J Hand Surg Eur Vol. 2009;34:329–332.

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20. Chang JH, Shen HC, Huang GS, et al. A biomechanical comparison of all-inside meniscus repair techniques. J Surg Res. 2009;155:82–88.

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