Arthroscopic capsulodesis of the lunotriquetral joint

Ulnar-sided wrist pain in the athlete can be caused by a single macrotraumatic event (e.g., a hyperextension injury) or repetitive microtraumatic events (e.g., repetitive ulnar deviation and wrist flexion). The athlete complains of pain and giving way during grip, forearm rotation, and wrist extension with axial load. Tennis players and gymnasts particularly are prone to ulnar-sided injuries due to the repetitive stress placed upon the wrist during sport. Lunotriquetral interosseous ligament (LTIOL) tears can result in ulnar-sided wrist pain. Presumably, the pain is due to dynamic instability of the lunotriquetral joint; patients complain of pain, weakness, and giving way during load or motion. Radiographs are typically normal; static volar intercalated segement instability pattern is unusual. Normal lunotriquetral kinematics is imparted in part from the integrity of the LTIOL, ulnolunate, ulnotriquetral, dorsal radiocarpal, and scaphotriquetral (ST) ligaments. 13 , 31 , 32 , 33 The ulnolunate (UL) and ulnotriquetral (UT) ligaments currently are referred to as the disklunate ligaments, respectively, because their origin is the palmar radioulnar ligament, as opposed to the ulna. LTIOL tears, however, often coexist with disk–carpal ligament tears. In their prospective study, Zachee et al found a significant association of disk–carpal ligament fraying and LTIOL tears. 35 Triangular fibrocartilage complex (TFCC) tears often are found in association with LTIOL tears, and the presence of TFCC injury is often indicative of a more extensive ulnar-sided injury. 19 The TFCC is the primary stabilizer of the distal radioulnar joint via the dorsal and palmar radioulnar ligaments 7 , 18 and helps to stabilize the ulnar carpus and transmit axial forces to the ulnar wrist. 23 , 34 The disk–carpal ligament is composed of the disk–lunate (DL), ulnocapitate (UC), and disk–triquetral (DT) ligaments. Each of the ulnocarpal ligaments originates in part from the palmar radioulnar ligament. 4 The DL and DT ligaments originate on the palmar radioulnar ligament and insert on the lunate and triquetrum, respectively, and the lunotriquetral interosseous (LTI) ligament. 9 , 11 , 19 , 22 The UC ligament originates in part from the base of the ulnar styloid process and in part from the palmar radioulnar ligament. Fibers of the UC ligament insert into the radial triquetrum, pisiform, and pisotriquetral ligaments and interdigitate with the LTI ligament. 4 The TFCC originates from the ulnar aspect of the lunate fossa of the radius and inserts on the base of the ulnar styloid and distally in the lunate, triquetrum, hamate, and fifth metacarpal base. 18 Patients with lunotriquetral joint injuries often are managed initially by immobilization, and many patients regain comfort and function. Intraarticular ligament tears, such as the anterior cruciate, do not heal because the synovial fluid inhibits clot formation. Perhaps, patients who respond to immobilization have enough capsular ligamentous scarring to improve joint stability or have minimal injuries. Patients who have failed nonoperative management and have LTIOL tears have been managed by ulnar shortening, which theoretically tightens the ulnar-sided ligaments and does not address the interosseous ligament directly. Ulnar shortening has less of a role for patients who are ulnar neutral or ulnar negative. In this study, we first describe a technique for arthroscopic stabilization of the lunotriquetral joint by disk–carpal ligament suture plication with arthroscopic reduction and internal fixation of the joint with interosseous Kirschener wires. The goals of surgery are to shorten the functionally elongated disk–carpal ligament analogous to an ulnar shortening operation, augment the palmar LTIOL, and maintain joint congruity. Second, using the Modified Mayo Wrist score, the postoperative clinical outcome of a case series of 20 consecutive patients is reviewed.