Arthroscopic dorsal intercarpal ligament plication in high grade scapholunate instability treatment: description of the technique and preliminary results

The treatment of scapholunate instability (SLI) is still debated. The crucial role of the dorsal intercarpal ligament (DIC) in high-grade instability is also recognized following recent anatomical studies.

The objective is to describe the arthroscopic DIC plication procedure (ADICP) in high-grade scapholunate instability treatment and present the preliminary results. Patients who underwent the ADICP technique for SLI of grade equivalent or higher than EWAS IIIC, evaluated at a minimum follow-up of one year, were retrospectively included. The EWAS stage was confirmed intraoperatively, and two converging wide dorsal arthroscopic capsulo-ligamentous sutures (ADCLR) were performed. Stabilization of the scapholunate space (SL) by traction on the 2 sutures (DIC plication) was assessed intraoperatively; it was judged complete (C= complete), satisfactory (G= good), or incomplete (F= fair). Clinical and paraclinical evaluations were carried out postoperatively at 3 months, 6 months and one year. 

Twelve patients were included. The average time between surgery and trauma was 8.5 months. Nine SLI grade EWAS IIIC and 3 EWAS IV were observed intraoperatively. Stabilization of the SL space was judged complete in 10 cases, satisfactory in 1 case and incomplete in 1 case. At 1 year follow-up , compared to the preoperative evaluation, and on average: the VAS decreased by 69%, the grip strength increased by 24.3%; extension was not significantly modified, and flexion decreased by 16.8%. The Watson test was positive in 11 cases preoperatively; it was negative in 10 of these cases at final follow-up. Finally, the average Mayo Wrist Score increased by 26.64%. 

Previously described treatments for SLI are intrusive, often requiring dissection of crucial stabilizing structures, and mid and long-term results are often disappointing. The ADCLR technique and its enlarged modification have shown satisfactory results. Recent anatomical studies have also demonstrated the crucial role of the DIC in high-grade SLI. ADICP is an original alternative technique, which presents the advantages of a minimally invasive arthroscopic procedure allowing the DIC to be effectively tightened and stabilized, while avoiding complications linked to the bone tunnels of ligamentoplasties. However, like other techniques for "retightening" the broad dorsal capsuloligamentous structures of the scapholunate complex, it seems to be correlated with a reduction in flexion mobility. These techniques should only be indicated in high grades of ISL.

ADICP is a reproducible procedure that targets the DIC. The preliminary results are satisfactory and show effectiveness in scapholunate stabilization. A greater follow-up and a larger series are nevertheless necessary to conclude on its superiority over the other current procedures available for high-grade scapholunate instability treatment.   

Keywords: scapholunate instability , dorsal intercarpal ligament , DCSS , dorsal reinforcement procedures