A Review of Arthroscopic Volar Scapholunate Complex Repairs

Abstract

While the volar scapholunate complex's role in wrist stability is increasingly recognized, the literature on its repair techniques and outcomes remains limited. This paper seeks to fill that gap by providing a comprehensive overview of the volar scapholunate complex's anatomy, biomechanics, and clinical significance alongside the most up-to-date arthroscopic repair techniques. By presenting the advancements and challenges of these minimally invasive approaches, we aim to encourage further research and development in addressing this underappreciated yet critical aspect of scapholunate instability.

 

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Keywords

wrist arthroscopy - carpal ligaments - volar scapholunate - scapholunate ligament - review

Introduction

The evolution of arthroscopic repairs for scapholunate (SL) instability has expanded from addressing solely the dorsal SL complex to encompassing both dorsal and volar components as well as some of the extrinsic ligaments, when indicated. Previous methods for repairing chronic SL ruptures primarily reinforced/reconstructed the dorsal SL, often neglecting the anterior portion. Given this, attention has been paid to addressing these as well as the volar critical stabilizing structures.[1] [2] [3] The optimal approach to managing SLIL injuries remains a considerable debate among hand surgeons. Berger et al. demonstrated that the dorsal segment of the SLIL plays a critical role in providing biomechanical stability.[4] Furthermore, studies investigating the dorsal extrinsic ligaments, particularly the dorsal intercarpal ligament (DICL), have established its significant contribution to the stability of the proximal carpal row (PCR).[5] [6] [7] [8]

The volar SL complex is often underappreciated; however, it has been demonstrated to play a crucial role in maintaining the stability of the PCR.[7] [9] [10] [11] [12] Isolated tears of the volar SLIL are uncommon, or they may be underreported in the literature, as injuries typically involve both dorsal and volar tears. Mathoulin described the arthroscopic dorsal capsuloligamentous repair (ADCLR) for cases up to European Wrist Arthroscopy Society (EWAS) stage 4, which involves combined dorsal and volar SL instability. This technique has shown favorable outcomes, especially in reducible SL dysfunctions.[13] Numerous other ADCLR techniques in the literature focus on dorsal SL complex plication for managing advanced SL dysfunctions, yielding promising results.[14] [15]

Open volar SL reinforcement was described by van Kampen et al., who utilized the long radiolunate ligament (LRL) to reinforce the volar SL in cases of isolated volar SL instability.[16] Over time, with a growing understanding of the importance of secondary stabilizers of the volar SL joint, this approach has evolved into minimally invasive techniques aimed at reinforcing the volar SL stabilizers.[17] [18] [19] [20] Though reported primarily in small case series, these arthroscopic techniques have shown favorable outcomes, offering the ability to address the volar component of the SL complex with less surgical morbidity. This article aims to analyze and summarize the existing literature on arthroscopic volar SL repair techniques, providing insights into their advancements, limitations, and clinical relevance in managing SL instability.

 

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Anatomy and Biomechanics of the Scapholunate Complex

The SL ligament is anatomically divided into dorsal, volar, and intermediate/membranous portions.[21] Among these, the dorsal SL ligament is the strongest, withstanding over 300 N of tensile stress, while the volar and intermediate portions are less robust, tolerating ∼150 N and 25–50 N, respectively. ([Fig. 1A]) While the dorsal SL ligament controls wrist flexion and extension, the volar SL complex ensures rotational and translational stability of the scaphoid.[21] The stabilizers of the volar SL joint consist of:

Fig. 1 (Left wrist); (A) Radial aspect of the proximal carpal row showing the dorsal (red), intermediate (yellow), and volar (blue) portions of the scapholunate ligament (SLIL). The joint exhibits a C-shaped configuration, as outlined by the black dotted lines, emphasizing the anatomical alignment of the SLIL components; (B) The scaphotrapeziotrapezoid (STT) ligament (shaded blue) stabilizes the distal pole of the scaphoid and prevents diastasis of the STT joint. Abbreviations: Cp, capitate; L, lunate; MC, metacarpal; Sc, scaphoid; Tz, trapezium.

• 1. Volar Scapholunate Interosseous Ligament (SLIL)

The volar SLIL comprises obliquely oriented collagen fascicles with a tensile strength of ∼150 N, providing resistance to rotational forces.[21]

• 2. Scaphotrapeziotrapezoid Complex (STTC)

The STTC ([Fig. 1B]) stabilizes the distal pole of the scaphoid and prevents diastasis at the scaphotrapezial joint. This complex also stabilizes the scaphoid's rotational axis, preventing SL instability by preventing scaphoid flexion.[10] Sectioning of both the SLIL and the STT ligament has been shown to produce DISI deformity (radiolunate angle >15 degrees), highlighting its destabilizing effect on the PCR.[7]

• 3. Volar Radiocarpal Ligament Complex (VRCLC)

The VRCLC consists of the radioscaphocapitate ligament (RSC), long radiolunate (LRL) and short radiolunate (SRL) ligaments, and the radioscapholunate ligament (RSL). The RSC originates radially and extends to the capitate ([Fig. 2A]), stabilizing the scaphoid during wrist motions. The RSC ligament wraps around the volar radial aspect of the scaphoid waist and has a variable attachment to the scaphoid.[22] [23] The scaphoid functions as a pulley over the RSC ligament, flexing and rotating around it during wrist movement.

Fig. 2 (Left wrist) (A) illustrates the volar aspect of the left wrist and the volar radiocarpal ligament complex (VRCLC), with black dotted lines outlining the distal radius and the red line demarcating the watershed ridge. The VRCLC comprises the radioscaphocapitate ligament (RSC, shaded red), long radiolunate ligament (LRL, shaded blue), short radiolunate ligament (SRL, shaded yellow), and radioscapholunate ligament (RSL, indicated by the black asterisk in (B). (B) demonstrates the radial aspect of the radiocarpal joint, with the RSC and LRL ligaments reflected proximally from their radial attachments. The black asterisk in (B) highlights the origin and insertion of the RSL.

The SRL and LRL ligaments enhance volar stability by linking the radius and lunate, indirectly supporting the volar SL complex. The LRL specifically resists lunate extension, and combined sectioning of the LRL and SLIL significantly increases the radiolunate angle, though LRL sectioning alone does not cause DISI.[7] Sandow et al. demonstrated that the LRL remains isometric during wrist motion, confirming its stabilizing effect on the proximal carpal row during flexion and extension.[24] The SRL originates from the anteromedial surface of the distal radius, just ulnar to the LRL ligament, and inserts vertically onto the palmar aspect of the lunate. It indirectly stabilizes the SL joint by preserving the alignment and positioning of the lunate.[25]

The RSL plays a role in stabilizing the proximal pole of the scaphoid, preventing palmar flexion of the distal pole and dorsal rotation of the proximal pole during wrist motion. ([Fig. 2B]) It consists of loosely arranged collagen fibers and is highly vascularized. The RSL originates from the prominence between the scaphoid and lunate facets on the distal radius, inserting primarily on the medial proximal scaphoid pole and secondarily on the lateral lunate, contributing to the proximal scapholunate interosseous ligament.[22]

• 4. Volar ScaphoTriquetral Ligament (VSTq)

The VSTq ligament connects the scaphoid to the triquetrum, with a substantial attachment to the triquetrum and a thin, fan-shaped insertion on the scaphoid that interdigitates with the RSC ligament. It tightens during dorsiflexion and relaxes during palmar flexion, supporting the capitate and contributing to carpal stability during wrist dorsiflexion. Functionally, it acts like the dorsal intercarpal ligament by holding the scaphoid and triquetrum together, preventing excessive motion ([Fig. 3]).[9]

Fig. 3 (Left wrist) Displays the proximal carpal row from a superior (top-down) view. (A) Shows the red highlight depicting the volar scaphotriquetral ligament, and (B) illustrates a detailed aspect of the ligaments, showing the scaphocapitate ligament (highlighted yellow), the triquetrocapitate ligament (highlighted blue), and the volar scaphotriquetral ligament (highlighted red). Abbreviations: DIC, dorsal intercarpal ligament; L, lunate; Sc, scaphoid; Tq, triquetrum.

 

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Clinical and Radiological Assessment

The clinical presentation of volar SL tears closely resembles that of general SL injuries, typically resulting from hyperextension wrist trauma. Patients often present with radial or central wrist pain, weakness, and limited range of motion. Clinical examination may reveal non-specific tenderness over the dorsal or volar scapholunate region with a positive Watson's shift test.[26] Patients may complain of pain volarly and can be ascertained by the examiner pushing deep and radial to the FCR tendon. In some cases, provocative tests for SL instability may be normal.

Ultrasound is a good tool to visualize the dynamic instability of the volar SL. ([Fig. 4]) According to the findings by Dao et al., ultrasound has a specificity of 100% and a sensitivity of 46.2% in diagnosing dynamic scapholunate ligament instability, with an overall accuracy of 89.1%.[27]

Fig. 4 (Left wrist) (A) shows the wrist with fingers in a clenched fist position, where the volar scapholunate joint widens, and (B) illustrates the wrist with fingers in full extension, where the volar scapholunate joint closes. Photo courtesy of Dr. Lucian Lior Marcovici, Hand and Microsurgery, Jewish Hospital of Rome.

Advanced imaging, such as MRI, may show attenuation or tearing of the volar SL complex, specifically the volar SLIL, best seen on the axial T2 views. ([Fig. 5]) The increasing use of 4D CT has provided valuable insights into scapholunate joint kinematics, especially following targeted ligament sectioning.[28] [29] [30] [31]

Fig. 5 Axial T2-weighted MRI image of the proximal carpal row. The yellow arrows indicate volar scapholunate insufficiency or tear, with the dorsal aspect remaining intact.

 

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Arthroscopic Assessment of Volar Scapholunate Dysfunction

Wrist arthroscopic assessment begins with a standard setup using a 1.9-mm, 2.4-mm, or 2.7mm arthroscope and the 3–4 and 6R radiocarpal portals, followed by midcarpal ulnar (MCU) and midcarpal radial (MCR) portals are created. Evaluation of the SL joint starts with radiocarpal joint (RCJ) assessment, using the 3–4 portal for viewing and 6R portals for working. 1–2 or 2R portals can also be created as needed.[32] A dry arthroscopy technique is preferred to avoid capsular distension and fluid extravasation into the subcutaneous tissue.[33] The Geissler and EWAS classification is used to grade SL dysfunction, systematically assessing intrinsic and extrinsic ligament injuries based on arthroscopic findings from the midcarpal joint (MCJ).[14] [34] [35] [36]

A comprehensive assessment of the SL joint has been detailed by Goorens et al.[37] Specific to the volar SL complex, evaluation from the RCJ using the arthroscope in the 3–4 portal and a probe in the 1–2 or 2R portal allows visualization of the RSC and LRL. ([Fig. 6]) Alternatively, the camera can be placed in the 6R portal with the 3–4 portal as a working portal. Their integrity can be assessed with a 1-mm arthroscopic probe and graded according to the Van Overstraeten and Camus classification of extrinsic ligament injury (Grades E0-E3).[38] In low-grade injuries (E1-E2), extrinsic ligaments often appear attenuated, whereas high-grade injuries (E3) present as frayed or torn structures. The SRL ligament, typically obscured by synovium, requires synovial debridement for adequate visualization. Its integrity can then be probed and assessed from the 6R portal.[37]

Fig. 6 (Left wrist) (A) Arthroscopic view from the 3–4 portal demonstrating the volar radiocarpal ligaments, including the radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments. (B) Illustrates the use of a hemostat, inserted through the 1–2 portal, to assess the laxity of these ligaments. Ligament tension is evaluated by gently stretching the ligament from volar to dorsal direction, revealing laxity and attenuation.

The volar SLIL is assessed through the MCJ portals, with the arthroscope placed in the MCU portal and the probe in the MCR portal. The SL joint is evaluated using the Geissler ([Table 1]) and EWAS classifications.[13] [36] In acute injuries, isolated volar SL joint laxity may be detected with a probe corresponding to EWAS grades IIA or IIIA. Grade IIA indicates a volar SLIL injury, while grade 3A reflects a combined volar SLIL and VRCLC injury. ([Table 2]) A limitation of assessing the volar SL joint through the MCJ portal is that the volar SLIL fibers are evaluated indirectly without direct visualization. Abe et al.[39] described a more direct visualization of the volar SLIL fibers using a volar radial portal adjacent to the flexor carpi radialis (FCR) tendon. This approach enables a more precise assessment to identify midsubstance tears or avulsions from the bone.[40]

Table 1 Arthroscopic classification of Scapholunate (SL) injury by Geissler et al.[36]

Grade	Radiocarpal view	Midcarpal view
I	Attenuation / hemorrhage seen.	No midcarpal step / malalignment.
II	Attenuation / hemorrhage seen.	Midcarpal malalignment. Probe enters SL space but does not turn.
III	Radiocarpal step-off / incongruity / discreet tear visualized.	Midcarpal step-off / incongruity. Probe enters SL space and turns easily.
IV	2.7-mm scope drives through SL space.	2.7-mm scope drives through SL space.

Table 2 European Wrist Arthroscopy Society (EWAS) Classification for Scapholunate and Lunotriquetral Interosseous Ligament Tears.[13]

EWAS arthroscopic classification of SL and LT dysfunction (from MC joint)
I	No passage of the probe in SL or LT joint, but synovitis
IIA	Volar passage in the SL or LT space without widening
IIB	Dorsal passage in the SL or LT space without widening
IIC	Complete passage in the SL or LT space without widening
IIIA	Volar partial widening at dynamic instability test from MC joint (volar instability)
IIIB	Dorsal partial widening at dynamic instability test from MC joint (dorsal instability)
IIIC	Complete widening of the space at dynamic test
IV	Gap with passage of the 2.7 mm arthroscope from MC to RC joint

A summary of the arthroscopic assessment techniques and expected findings for the volar scapholunate complex is provided in [Table 3].

Table 3 Summarizes the arthroscopic assessment of the volar scapholunate (SL) complex, detailing the expected findings associated with ligament incompetence

Ligament of Interest	Portal Used	Assessment Technique	Expected Findings
VRCLC (RSC, LRL, SRL, RSL)	Radiocarpal:  • 3–4 (viewing)  • 1–2, 2R (working)  • 3–4 (working) and 6R (viewing)	Gentle hooking of volar aspect of the ligaments using a probe in a volar to dorsal direction.	Laxity of the ligaments according to the Van Overstraeten and Camus classification of extrinsic ligament injury (Grades E0-E3)[38]
Volar SLIL	Midcarpal:  • MCU (viewing)  • MCR (working)	Placing the probe within the SL gap and twisting the probe between the scaphoid and lunate bone.	EWAS IIA for isolated volar SLIL injury; EWAS IIIA for combined volar SLIL and VRCLC injury.
	Radiocarpal[39]:  • Volar radial portal (viewing)  • 3–4 (working)	Volar radial portal created adjacent to FCR tendon at proximal wrist crease. Direct visualization of Volar SLIL fibers, followed by probe assessment.	Volar SLIL may be laxed, torn at midsubstance, or avulsed from scaphoid or lunate bone.
STTC	Midcarpal:  • STT  • MCR	Volar STT ligaments are difficult to visualize from dorsal portals, but the STT portal, often used for STT arthritis, allows assessment of the STT joint.	STT joint laxity or widening may indicate STTC incompetence.
VSTq	−	−	−

 

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Indications and Contraindications of Volar Scapholunate Complex Repair

The indications for volar SL complex repair include symptomatic isolated volar SL tears, classified as EWAS IIA or IIIA, and reducible SL dysfunctions such as EWAS IIIC and IV, where a volar SL repair may be combined with dorsal reinforcement. Repair is also indicated in cases of persistent symptoms or volar instability following dorsal plication. Contraindications include chronic SL complex tears without sufficient ligament remnants for repair, static irreducible SL dysfunction, arthritis, and infection.

 

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Arthroscopic Volar Repair Techniques

All-inside Repair[40]

The repair begins with MCJ portal assessment of the volar SL joint, classified using the Geissler and EWAS grading systems. With the arthroscope positioned in the MCU portal and a full-radius shaver in the MCR portal, volar synovectomy and debridement of ligament stumps are performed. The adjacent bony surfaces are refreshed with a burr, and dry arthroscopy is preferred to enhance visualization. A Tuohy needle is inserted just ulnar to the FCR tendon through a mini-open incision over the volar wrist, ∼1 cm proximal to the distal wrist crease, targeting the SL space. A 2–0 polydioxanone (PDS) suture is introduced via the Tuohy needle and retrieved through the MCR portal.

The Tuohy needle is then retracted to the subcutaneous plane, repositioned radially, and reinserted distally to the scaphoid's palmar edge to pass the suture again into the MC joint, creating a loop within the joint. The opposite end of the suture is retrieved from the MCR portal, ensuring both ends are external to the joint. A sliding knot is tied dorsally and seated within the joint, plicating the RSC and LRL ligaments to stabilize the volar SL complex.

The outcomes of del Piñal's arthroscopic technique for volar scapholunate ligament repair have demonstrated favorable results in a small case series. This technique was successfully applied in eight patients, six of whom underwent concurrent dorsal capsuloligamentous plication to address combined dorsal and volar instability. Postoperatively, no complications such as infection, neurovascular injury, or knot failure were reported. All patients achieved closure of the volar scapholunate gap, restoring stability of the volar SL complex.

 

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Inside-out Repair[41]

Following the assessment of ligament dysfunction and debridement of ligament stumps and scar tissue, the repair begins with the insertion of an 18-G spinal needle pre-threaded with a 2–0 nonabsorbable suture through the MCR portal in an inside-out approach with the arthroscope in the MCU portal. A volar incision is made ∼1 cm proximal to the distal wrist crease, just ulnar to the FCR tendon, ensuring safe access while protecting adjacent neurovascular structures. The needle is first advanced through the radial portion of the volar capsule immediately adjacent to the ulnar border of the scaphoid. One end of the suture is retrieved through the volar incision using a hemostat.

The needle is then retracted back into the joint and redirected to pierce the capsule toward the radial border of the lunate, capturing the volar ulnar capsule. It is critically important when making the second suture passage through the capsule adjacent to the lunate that the needle not be withdrawn outside the MCR portal to ensure a soft tissue capsular bridge isn't created. The opposite end of the suture is retrieved through the same volar incision. Both ends of the suture are gently pulled to confirm reduction of the scapholunate joint under arthroscopic visualization. The wrist is removed from traction, and the sutures are securely tied over the volar capsule to stabilize the volar SL complex. Kirschner wires may be added if additional stabilization is required.

Lui and Kakar noted significant improvement in pain following arthroscopic-assisted volar scapholunate capsulodesis, with the visual analog scale (VAS) score decreasing from 8 ± 1 preoperatively to 0.7 ± 1.1 at a mean follow-up of 41 ± 17 weeks (p = 0.00004). Functional outcomes also improved, with the Mayo Wrist Score increasing from 42 ± 15 to 80 ± 11 (p = 0.001). Grip strength recovered to 86 ± 15% of the contralateral side, and range of motion (ROM) improved to 81 ± 15% of the contralateral wrist's flexion arc. Radiographic parameters, including the SL gap, SL angle, and radiolunate angle, demonstrated notable improvements, further confirming joint stabilization (p = 0.03, p = 0.11, and p = 0.15, respectively). No complications or revision surgeries were reported ([Table 4]).

Table 4 Summary of Arthroscopic Volar Scapholunate (SL) Repair Techniques. Summary of study types, indications, ligaments addressed, approaches, techniques, and outcomes for volar scapholunate repairs

Study type	Level of evidence	Indications	Ligaments addressed	Approach	Repair technique	Outcomes
Del Piñal et al. 2011	Case series	Symptomatic isolated volar SL tears (EWAS 2A/3A)	RSC, LRL	MCJ	All-inside repair with Tuohy needle and PDS suture passed through ligament stumps and tied dorsally.	Closure of volar SL gap; improved stability.
Lui and Kakar 2022	Case series	Persistent volar instability; failed dorsal repair	Volar capsule	MCJ	Inside-out repair with spinal needle capturing volar capsule near the ulnar border of the scaphoid and lunate.	VAS pain reduced from 8 to 0.7; no revisions.
Kakar et al. 2024	Case series	MIRLIN 1: Moderate SL dissociation (Geissler 1–3) MIRLIN 2: Severe SL dissociation (Geissler 4), wide SL gap	LRL (MIRLIN 1), Severe SL dissociation (MIRLIN 2)	RCJ and MCJ	MIRLIN Type 1: Inside-out via RC portal; Type 2: Outside-in suture passage across MCJ and RCJ for wide SL gap with dorsal SL stabilization.	Improved SL stability; combined stabilization required.
Goorens et al. 2024	Technique paper	Symptomatic volar SL instability	RSL, LRL	RCJ	Curved needle plicating volar capsule, RSC, and LRL via 1–2 portal with intra-articular knot tying.	Not reported
Corella et al. 2024	Technique paper	Detachment of volar ligament	Volar ligaments based on injury	MCJ	Suture anchor capsuloligamentous repair with anchor insertion via volar portals and “U” suture configuration to reattach ligament.	Not reported

To further improve the reduction of the volar SL joint, we describe a technique where the arthroscope can be placed into the 6R portal. An 18-G spinal needle pre-threaded with a 2–0 nonabsorbable suture (as noted above) is placed through the 3–4 portal. A volar radial incision is fashioned with the FCR retracted radially and the median nerve with its palmar cutaneous branch and flexor tendons retracted ulnarly. The needle is angled distally through the RSC ligament adjacent to the scaphoid, and one end of the suture is pulled volarly. The 18 g needle is then pulled back and stays within the radiocarpal joint and angled distally through the LRL adjacent to the lunate. The other free end of the suture is withdrawn palmarly. The arthroscope is placed within the MCU portal, and both ends of the sutures are pulled to confirm reduction. Traction is released, and the sutures are tied down onto the capsule ([Fig. 7]). Depending upon the degree of injury of the volar SL, we first perform the repair technique from the midcarpal joint as described previously and then add this, as needed, from the radiocarpal joint.

Fig. 7 (Right wrist) (A-B) Unstable volar SL injury visualized with the camera in the MCU portal and probe through the MCR portal; (C) Preloaded needle inserted distally adjacent to the scaphoid through the RSC via the 3–4 portal with the camera in the 6R portal; (D) Preloaded needle directed distally adjacent to the lunate through the LRL; (E) Completion of volar imbrication viewed through the radiocarpal joint; (F) Reduction of volar SL injury observed from the midcarpal joint. The white asterisk indicates the volar step-off at the SL joint, and the yellow asterisk marks the radioscaphocapitate ligament. Abbreviations: Cp, capitate; Sc, scaphoid.

 

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Minimally Invasive Radiolunate Imbrication Neutralization (MIRLIN) Procedure[42]

The MIRLIN Type 1 procedure is similar to the inside-out technique but is performed through the RC portal for Geissler 1–3 instability. The arthroscope is positioned in the 6R portal, while an 18-gauge spinal needle preloaded with a 2–0 nonabsorbable suture is passed through the 3–4 portal. The needle pierces the volar capsule, capturing the proximal portion of the LRL ligament. One end of the suture is retrieved through a volar incision near the FCR tendon. The needle is then withdrawn into the radiocarpal joint, redirected to the distal portion of the LRL, and reinserted, ensuring no dorsal soft tissue bridge. ([Fig. 8]) The opposite end of the suture is retrieved through the same volar incision. Both suture ends are tied under tension, plicating the LRL and restoring volar scapholunate complex stability.

Fig. 8 (Right wrist, 6R portal view) (A) Needle loaded with a 2–0 suture introduced through the 3–4 portal, angled proximally to engage the origin of the LRL; (B) Needle repositioned distally toward the lunate region to pass through the LRL; (C) Completion of volar imbrication of the LRL (MIRLIN 1) as viewed from the 3–4 portal.

The MIRLIN Type 2 procedure is an alternate technique for cases of complete SL dissociation (Geissler 4), involving suture passage between the MCJ and RCJ. Using an outside-in technique, a spinal or 21-gauge needle loaded with a 2–0 polydioxanone or nonabsorbable suture is inserted from the volar wrist, just radial to the FCR tendon. The needle is directed toward the volar horn of the lunate, visualized within the MCJ, and the suture is retrieved through a central MCJ portal created distal and ulnar to the MCR portal. The needle is then retracted outside the capsule, repositioned along the LRL orientation, and reinserted into the RCJ. The suture is retrieved through the 1–2 or 2R portal, creating a pathway that includes the volar lunate and radial insertions of the LRL. For the other suture end, a cannula or knot pusher is used via the central MCJ portal to guide the suture through the SL diastasis into the volar RCJ, which is retrieved through the 1–2 or 2R portal. The sutures are tied securely, reinforcing the LRL ligament. This procedure often requires combination stabilization procedures, such as dorsal SL stabilization and volar STT stabilization.[43] Based on Smith et al. (2023), combined volar STT reconstruction and Mathoulin's ADCLR significantly improved outcomes, reducing pain and allowing most patients to resume normal activities with minimal symptoms by 12 months postoperatively.

 

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Radiocarpal Volar Extrinsic Plicature[37]

The arthroscopic volar extrinsic plicature technique uses a curved SutureLasso needle introduced through the 1–2 portal with visualization via the 3–4 portal. The needle is carefully directed between the extrinsic ligaments (RSC, LRL, and RSL) and the volar neurovascular structures, including the flexor tendons, ensuring proper placement volar to the RSC and LRL while avoiding injury to adjacent soft tissues. The curved tip re-enters the radiocarpal joint ulnar to the LRL, and a lasso wire is deployed and retrieved through the 3–4 portal. A 2–0 nonabsorbable suture is then passed along the needle trajectory and retrieved via the 1–2 portal while maintaining needle stability. The needle is then withdrawn toward the interval between RCL and RSC, redirected into the RC joint, and reinserted without breaching the capsule to avoid neurovascular injury. The opposite suture end is retrieved through the 3–4 portal, and both suture ends are secured intra-articularly using a knot pusher from the 3–4 portal. This plication technique stabilizes the volar scapholunate complex by reinforcing the RSC and LRL. ([Fig. 9])

Fig. 9 (Right wrist) Arthroscopic view of the radiocarpal volar extrinsic plicature technique performed through the 1–2 portal with visualization via the 3–4 portal. Sutures were tied through the 1–2 portal to indirectly stabilize the volar scapholunate complex by reinforcing the radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments. While the original technique described by Goorens et al. (2024) includes suture tying from the 3–4 portal, this figure demonstrates the adaptation to the 1–2 portal for this procedure. Abbreviations: Sc, scaphoid; RSC, radioscaphocapitate; LRL, long radiolunate; DR, distal radius.

 

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Suture Anchor Capsuloligamentous Repair[19]

The arthroscopic volar capsuloligamentous reattachment and reinforcement technique begins with the creation of volar portals, including the volar radial (VR), volar central (VC), or volar ulnar (VU) portals, depending on the injured ligament. The detached area of the ligament is identified arthroscopically, and an anchor is placed at the insertion site on the carpal bone via one of the volar portals. The anchor sutures are then transported out of the MCR portal using a knot pusher. A 18G needle loaded with a suture loop is used to pierce one side of the ruptured volar ligament through the volar portals. The suture loop is retrieved from the MCR portal, threaded with one of the anchor threads, and shuttled back to the volar portal. This process is repeated for the second thread on the opposite side of the ruptured ligament, completing a “U” suture configuration. Finally, both threads are tied outside the joint, ensuring secure reattachment or reinforcement of the ligament to the bone.

 

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Pearls and Pitfalls

Safety is paramount when performing arthroscopic repairs of the volar scapholunate complex, as the procedure involves delicate handling of soft structures like neurovascular bundles and tendons that are susceptible to injury if not executed with precision. While various techniques are available, each has challenges, including a learning curve for proper portal placement, suture handling, and ligament stabilization. For surgeons new to these procedures, it is often advisable to make larger incisions to enhance visualization and minimize the risk of complications. [Table 5] highlights key considerations, including pearls and pitfalls to aid in performing these techniques safely and effectively. ([Table 5])

Table 5 Highlights critical arthroscopic volar SL complex repair considerations by outlining key pearls and pitfalls

	Pearls	Pitfalls
Visualization	Use dry arthroscopy to enhance visualization and minimize capsular distortion.	Capsular breach due to repeated needle retraction increases the risk of neurovascular injury.
Portal Placement	Accurate portal placement is essential to access specific components of the volar SL complex, such as RSC, LRL, SRL, and SLIL.	Incorrect portal placement can limit visualization and access to specific ligaments, resulting in incomplete or ineffective repairs.
Suture Placement	A small curved hemostat is gently used to spread the soft tissue before placing the suture with a needle.	Ensure proper handling to prevent entanglement of tendons or neurovascular structures in the sutures.
Combination Stabilization	Adding dorsal SL stabilization or volar STT reconstruction improves biomechanical outcomes in severe instabilities.	High-grade static dissociations (EWAS IV) may have lower success rates, which may require reconstruction instead.
Instrumentation	Small-bore needles (e.g., 22G or SutureLasso) minimize tissue disruption during suture passage.	Suture anchor placements require a learning curve and increased operative time. Use of fluoroscopy is recommended.

 

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Conclusion

This article provides an overview of the stability of the volar SL complex and summarizes the arthroscopic repair techniques described in the literature to date. The evolution of arthroscopic techniques for volar SL instability highlights an increasing recognition among surgeons of the importance of addressing the SL complex's dorsal and volar components. The techniques detailed in this article offer distinct advantages in stabilizing specific volar ligament complexes using varied approaches. Despite these advancements, these approaches present technical challenges, including the necessity for precise portal placement, meticulous suture handling, and the potential need for combination stabilization in complex cases. Further comparative studies and long-term outcomes are necessary to develop evidence-based guidelines.

 

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Conflictos de interés

None.

Acknowledgments

The authors would like to thank Dr Lucian Lior Marcovici for contributing to the ultrasound diagram.

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Publication History

Received: 24 March 2025

Accepted: 02 May 2025

Article published online:
21 July 2025