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Arthrosc Tech
Arthrosc Tech
Arthroscopy Techniques
2212-6287
Elsevier

S2212-6287(24)00137-3
10.1016/j.eats.2024.103028
103028
Technical Note
Hand and Wrist
Arthroscopic Midcarpal Suture Anchor Repair of Dorsal Intercarpal Ligament Avulsion
Chung Sze Ryn M.R.C.S.(Edin) szeryn@gmail.com
ab∗
Caloia Martin F. M.D. c
Merlini Lorenzo M.D. a
a International Wrist Center, Clinique Bizet, Paris, France
b Hand and Reconstructive Microsurgery, Singapore General Hospital, Singapore, Singapore
c Division of Hand and Upper Extremity Surgery, Austral University Hospital, Buenos Aires, Argentina
∗ Address correspondence to Sze Ryn Chung, M.R.C.S.(Edin), Department of Hand and Reconstructive Microsurgery, Academia Level 4, Outram Road, Singapore 169608. szeryn@gmail.com
18 5 2024
8 2024
18 5 2024
13 8 10302818 1 2024
28 3 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
The dorsal intercarpal ligament (DICL) is crucial for carpal stability and is frequently associated with injuries to other carpal ligaments, notably the scapholunate and lunotriquetral interosseous ligaments. Although isolated DICL injuries are uncommon, they can manifest as ligament avulsions, bony avulsions, or attenuations from chronic injury. Surgical repair of isolated DICL tears may be necessary when conservative management fails. We have previously described the first isolated DICL avulsion from the scaphoid dorsal ridge, suggesting an arthroscopic repair via the radiocarpal joint. This article details a repair technique through the midcarpal joint.

Technique Video

Video 1

Dorsal intercarpal ligament avulsion repair from midcarpal joint approach in right wrist.
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pmcThe dorsal intercarpal ligament (DICL) extends from the triquetrum’s dorsal tubercle to the scaphoid’s dorsal ridge, encompassing the dorsal scapholunate interosseous ligament (SLIL) and attaching to the lunate, trapezium, trapezoid, and capitate.1 Its deep fibers, the dorsal scaphotriquetral ligament, connect the proximal carpal row (PCR) dorsally, crucial for midcarpal and radiocarpal joint kinematics.2, 3, 4 The DICL is a key component of the dorsal scapholunate (SL) complex, contributing to SL joint stability alongside the dorsal radiocarpal ligament and the dorsal capsule-scapholunate septum (DCSS).5, 6, 7

DICL injuries are often associated with SLIL or lunotriquetral interosseous ligament (LTIL) tears, although isolated DICL injuries such as avulsions or avulsion fractures are uncommon. Treatment typically involves a comprehensive approach, addressing both intrinsic and extrinsic ligaments through capsuloligamentous repair or capsulodesis.8,9 We have previously reported arthroscopic repair of isolated DICL avulsions using a suture anchor via the radiocarpal portal in 7 cases.10 This article presents a simplified technique for DICL avulsion repair using a suture anchor through the midcarpal portal.

Surgical Technique

Patient Preparation

The procedure is performed with the patient under general or regional anesthesia with an arm tourniquet via a standard wrist arthroscopy setup (Video 1). We use the following arthroscopic portals: 3-4, 6-R (6-radial), midcarpal radial (MCR), midcarpal ulnar (MCU), and accessory radial-midcarpal radial (R-MCR) portal (Fig 1).Fig 1 With a standard wrist arthroscopy setup, standard portals (3-4, 6-radial [6-R], midcarpal radial [MCR], and midcarpal ulnar [MCU]) are created, along with an accessory radial-midcarpal radial (R-MCR) portal, on the right wrist.

Assessment of Dorsal SL Complex

We begin by exploring the radiocarpal joint with a 30° 2.4-mm arthroscope via the 3-4 portal. One can visualize the dorsal SLIL, the DCSS, and the DICL insertion to the dorsal scaphoid ridge (Fig 2). The arthroscope is subsequently switched to the 6-R (6-radial) portal, with the 3-4 portal serving as the working portal for instrumentation. An arthroscopic synovectomy is performed using a 2.9-mm shaver, allowing clear visualization of the dorsal SL complex, including the DCSS.Fig 2 (A) Right wrist: Inspection of dorsal capsule-scapholunate septum, dorsal scapholunate interosseous ligament, and dorsal intercarpal ligament (DICL) with arthroscope in 3-4 portal. (B, C) Intact DICL insertion to dorsal scaphoid ridge (shaded blue) on 3-4 view. The yellow shaded area represents the dorsal wrist capsule, and the red dashed lines represents the fibers of the DICL. (MCR, midcarpal radial; MCU, midcarpal ulnar; R-MCR, radial-midcarpal radial; 6-R, 6-radial

The SL complex is then evaluated using an arthroscopic probe with the standard technique, followed by a “push test” to assess the integrity of the DCSS.11 A positive push test finding, indicated by the probe’s ability to enter the midcarpal joint (MCJ) unimpeded by the DCSS, suggests a disruption. In cases with associated DCSS tears, the surgeon may perform the classic repair technique described by Mathoulin et al.8 Attention is then diverted to the MCJ with the arthroscope within the MCU portal. The stability of the SL joint is first assessed according to the Geissler classification (Table 1) and European Wrist Arthroscopy Society (EWAS) classification9,12 (Table 2).Table 1 Geissler Arthroscopic Classification for Intracarpal Ligament Tears12

Grade	Description	
I	Attenuation or hemorrhage of interosseous ligament seen from RC space; no incongruence of carpal alignment in MC space	
II	Attenuation or hemorrhage of interosseous ligament seen from RC space; incongruence or step-off of carpal space; slight gap (less than width of probe) may be present between carpal bones	
III	Incongruence or step-off of carpal alignment as seen from both RC and MC space; probe may be passed through gap between carpal bones	
IV	Incongruence or step-off of carpal alignment as seen from both RC and MC space; gross instability with manipulation; 2.7-mm arthroscope may be passed through gap between carpal bones	
MC, midcarpal; RC, radiocarpal.

Table 2 EWAS Classification for SLIL Tears9

Arthroscopic Stage	Arthroscopic Testing of SLIL From MC Joint	
I	No passage of probe	
II: lesion of membranous SLIL	Passage of tip of probe in SL space with no widening (stable)	
III A: partial lesion involving volar SLIL	Volar SL widening on dynamic testing from MC joint (anterior laxity)	
III B: partial lesion involving dorsal SLIL	Dorsal SL widening on dynamic testing from MC joint (posterior laxity)	
III C: complete SLIL tear with reducible joint	Complete widening of SL space on dynamic testing; reducible with probe removal	
IV: complete SLIL tear with SL gap	SL gap with passage of arthroscope from MC to RC joint; no radiographic abnormalities	
V	Wide SL gap with passage of arthroscope through SL joint; frequent radiographic abnormalities (increased SL gap, DISI deformity)	
DISI, dorsal intercalated segment instability; EWAS, European Wrist Arthroscopy Society; MC, midcarpal; RC, radiocarpal; SL, scapholunate; SLIL, scapholunate interosseous ligament.

Assessment of DICL Tear

When the DICL detaches from the dorsal scaphoid ridge, its footprint appears as a bare area (Fig 3). To confirm detachment, we perform a “hook-sweep” test through the 3-4 portal.13 This test involves sweeping the scaphoid’s dorsal surface at the DICL’s usual insertion site and hooking the ligament dorsally while observing through the MCU portal (Fig 3A). A positive hook-sweep test finding suggests a complete DICL disruption, either avulsion or chronic attenuation. Additionally, the DICL’s condition can be assessed by gently hooking the distal DICL away from the scaphoid ridge using a probe through either the R-MCR or MCR portal (Video 1). An accessory R-MCR portal is created about 1.5 to 2 cm radially and distally to the MCR portal, ulnar to the extensor pollicis longus tendon. In Video 1, a distal partial DICL avulsion was observed in the patient, indicated by a negative hook-sweep test finding from the 3-4 portal and a positive distal DICL hook test finding from the R-MCR portal.Fig 3 Arthroscopic view from midcarpal ulnar (MCU) portal (right wrist) (A), revealing the bare footprint area on the dorsal scaphoid ridge (B, C), where the avulsed dorsal intercarpal ligament (DICL) (black arrows) typically attaches (shaded blue). The arthroscopic probe can be placed within the radial-midcarpal radial (R-MCR) portal (yellow 1) to evaluate the DICL by gently pulling it dorsally away from the scaphoid DICL footprint (shaded blue). Alternatively, one can perform the hook-sweep test from the 3-4 portal (yellow 2), as described by Caloia,13 using the 3-4 portal. (MCR, midcarpal radial; 6-R, 6-radial.)

Preparation of DICL Repair Site

One of the prerequisites for a successful DICL repair is the presence of a healthy footprint for DICL reattachment. Therefore, it is essential to focus on debriding the avulsed DICL footprint site and the ligament’s edge to establish an optimal healing repair zone. The footprint is debrided using an arthroscopic shaver from the R-MCR portal. This procedure removes all fibrous scar tissue until a punctate bleeding bone surface is visible. It is crucial to exercise caution and precision during the debridement of the DICL footprint to avoid damage to the adjacent cartilage (Table 3).Table 3 Pearls and Pitfalls

Pearls	
 To ensure an ideal environment for ligament repair, it is imperative to debride both the bony DICL footprint and the torn end of the ligament.	
 It is essential to perform thorough debridement and synovectomy to properly visualize the dorsal scaphoid surface before placing the suture anchor.	
 To facilitate the placement of the suture anchor guidewire within the bone, it is advisable to retract the tendons by gently opening a small hemostat to prevent iatrogenic tendon injury.	
Pitfalls	
 Care should be taken not to injure the cartilage during debridement of the DICL bony footprint.	
 Care should be taken not to over-debride the DICL and the dorsal capsule.	
 Using the nonoscillating mode for predrilling the suture anchor can potentially lead to iatrogenic tendon injury. It is, therefore, advisable to use a mallet or an oscillating drill to predrill the suture anchor.	
DICL, dorsal intercarpal ligament.

Suture Anchor Repair From Midcarpal Portal

The optimal position for the suture anchor is over the dorsal scaphoid ridge (Fig 4). We typically use a 2.2- or 2.7-mm suture anchor in most cases. After preparing the DICL repair site using the arthroscopic shaver, we predrill the scaphoid repair site (Fig 4A) and insert the suture anchor (Fig 4B) aligned with the drill hole through the R-MCR portal. After the anchor is secured, the 2 FiberWire sutures (Arthrex) with attached needles are left outside the R-MCR portal. The needles are removed. Subsequently, 1 end of the suture is introduced back into the MCJ through the R-MCR portal using a hemostat. It is then retrieved from the MCR portal (Fig 5). A suture lasso (No. 3-0 PDS; Ethicon) is introduced from the R-MCR portal into the MCJ, and the suture lasso is retrieved from a separate capsular perforation through the MCR portal (Fig 6). During this step, special care is taken to avoid any damage to the extensor tendons.Fig 4 Arthroscope in midcarpal ulnar (MCU) portal (right wrist). After preparation of the dorsal intercarpal ligament (DICL) repair site with a shaver, predrilling is performed at the dorsal scaphoid footprint (black asterisk) (A), followed by insertion of a suture anchor oriented in the same direction as the drill hole (black asterisk) (B). (MCR, midcarpal radial; R-MCR, radial-midcarpal radial; 6-R, 6-radial.)

Fig 5 Arthroscope in midcarpal ulnar (MCU) portal (right wrist). (A) After the suture anchor is secured, 2 FiberWire sutures are left outside the radial-midcarpal radial (R-MCR) portal. The needles of the FiberWire sutures are then removed. One of the FiberWire sutures is introduced back into the midcarpal joint (MCJ) (yellow arrows) through the R-MCR portal (B) and then retrieved from the midcarpal radial (MCR) portal using a hemostat (yellow arrow) (C). (DICL, dorsal intercarpal ligament; 6-R, 6-radial.)

Fig 6 Arthroscope in midcarpal ulnar portal (right wrist). A 21-gauge hypodermic needle with a suture lasso (No. 3-0 PDS) is inserted into the radial-midcarpal radial (R-MCR) portal (A) and is retrieved from the midcarpal radial (MCR) portal through a separate capsular perforation (black asterisk) using a hemostat (B, C). (DICL, dorsal intercarpal ligament.)

The end of the same FiberWire suture is placed within the suture lasso loop and pulled out through the R-MCR portal (Fig 7). Pulling both FiberWire sutures together, the surgeon can observe the DICL reattaching to the repair footprint. Subsequently, the traction tower is removed, and both FiberWire sutures are securely tied (Fig 8) with the wrist slightly extended. If DCSS sutures are also present, they may be tied at this stage.Fig 7 Arthroscope in midcarpal ulnar portal (right wrist). The end of the same FiberWire is placed within the suture lasso (A) and is pulled out through the radial-midcarpal radial (R-MCR) portal (B). The black asterisk in (A) indicates a separate capsular perforation, through which the suture is passed from the MCR portal. The yellow arrow indicates the direction in which the PDS suture lasso is pulled to transport the FiberWire suture out of the R-MCR portal. (DICL, dorsal intercarpal ligament; MCR, midcarpal radial.)

Fig 8 Arthroscope in midcarpal ulnar portal (right wrist). (A) By pulling both FiberWire sutures through the radial-midcarpal radial (R-MCR) portal, we can observe the reattachment of the dorsal intercarpal ligament (DICL) to the dorsal scaphoid footprint. The yellow arrow indicates the direction in which the suture is pulled before securing the repair. (B) The sutures are tied with wrist traction removed. The black asterisk in (A) indicates a separate capsular perforation, through which the suture is passed from the MCR portal. (MCR, midcarpal radial.)

Alternative Approach for Wider Repair

An additional step involves passing a suture lasso through a separate radial capsular perforation from the R-MCR portal. This suture lasso is retrieved from the R-MCR portal’s original capsular perforation, and a second FiberWire suture is lassoed out from the radial capsular perforation of the R-MCR portal. This extra step is useful for more extensive DICL tears, capturing a larger portion of the DICL complex. Both FiberWire sutures are then tied in an extracapsular manner for a more secure repair.

Postoperative Care

The patient is immobilized with a volar wrist splint for 4 weeks. Thereafter, the patient will begin progressive active and passive wrist motion exercises up to week 6, followed by extrinsic muscle strengthening exercises. The splint is removed at week 6.

Discussion

The literature on isolated DICL tears is limited. This scarcity of data is likely attributable to an insufficient understanding of such pathology, resulting in frequent misdiagnoses and delayed clinical presentations. Our understanding of the DICL’s role in wrist stability, particularly in relation to other extrinsic ligaments such as the dorsal radiocarpal ligament, SLIL, and LTIL has evolved significantly over time. Studies have shown the significance of the DICL, especially its deep fibers, known as the dorsal scaphotriquetral ligament, in maintaining the stability of the PCR.2,5,14 Moreover, the DICL’s role in preventing dorsal intercalated segment instability deformity, as highlighted by Pérez et al.,15 underscores its functional importance.

DICL tears are categorized based on their origin: from the scaphoid dorsal ridge (type 1), from the triquetral bone (type 2), or from the dorsal SLIL (type 3). These injuries may present as ligamentous or bony avulsions or chronic attenuation (type 4), as detailed in Table 4. In scenarios in which the quality of the DICL is too compromised for suture anchor repair, an internal brace extending from the scaphoid to the triquetrum can be used to re-establish DICL continuity.Table 4 Proposed Classification for DIC Ligament Injury and Suggested Treatment

Proposed Classification	Arthroscopic Findings	Suggested Treatment	
Type 1: DIC avulsion from dorsal scaphoid ridge			
 A	Pure ligament and capsular avulsion	Suture anchor repair	
 B	Type 1A plus avulsion fracture	Suture anchor repair with or without SL pinning or internal brace from scaphoid to Tq	
Type 2: DIC avulsion from Tq			
 A	Pure ligament and capsular avulsion	Suture anchor repair with or without capsulodesis	
 B	Type 2A plus avulsion fracture	Suture anchor repair with or without LT pinning or internal brace from scaphoid to Tq	
Type 3: DIC avulsion from SL dorsal footprint			
 A	Pure ligament and capsular avulsion	SL dorsal capsulodesis with or without temporary SL screw and with or without internal brace from scaphoid to Tq	
 B	Type 3A plus avulsion fracture (from scaphoid or lunate)	SL dorsal capsulodesis with or without suture anchor, with or without temporary SL screw, and with or without internal brace from scaphoid to Tq	
Type 4: DIC attenuation or laxity			
 A	Associated SLIL tear	SL dorsal capsulodesis with or without SL pinning	
 B	Associated LTIL tear	LT dorsal capsulodesis with or without LT pinning	
 C	Associated SLIL and LTIL tears	Double SL and LT capsulodesis or DIC ligament plicature techniques with or without internal brace from scaphoid to Tq	
DIC, dorsal intercarpal; LT, lunotriquetral; LTIL, lunotriquetral ligament; SL; scapholunate; SLIL, scapholunate interosseous ligament; Tq, triquetrum.

A recent publication from Merlini and Mathoulin10 detailed a technique for DICL capsuloligamentous repair in type 1 DICL tears using a suture anchor approach from the radiocarpal joint. This article introduces a similar DICL suture anchor repair method via the MCJ approach. The MCJ approach allows more precise visualization and assessment of the DICL attachments, especially during the hook-sweep test. The treatment for DICL reattachment in type 1 and type 2 tears is similar (Table 4), mainly differing in the placement of surgical portals. The hook-sweep test is conducted by directing a probe from the 3-4 portal toward the MCJ, sweeping along the dorsal surface of the PCR, and hooking the DICL dorsally to verify detachment.13 Our experience shows that a negative hook-sweep test finding from the 3-4 portal does not always rule out a DICL tear. In the case shown in Video 1, even though the hook-sweep test finding was negative (not shown), we could still hook the distal attachment of the DICL off the dorsal scaphoid ridge from the MCR portal (Fig 3), indicating a partial distal avulsion of the DICL.

This article adds to the limited but essential knowledge of DICL tears. Although we present a specific method for DICL repair, it is crucial to recognize the variety of available techniques. Our findings highlight the importance of including DICL assessment using the hook-sweep test in treating SLIL and LTIL injuries.13 Neglecting this can lead to unresolved pain, even with successful treatment of other ligaments. The growing understanding of the DICL’s role in wrist biomechanics emphasizes the need for comprehensive evaluation and diverse treatment approaches. This focus is critical to improving outcomes for patients with wrist ligament injuries.

Disclosures

All authors (S.R.C., M.F.C., L.M.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

Dorsal intercarpal ligament avulsion repair from midcarpal joint approach in right wrist.
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References

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