Wrist arthroscopy techniques [2 ed.] 9783132429109, 3132429104
218 51 151MB
English Pages [203] Year 2019
Wrist Arthroscopy Techniques 2nd Edition
Title Page
Copyright
Contents
Videos
Foreword
Preface
Acknowledgments
Contributors
1 Materials and Set-Up
1.1 Introduction
1.2 Materials
1.2.1 Arthroscopy Column
1.2.2 Arthroscope
1.2.3 Instruments
1.2.4 Traction
1.2.5 Irrigation
1.3 Set-Up
1.4 Conclusion
Reference
2 Surgical Approaches
2.1 Introduction
2.2 General Principles of Approaches
2.3 Radiocarpal Portals
2.3.1 3?4 Radiocarpal Portal
2.3.2 6R Radiocarpal Portal
2.3.3 4?5 Radiocapral Portal
2.3.4 6U Radiocarpal Portal
2.3.5 1?2 Radiocarpal Portal
2.4 Midcarpal Portals
2.4.1 Midcarpal Ulnar Portal
2.4.2 Radial Midcarpal Portal
2.4.3 STT Midcarpal Portal
2.5 Distal Radioulnar Portals
2.5.1 Distal Radioulnar Portal
2.5.2 Direct Foveal Portal
2.5.3 Proximal
Distal Radioulnar? Portal
2.6 Trapeziometacarpal Portal
2.6.1 Palmar 1 Portal
2.6.2 Dorsal 1 Portal
2.7 Palmar Portals
2.7.1 Radial Palmar Radiocarpal Portal
2.7.2 Ulnar Palmar Radiocarpal Portal
2.7.3 Palmar Midcarpal Portal
2.8 Conclusion
Reference
3 Arthroscopic Anatomy of theWrist
3.1 Introduction
3.2 Principles of Exploration
3.3 Radiocarpal Exploration
3.4 Midcarpal Assessment
3.5 Conclusion
4 Arthroscopic Treatment of DorsalWrist Ganglia
4.1 Introduction
4.2 Ligament Anatomy of the Dorsal Scapholunate Region
4.3 Operative Technique
4.3.1 Patient Preparation
4.3.2 Assessment of the Size and Position of the Ganglion
4.3.3 Exploration of the Midcarpal Joint
4.3.4 Resection of the Dorsal Mucoid Dysplasia at the Midcarpal Interval through a Transcystic Approach
4.3.5 Resection of the Ganglion Wall
4.3.6 Closing and Postoperative Care
4.4 Conclusion
References
5 Arthroscopic DorsalWrist Ganglion Excision with Colored Dye-Aided Stalk Resection
5.1 Introduction
5.2 Operative Technique
5.2.1 Patient Preparation and Positioning
5.2.2 Surgical Steps
5.2.3 Closure and Postoperative Care
5.3 Conclusion
References
6 Arthroscopic Excision of VolarWrist Ganglia
6.1 Introduction
6.2 Operative Technique
6.2.1 Patient Preparation and Positioning
6.2.2 First Surgical Phase: Intra-articular Assessment
6.2.3 Second Surgical Phase: Identification and Resection of the Ganglion
6.2.4 Closure and Postoperative Care
6.3 Conclusion
7 Arthroscopic Radial Styloidectomy
7.1 Introduction
7.2 Operative Technique
7.2.1 Patient Preparation
7.2.2 Exploration of the Radiocarpal Joint
7.2.3 Styloidectomy through the 1?2 Radiocarpal Portal
7.2.4 Styloidectomy through the 3?4 Portal
7.2.5 Styloidectomy through a Palmar Approach
7.2.6 Closure and Postoperative Care
7.3 Conclusion
Reference
8 Anatomy of the TFCC: Current Concepts
8.1 Introduction
8.2 Histology
8.3 Anatomy
8.4 Biomechanics
8.5 Arthroscopic Examination of TFCC Tears or Injuries
8.6 Conclusion
References
9 Arthroscopic Repair of Peripheral Tears of the TFCC
9.1 Introduction
9.2 Operative Technique
9.2.1 Patient Preparation and Set-Up
9.2.2 Exploration
9.2.3 Creation of a DRUJ Portal
9.2.4 Performing the Suture
9.2.5 Securing the Final Suture
9.2.6 Postoperative Care
9.3 Conclusion
References
10 "Double Loop? Suture Repair in Large Dorsal Tears of the TFCC
10.1 Introduction
10.2 Operative Technique
10.2.1 Patient Preparation
10.2.2 Exploration
10.2.3 TFCC Repair
10.2.4 Postoperative Care
10.3 Conclusion
11 Arthroscopy-Assisted Foveal Reinsertion of the TFCC with an Anchor
11.1 Introduction
11.2 Operative Technique
11.2.1 Patient Preparation
11.2.2 Exploration
11.2.3 Extending the Medial Incision
11.2.4 Exploration and Debridement of the Distal Radioulnar Joint
11.2.5 Insertion of the Anchor
11.2.6 TFCC Suture
11.2.7 Postoperative Care
11.3 Conclusion
References
12 Arthroscopic-Assisted Foveal Reinsertion of the TFCC
12.1 Introduction
12.2 Operative Technique
12.2.1 Patient Preparation
12.2.2 Exploration
12.2.3 Arthroscopic-Assisted Foveal Refixation of the TFCC
12.2.4 Postoperative Care
12.3 Conclusion
13 Arthroscopic Reconstruction of the TFCC Using a Free Tendon Graft
13.1 Introduction
13.2 Operative Technique
13.2.1 Patient Preparation
13.2.2 Harvesting the Tendon Graft
13.2.3 Making the Radial Tunnel and Passing the Tendon through
13.2.4 Preparation of the Graft Area in the TFCC
13.2.5 Creating the Ulnar Tunnel
13.2.6 Passing the Graft through the Ulnar Tunnel
13.2.7 Passage and Fixation of the Graft
13.2.8 Closure and Postoperative Care
13.3 Conclusion
References
14 Arthroscopic Distal Ulnar Resection
14.1 Introduction
14.2 Operative Technique
14.2.1 Patient Preparation and Positioning
14.2.2 Exploration and Synovectomy of the Radiocarpal Joint
14.2.3 Preparation of TFCC Ligament
14.2.4 Distal Ulnar Resection
14.2.5 Ulnar Head Resection when the TFCC Is Intact
14.2.6 Closure and Postoperative Care
14.3 Conclusion
15 Arthroscopic Hamatum Head Resection for HALT Syndrome
15.1 Introduction
15.2 Operative Technique
15.2.1 Patient Preparation and Positioning
15.2.2 Exploration of the Bones
15.2.3 Resection of the Tip of the Hamate
15.2.4 Closure and Postoperative Care
15.3 Conclusion
16 Anatomy of the Scapholunate Complex
16.1 Introduction
16.2 Applied Anatomy and Biomechanics of the Carpal Ligaments
16.2.1 Intrinsic Ligament: Scapholunate Interosseous Ligament
16.2.2 Extrinsic Ligaments
16.3 Arthroscopic Testing of Scapholunate Stability桸ew Classification System
16.3.1 Arthroscopic Testing of Predynamic Instability
16.3.2 EWAS Classification for Scapholunate Instability
16.4 Arthroscopic Testing of Extrinsic Ligaments桰njury Classification
16.4.1 Classification for Extrinsic Ligament Injury
16.4.2 Method for Arthroscopic Testing of Extrinsic Ligaments
16.5 Conclusion
References
17 Dorsal Capsuloligamentous Repair of the Scapholunate Ligament Tear
17.1 Introduction
17.2 Operative Technique
17.2.1 Patient Preparation and Positioning
17.2.2 Radiocarpal Exploration
17.2.3 Exploration of the Midcarpal Joint
17.2.4 Performing the Dorsal Capsuloligamentous Suture
17.2.5 Tying the First Knot
17.2.6 K-Wire Fixation of the SL Joint (Optional)
17.2.7 Tying the Second (Last) Knot
17.2.8 Large SL Ligament Tear with Instability (EWAS 4)
17.2.9 Large SL Ligament Detachment without Ligament Stump on the Scaphoid
17.2.10 Postoperative Care
17.3 Conclusion
References
18 Arthroscopic-Assisted Box Reconstruction of Scapholunate Ligament with Tendon Graft
18.1 Introduction
18.2 Operative Techniques
18.2.1 Patient Preparation and Positioning
18.2.2 Exploration of Radiocarpal Joint and Midcarpal Joint
18.2.3 Preparation of Dorsal and Volar TunnelWound
18.2.4 Correction of the DISI Deformity and Stabilization of Scaphoid and Lunate Position
18.2.5 Preparation of Lunate Bone Tunnel
18.2.6 Preparation of Scaphoid Bone Tunnel
18.2.7 Passing the PL Tendon Graft through the Scaphoid and Lunate Bone Tunnel
18.2.8 Assessment through Midcarpal Joint Arthroscopy and Scapholunate Interval Reduction with PL Tendon Graft
18.3 Closure and Postoperative Care
18.4 Conclusion
References
19 Arthroscopic-Assisted Reconstruction of LT-Ligament
19.1 Introduction
19.2 Operative Technique
19.2.1 Patient Preparation and Positioning
19.2.2 Exploration of the Ligament and the Bone
19.2.3 Preparation of the Tendon Slip and the Bones
19.2.4 Passing the Tendon Slip through and Securing the Graft in the Bones
19.3 Closure and Postoperative Care
19.4 Conclusion
References
20 Arthroscopic-Assisted Fixation of Trans-Scaphoid Perilunate Dislocation
20.1 Introduction
20.2 Operative Technique
20.2.1 Patient Preparation and Positioning
20.2.2 Radiocarpal Arthroscopy and Synovectomy
20.2.3 Midcarpal Arthroscopy and Exploration
20.2.4 Dissection of the Volar Capsule
20.2.5 Assessment of Intercarpal Ligaments Stability
20.2.6 Screw Fixation of Scaphoid
20.2.7 K-Wire Fixation of Lunotriquetral Joint
20.2.8 Assessment of Stability after Fixation
20.2.9 Closure and Postoperative Care
20.3 Conclusion
References
21 Volar Capsuloligamentous Suture as Treatment of Volar Midcarpal Instability
21.1 Introduction
21.2 Operative Technique
21.2.1 Patient Preparation and Positioning
21.2.2 First Phase: Arthroscopic Exploration
21.2.3 Second Phase: Volar Ulnar Approach
21.2.4 Third Phase: Volar CapsuleLigament Suturing
21.2.5 Postoperative Care
21.3 Conclusion
References
22 Arthroscopic-Assisted Fixation of Intra-Articular Distal Radius Fractures
22.1 Introduction
22.2 Operative Technique (J. M. Cogent)
22.2.1 Patient Preparation and Positioning
22.2.2 First Surgical Phase: Provisional Fixation
22.2.3 Second Surgical Phase: Arthroscopic Evaluation
22.2.4 Third Surgical Phase: Final Fixation
22.2.5 Postoperative Care
22.3 Conclusion
Reference
23 Arthroscopic-Guided Osteotomy for Distal Radius Malunion
23.1 Introduction
23.2 Indications and Contraindications
23.3 Operative Technique
23.4 Conclusion
References
24 Arthroscopic-Assisted Scaphoid Fracture Fixation
24.1 Introduction
24.2 Operative Technique
24.2.1 Patient Preparation and Positioning
24.2.2 First Phase: K-Wire Insertion into the Scaphoid
24.2.3 Second Phase: Arthroscopic Checking
24.2.4 Third Phase: Screw Insertion
24.2.5 Final Arthroscopic Checking
24.2.6 Postoperative Care
24.3 Conclusion
Reference
25 Arthroscopic Bone Grafting for Scaphoid Nonunion
25.1 Introduction
25.2 Operative Technique
25.2.1 Patient Preparation and Positioning
25.2.2 Radiocarpal and Midcarpal Exploration
25.2.3 Nonunion Site Preparation
25.2.4 Bone Graft Harvesting
25.2.5 Temporary Fixation of the Nonunion
25.2.6 Graft Implantation and Fixation
25.2.7 Closure and Postoperative Care
25.3 Conclusion
26 Arthroscopic Replacement of the Proximal Pole of the Scaphoid with a Pyrocarbon Implant
26.1 Introduction
26.2 Operative Technique
26.2.1 Patient Preparation and Positioning
26.2.2 Arthroscopic Portals and Exploration
26.2.3 Proximal Pole Excision
26.2.4 Selection of Implant Size
26.2.5 Placement of the Final Implant
26.2.6 Postoperative Care
26.3 Conclusion
References
27 Arthroscopic Arthrolysis of theWrist
27.1 Introduction
27.2 Operative Technique
27.2.1 Patient Preparation and Positioning
27.2.2 Debridement of the Medial Radiocarpal Joint
27.2.3 Resection of the Fibrous Radiocarpal Wall
27.2.4 Debridement of the Radiocarpal Dorsal Recess
27.2.5 Inspection of the Radiocarpal Joint
27.2.6 Debridment of the Midcarpal Joint
27.2.7 Postoperative Care
27.3 Conclusion
28 Arthroscopic Scaphotrapeziotrapezoidal Interposition Arthroplasty
28.1 Introduction
28.2 Operative Technique
28.2.1 Patient Preparation and Positioning
28.2.2 Midcarpal Joint Debridement
28.2.3 Scaphotrapeziotrapezoid Joint Exploration
28.2.4 Distal Resection of the Scaphoid
28.2.5 Implant Selection
28.2.6 Implant Placement
28.2.7 Closure and Postoperative Care
28.3 Conclusion
Reference
29 Arthroscopic Resection Arthroplasty of Thumb Carpometacarpal Joint
29.1 Introduction
29.2 Operative Technique
29.2.1 Patient Preparation and Positioning
29.2.2 Portal Placement and Exploration of the Thumb CMC Joint
29.2.3 Debridement and Denervation of the Thumb CMC Joint
29.2.4 Arthroscopic Resection Arthroplasty: CMC Joint
29.2.5 Arthroscopic Resection Arthroplasty: STT Joint
29.2.6 Tourniquet Removal, Hemostasis, and Pain Control
29.2.7 Closure and Postoperative Care
29.3 Conclusion
References
30 Arthroscopic Thumb Carpometacarpal Interposition Arthroplasty
30.1 Introduction
30.2 Operative Technique
30.2.1 Patient Preparation and Positioning
30.2.2 Exploration of the Thumb Carpometacarpal Joint
30.2.3 Debridement of the Thumb Carpometacarpal Joint
30.2.4 Osteophyte Resection
30.2.5 Placement of Implant
30.2.6 Closure and Postoperative Care
30.3 Conclusion
31 Arthroscopic Interposition Arthroplasty in Stage II Scapholunate Advanced CollapseWrists
31.1 Introduction
31.2 Operative Technique
31.2.1 Patient Preparation and Positioning
31.2.2 Harvesting the Tendon Graft
31.2.3 Debridement and Exploration of Radiocarpal Joint
31.2.4 Styloidectomy
31.2.5 Stabilization of SL Joint Space
31.2.6 Preparation for Interposition Arthroplasty
31.2.7 Passage of the Implant抯 Dorsal Portion
31.2.8 Passage of the Implant抯 Volar Portion
31.2.9 Stabilization of Tendon Graft
31.2.10 Closure and Postoperative Care
31.3 Conclusion
32 Arthroscopic Resection Arthroplasty of the Radial Column for Scapholunate Advanced CollapseWrist
32.1 Introduction
32.2 Surgical Technique
32.2.1 Patient Preparation and Positioning
32.2.2 Arthroscopy
32.2.3 Resection
32.2.4 Completion
32.2.5 Postoperative Care
References
33 Arthroscopic PartialWrist Fusion
33.1 Introduction
33.2 Surgical Technique
33.2.1 Patient Preparation and Positioning
33.2.2 Scaphoidectomy
33.2.3 Exploration of Radiocarpal Joint
33.2.4 Exploration of the Midcarpal Joint
33.2.5 Preparation for Arthrodesis
33.2.6 Hamate Resection
33.2.7 Addition of Bone Graft Material
33.2.8 Fixation of the Arthrodesis
33.2.9 Closure and Postoperative Care
33.3 Conclusion
34 Arthroscopic Assessment of Kienbock抯 Disease
34.1 Introduction
34.2 Technique
34.2.1 Set-Up
34.2.2 Inspection
34.2.3 Simple Procedures and Decision-Making
34.3 Conclusion
References
35 Arthroscopic Bone Grafting for Lunate Ganglion
35.1 Introduction
35.2 Operative Technique
35.2.1 Patient Preparation and Positioning
35.2.2 Radiocarpal Exploration
35.2.3 Locating and Curettage of Cyst
35.2.4 Bone Graft Harvesting
35.2.5 Bone Graft Application
35.2.6 Closure and Postoperative Care
35.3 Conclusion
Index
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To access the additional media content available with this e-book via Thieme MedOne, please use the code and follow the instructions provided at the back of the e-book.
Mathoulin, Wrist Arthroscopy Techniques, 2nd Ed. (ISBN 978-3-13-242910-9), copyright © 2019 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
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Wrist Arthroscopy Techniques
2nd Edition
Christophe Mathoulin, MD, FMH Vice-President Institut de la Main; Founder and Honorary Chairman European (International) Wrist Arthroscopy Society (EWAS - IWAS); Founder International Wrist Center Clinique Bizet Paris, France
635 illustrations
Thieme Stuttgart • New York • Delhi • Rio de Janeiro
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Library of Congress Cataloging-in-Publication Data Names: Mathoulin, Ch. (Christophe), author. Title: Wrist arthroscopy techniques / Christophe Mathoulin. Description: 2nd edition. | Stuttgart ; New York : Thieme, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2019012210 (print) | LCCN 2019012986 (ebook) | ISBN 9783132429116 (ebook) | ISBN 9783132429109 (hardcover) | ISBN 9783132429116 (ebook) Subjects: | MESH: Wrist Joint–surgery | Arthroscopy– methods | Arthroscopes | Joint Diseases–surgery Classification: LCC RD559 (ebook) | LCC RD559 (print) | NLM WE 830 | DDC 617.5/75059–dc23 LC record available at https://lccn.loc.gov/2019012210
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Contents Videos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
vii
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ix
Terry L. Whipple
Preface
...................................................................................
x
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
xi
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
xii
1. Materials and Set-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
2. Surgical Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
3. Arthroscopic Anatomy of the Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
4. Arthroscopic Treatment of Dorsal Wrist Ganglia
....................................
17
5. Arthroscopic Dorsal Wrist Ganglion Excision with Colored Dye-Aided Stalk Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23
6. Arthroscopic Excision of Volar Wrist Ganglia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26
7. Arthroscopic Radial Styloidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
30
8. Anatomy of the TFCC: Current Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33
9. Arthroscopic Repair of Peripheral Tears of the TFCC
................................
38
10.
“Double Loop” Suture Repair in Large Dorsal Tears of the TFCC . . . . . . . . . . . . . . . . . . .
44
11.
Arthroscopy-Assisted Foveal Reinsertion of the TFCC with an Anchor
............
48
12.
Arthroscopic-Assisted Foveal Reinsertion of the TFCC
..............................
54
13.
Arthroscopic Reconstruction of the TFCC Using a Free Tendon Graft . . . . . . . . . . . . . .
59
14.
Arthroscopic Distal Ulnar Resection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
64
15.
Arthroscopic Hamatum Head Resection for HALT Syndrome . . . . . . . . . . . . . . . . . . . . . . .
68
16.
Anatomy of the Scapholunate Complex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
72
17.
Dorsal Capsuloligamentous Repair of the Scapholunate Ligament Tear
..........
79
18.
Arthroscopic-Assisted Box Reconstruction of Scapholunate Ligament with Tendon Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
87
v
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Contents
19.
Arthroscopic-Assisted Reconstruction of LT-Ligament . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
93
20.
Arthroscopic-Assisted Fixation of Trans-Scaphoid Perilunate Dislocation . . . . . . . . .
102
21.
Volar Capsuloligamentous Suture as Treatment of Volar Midcarpal Instability. . .
108
22.
Arthroscopic-Assisted Fixation of Intra-Articular Distal Radius Fractures . . . . . . . . .
113
23.
Arthroscopic-Guided Osteotomy for Distal Radius Malunion. . . . . . . . . . . . . . . . . . . . . . .
118
24.
Arthroscopic-Assisted Scaphoid Fracture Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
126
25.
Arthroscopic Bone Grafting for Scaphoid Nonunion
................................
131
26.
Arthroscopic Replacement of the Proximal Pole of the Scaphoid with a Pyrocarbon Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
136
27.
Arthroscopic Arthrolysis of the Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
141
28.
Arthroscopic Scaphotrapeziotrapezoidal Interposition Arthroplasty . . . . . . . . . . . . . .
145
29.
Arthroscopic Resection Arthroplasty of Thumb Carpometacarpal Joint . . . . . . . . . . .
149
30.
Arthroscopic Thumb Carpometacarpal Interposition Arthroplasty . . . . . . . . . . . . . . . .
154
31.
Arthroscopic Interposition Arthroplasty in Stage II Scapholunate Advanced Collapse Wrists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
159
Arthroscopic Resection Arthroplasty of the Radial Column for Scapholunate Advanced Collapse Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
165
33.
Arthroscopic Partial Wrist Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
170
34.
Arthroscopic Assessment of Kienbock’s Disease
....................................
175
35.
Arthroscopic Bone Grafting for Lunate Ganglion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Index
183
32.
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Videos 1. Materials and Set-Up Video 1.1, Video 1.2 2. Surgical Approaches Video 2.1–Video 2.13 3. Arthroscopic Anatomy of the Wrist Video 3.1–Video 3.12 4. Arthroscopic Treatment of Dorsal Wrist Ganglia Video 4.1–Video 4.5 5. Arthroscopic Dorsal Wrist Ganglion Excision with Colored Dye-Aided Stalk Resection Video 5.1, Video 5.2 6. Arthroscopic Excision of Volar Wrist Ganglia Video 6.1–Video 6.4 7. Arthroscopic Radial Styloidectomy Video 7.1, Video 7.2 8. Anatomy of the TFCC: Current Concepts Video 8.1 9. Arthroscopic Repair of Peripheral Tears of the TFCC Video 9.1–Video 9.8 10. “Double Loop” Suture Repair in Large Dorsal Tears of the TFCC Video10.1–Video 10.7 11. Arthroscopy-Assisted Foveal Reinsertion of the TFCC with an Anchor Video 11.1–Video 11.13 12. Arthroscopic-Assisted Foveal Reinsertion of the TFCC Video 12.1 13. Arthroscopic Reconstruction of the TFCC Using a Free Tendon Graft Video 13.1–Video 13.8 14. Arthroscopic Distal Ulnar Resection Video 14.1–Video 14.4 15. Arthroscopic Hamatum Head Resection for HALT Syndrome Video 15.1–Video 15.4 16. Anatomy of the Scapholunate Complex Video 16.1–Video 16.5 17. Dorsal Capsuloligamentous Repair of the Scapholunate Ligament Tear Video 17.1–Video 17.11 18. Arthroscopic-Assisted Box Reconstruction of Scapholunate Ligament with Tendon Graft Video 18.1
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Videos 19. Arthroscopic-Assisted Reconstruction of LT Ligament Video 19.1–Video 19.6 20. Arthroscopic-Assisted Fixation of Trans-Scaphoid Perilunate Dislocation Video 20.1 21. Volar Capsuloligamentous Suture as Treatment of Volar Midcarpal Instability Video 21.1–Video 21.7 22. Arthroscopic-Assisted Fixation of Intra-Articular Distal Radius Fractures Video 22.1–Video 22.5 23. Arthroscopic-Guided Osteotomy for Distal Radius Malunion Video 23.1 24. Arthroscopic-Assisted Scaphoid Fracture Fixation Video 24.1–Video 24.5 25. Arthroscopic Bone Grafting for Scaphoid Nonunion Video 25.1–Video 25.6 26. Arthroscopic Replacement of the Proximal Pole of the Scaphoid with a Pyrocarbon Implant Video 26.1–Video 26.5 27. Arthroscopic Arthrolysis of the Wrist Video 27.1–Video 27.5 28. Arthroscopic Scaphotrapeziotrapezoidal Interposition Arthroplasty Video 28.1–Video 28.5 29. Arthroscopic Resection Arthroplasty of Thumb Carpometacarpal Joint Video 29.1, Video 29.2 30. Arthroscopic Thumb Carpometacarpal Interposition Arthroplasty Video 30.1–Video 30.5 31. Arthroscopic Interposition Arthroplasty in Stage II Scapholunate Advanced Collapse Wrists Video 31.1–Video 31.11 32. Arthroscopic Resection Arthroplasty of the Radial Column for Scapholunate Advanced Collapse Wrist Video 32.1 33. Arthroscopic Partial Wrist Fusion Video 33.1–Video 33.3 34. Arthroscopic Assessment of Kienbock’s Disease Video 34.1 35. Arthroscopic Bone Grafting for Lunate Ganglion Video 35.1–Video 35.7
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Foreword It is a privilege to be asked to write a Foreword for this magnificent e-textbook. Exceptional video content propels this 2nd edition far beyond the original version. I am humbled by Prof. Christophe Mathoulin and the contributing authors who have invited me to provide an introduction to this display of their academic works. By many, it seems, I have become known as “the Grandfather of Wrist Arthroscopy.” I do hope that suggests at least a seasoned perspective for the techniques. Surgeons have a conundrum. Surgical repair or reconstruction of tissues subjects a patient to additional iatrogenic trauma. Any rearrangement of a patient’s anatomy requires surgeons to take a recuperative step backward before progressing forward. For surgical patients, it is the proverbial quid pro quo. Balancing that “cost : benefit” ratio for surgery is challenging. Ensuring a patient’s benefit, the surgeon’s judgment, skill, and compassion will exceed the patient's test costs. This e-textbook will guide that judgment and can enhance our surgical skills. Conceived and designed— and largely written—by Prof. Mathoulin, this text offers pioneering as well as new state-of-the-art surgical approaches and solutions to many common disorders of the wrist. It displays innovative wrist surgical procedures with succinct descriptions, outstanding illustrations, and video demonstrations. The e-book format makes the text uniquely accessible and portable. It can be either studied or used for reference by surgeons preparing for sound, precise, and logical surgical procedures for the wrist. This e-textbook advances wrist surgery enormously. It does not attempt to be comprehensive in addressing every wrist injury, congenital deformity, and degenerative condition. But it is a practical, if not essential, source for wrist surgeons dealing with challenging cases who have basic competence with wrist arthroscopy. Prof. Mathoulin is a creative thinker and an innovative surgeon. His personal surgical experience is legion and his devoted interest in surgical education, especially regarding the wrist, has become an internationally known phenomenon. Wrist Arthroscopy Techniques will both educate and challenge wrist surgeons of all levels worldwide. It will help us broaden our surgical prowess and
enhance our understanding of many wrist disorders. Wrist anatomy is complex and its functional anatomy is even more so. Wrist biomechanics are difficult to fully comprehend. This text elucidates many of those puzzles. In the past years, I composed this triplet for progress and success, whether for research and development or for complex and complicated surgical challenges: • Trust your imagination • Believe in possibility • Seize opportunity Prof. Mathoulin fulfils this mantra. In devising innovative surgical approaches to unsolved wrist disorders, many of which are described in this text, he has demonstrated a leadership role for progress and success in wrist surgery. He has become a wrist surgery evangelist. His passion for teaching gains new expression with this unique and elaborate e-textbook. The reader will surely use it often and enjoy it. The conundrum—the trauma of surgery must be justified by the therapeutic results. Wrist Arthroscopy Techniques truly helps to ensure that outcome. Arthroscopic or minimally invasive surgical approaches to the wrist preserve normal anatomy. Uninjured by the surgery, these protected tissues do not have to recover or be rehabilitated postoperatively. Reparative and reconstructive procedures described in this text are logical, have been practiced and proven, and address patients’ discomfort or dysfunction in a prudent and expeditious manner. I am confident this compendium of arthroscopic surgical techniques for the wrist will be enormously beneficial to surgeons throughout the world, as well as their patients, for a long time to come. Terry L. Whipple, MD, FAOA EWAS Emeritus Member and Honorary President Chief of Orthopaedics Hillelson-Whipple Clinic; Associate Professor of Orthopaedic Surgery Virginia Commonwealth University School of Medicine; Director Orthopaedic Research of Virginia Virginia, USA
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Preface Wrist arthroscopy is a much newer procedure than knee or shoulder arthroscopy, although Watanabe first explored the wrist arthroscopically in the early 1970s. More than 10 years passed before wrist arthroscopy was used for diagnostic purposes, and more than 20 years before feasible and reproducible treatments could be realistically contemplated. I started performing wrist arthroscopy in 1985. At that time, the scopes were not well suited to the small size of the wrist joint. Many of us abandoned this instrument in favor of CT arthrography and MRI for diagnosing wrist injuries. However, the limitations of these imaging modalities and the introduction of smaller scopes for the wrist joint soon led to a resurgence of interest in wrist arthroscopy, which has expanded beyond being merely a diagnostic tool. With a group of colleagues and the support of Karl Storz, the European Wrist Arthroscopy Society (EWAS) was created in 2005. This is the only scientific organization committed to developing and teaching wrist arthroscopy. The society immediately took off and its membership continues to grow. It gathers together surgeons interested in the technology from all four corners of the world. Within a span of 10 years, the EWAS has become an internationally renowned organization with its own peer-reviewed journal ( Journal of Wrist Surgery, JWS) and has been invited to participate in many scientific meetings. This
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success leads logically to evolve toward an international society, with the transformation of EWAS into IWAS (International Wrist Arthroscopy Society). With so many surgical techniques now available, performing wrist surgery without a mastery of arthroscopy seems inconceivable. The first edition, published in 2015, which I had written with Dr. Mathilde Gras, was a real success. But some techniques have evolved, and with Dr. JanRagnar Haugstvedt, and the contribution of new international authors, all experts in wrist arthroscopy, we have decided to create, thanks to the help of Thieme and all the Websurg team (Ircad-Strasbourg), a new book that will be published in two physical forms, classical printed and e-book, with many videos, which communicate much more than simple images. This book aims to become a single e-book, evolving over the years, getting enriched by new chapters, and even see some disappear. I would especially like to thank Terry Whipple, who was a teacher to all of us, having largely conceived most of the arthroscopic wrist procedures, and who remains actively involved in the EWAS and continues to support us. I hope this book helps you perform this groundbreaking technique or at least inspires you to try it! Christophe Mathoulin, MD, FMH
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Acknowledgments I would like to thank both the Deputy Editors of the book. Deputy Editors Mathilde Gras, MD Institut de la Main International Wrist Center Clinique Bizet Paris, France
Jan-Ragnar Haugstvedt, MD, PhD EWAS Secretary General Division of Hand Surgery Dept of Orthopedics Østfold Hospital Trust Moss, Norway
A special note of thanks to the following people for their efforts at various stages in shaping this book and to all the chapter authors for their written contributions to this book. Jean-Michel Cognet, MD SOS Main Champagne-Ardenne Polyclinique Saint-André Reims, France Max Haerle, MD, PhD EWAS Former President Head of Hand Surgery Department Orthopädische Klinik Markgröningen Markgröningen, Germany Michel Levadoux, MD Agrégé du Val de Grace Clinique ST Roch Toulon, France Lorenzo Merlini, MD Institut de la Main International Wrist Center Clinique Bizet Paris, France; Hopital Avicenne Bobigny, France
Abhijeet L. Wahegaonkar, MBBS, D.Ortho, M.Ch (Ortho) Diplomate in Hand Surgery Consultant Upper Extremity, Hand and Microvascular Reconstructive Surgeon Sancheti Institute for Orthopedics and Rehabilitation; Clinical Instructor in Upper Extremity, Hand and Microvascular Reconstructive Surgery Department of Orthopedics and Traumatology B.V.D.U. Medical College & Hospitals Pune, India Terry L. Whipple, MD, FAOA EWAS Emeritus Member and Honorary President Chief of Orthopaedics Hillelson-Whipple Clinic; Associate Professor of Orthopaedic Surgery Virginia Commonwealth University School of Medicine; Director Orthopaedic Research of Virginia Virginia, USA
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Contributors Greg Bain, MD APWA President Professor of Upper Limb and Research Department of Orthopaedic Surgery Flinders University Adelaide, Australia Jessica Cobb Medical Student Florida International University Florida, USA Tyson Cobb, MD EWAS Former President Director Hand and Upper Extremity Department Orthopaedics Specialists, PC Davenport, Iowa Jan Ragnar Haugstvedt, MD, PhD EWAS Secretary General; Senior Consultant Division of Hand Surgery Department of Orthopedics Østfold Hospital Trust Moss, Norway Pak-Cheong Ho, MD, MBBS, FRCS, FHKCOS, FHKAM (Ortho) EWAS Former President APWA Founder and Former President Department of Orthopaedics and Traumatology Prince of Wales Hospital Chinese University of Hong Kong Hong Kong, SAR China Siu Cheong Jeffrey Justin Koo, MD, MBBS (H.K.U.), FHKCOS FHKAM (Ortho), FRCSEd (Ortho), MHSM (NSW), MScSMHS (C.U.H.K.) Associate Consultant Department of Orthopaedics and Traumatology Alice Ho Miu Ling Nethersole Hospital Hong Kong, SAR China
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Simon MacLean, MD, MBChB, FRCS(Tr&Orth), PGDipCE Consultant Orthopaedic and Upper Limb Surgeon Tauranga Hospital, BOPDHB Tauranga, New Zealand Christophe Mathoulin, MD, FMH Vice-President Institut de la Main; Founder and Honorary Chairman European (International) Wrist Arthroscopy Society (EWAS - IWAS); Founder International Wrist Center Clinique Bizet Paris, France Toshyiasu Nakamura, MD, PhD EWAS Former President; APWA President-Elect; Editor-in-Chief Journal of Wrist Surgery; Professor Department of Orthopaedic Surgery School of Medicine International University of Health and Welfare Tokyo, Japan Francisco del Piñal, MD EWAS Former President Hand Surgeon Private Practice Madrid, Spain István Zoltán Rigó, MD, PhD Senior Consultant Division of Hand Surgery Department of Orthopedics Østfold Hospital Trust Moss, Norway
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Contributors
Edward Wu, MD Senior Orthopaedic Resident Robert A. Chase Hand and Upper Limb Center Department of Orthopaedic Surgery Stanford University Medical Center California, USA
Jeffrey Yao, MD Associate Professor Robert A. Chase Hand and Upper Limb Center Department of Orthopaedic Surgery Stanford University Medical Center California, USA
Wendong Xu, MD, PhD Elected President of IWAS (2020-2021) APWA Vice President President of Huashan Hospital Fudan University President of Chinese Society for Surgery of the Hand Shanghai Shi, China
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1 Materials and Set-Up 1.1 Introduction Arthroscopic exploration of the wrist has been practiced for decades, but the development of arthroscopic surgical techniques is relatively recent. The wrist is particularly mobile, with very little space between its constituent radiocarpal, midcarpal, and distal radioulnar joints. The aim of good set-up maintains joint position and produces axial traction to create sufficient space between the joints to pass instruments.
1.2 Materials 1.2.1 Arthroscopy Column The arthroscopy column is the same for all transmitted surgery and includes a monitor, a video camera, and a light source. A compact camera head is the most adapted to the small camera used. Light sources fitted with a xenon or LED lamp are now progressively replacing halogen sources, giving better quality lighting and lasting longer. Additionally, image or video sequence recording devices are available for records, publication, or teaching. Today’s progress in light sources and recording technology allows the integration of a video camera, a light source, and video exporting into the same compact box. The use of a printer is no longer necessary due to electronic exporting systems; however, immediate printing is still a simple method to show the patient the operation report and file a record in patient notes.
1.2.2 Arthroscope A small arthroscope, between 1.9 and 2.7 mm, is usually used for the wrist, with a camera angulated at 30° (▶ Fig. 1.1). It must be short (60 to 80 mm) to adapt to the
Fig. 1.1 Arthroscope with camera angulated at 30°, sizes 1.9 mm, and 2.4 mm in diameter.
size of the wrist and depth of the surgery zone and avoid the clash of instruments outside the wrist. The sheath includes a connector for irrigation and the trocar must be blunt to avoid cartilage lesions.
1.2.3 Instruments The instruments are also designed for precision and to limit the magnitude of external movements (▶ Video 1.1). The probe is the basic instrument for joint exploration. Fine instruments, such as graspers and resection forceps, are used. Angulated instruments can help access certain structures, which would otherwise be difficult due to the small joint intervals. A motor is fitted with abrasive instruments, such as shavers or burrs of appropriate sizes: 2 to 3 mm in diameter and 6 to 8 cm long. Basic instruments include a knife, for synovial resection (aggressive cutter) and a burr, usually 3 mm, for bony resection. A special electric bipolar diathermy machine is used for efficient tissue resection by vaporization. An irrigation system is used for joint cleaning and is absolutely necessary if using this system. A canulated wide-bore needle is used for the passage of sutures and mini anchors are used for ligament repair. Specific instrument kits are available for more complex procedures such as triangular fibrocartilage complex (TFCC) reinsertion.
1.2.4 Traction Arthroscopic approach to the wrist requires axial traction to separate the bones and create space for scope and instrument insertion. The traction applied is usually 5 to 7 kg, but can be only 2 to 3 kg for the thumb, for example. It allows stabilization of the limb for surgery. The traction is vertical in the axis of the forearm with the arm fixed on the table horizontally, and the elbow at 90° flexion and the hand pointing upward. This traction can be
Video 1.1 Video presenting the different instruments useful for the realization of arthroscopy of the wrist.
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Materials and Set-Up
Fig. 1.2 Set-up with vertical traction in “fishing rod” allowing the entire forearm to be free in the surgical field.
Fig. 1.3 Set-up using a traction tower.
Video 1.2 Video showing the use of the universal table that facilitates the installation of the wrist.
maintained using weights connected to a cable supported by stands, or sterilizable towers (▶ Fig. 1.2, ▶ Fig. 1.3). They allow orientation of the joint during arthroscopy. Traction is applied to the hand using Chinese finger traps or a traction hand. A new adapted table is now available, facilitating the installation (▶ Video 1.2).
1.2.5 Irrigation Not all surgeons use irrigation; some prefer “dry arthroscopy.” However, irrigation is frequently useful for cleaning the joint and is mandatory when using radiofrequency waves where the heat generated may cause burns. Irrigation in the wrist joint is not necessary for joint dilatation; this is maintained by traction. It is, therefore, possible to use low pressure, which limits the diffusion of saline into the tissues. The use of an arthropump is not necessary and is even discouraged: the pressure of 35 mmHg, used for wrist arthroscopy, can be obtained by simply raising the fluid pack 50 cm above the joint level. Irrigation inflow is through the sheath of the arthroscope.
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A trocar is not necessary for outflow as evacuation of the saline occurs through the portals used. The suction provided by the shaver is used for joint cleaning. Constant rinsing of the joint gives better visualization and eliminates debris from intra-articular procedures, thus reducing the risk of infection. It also prevents tissue heating when using motor powered instruments and diathermy or vaporization. If there is no tourniquet, the irrigation limits bleeding by increasing intra-articular pressure. However, if not controlled, irrigation may cause infiltration of the surrounding tissues. Classically, arthroscopic exploration may be started using the “dry method,” and irrigation may be used subsequently according to the view obtained, the procedure to be done, and the expected duration of surgery.
1.3 Set-Up Arthroscopy is usually performed under regional block with a tourniquet on the distal arm close to the elbow, which is fixed to the arm table, preventing movement between the fixed area and the elbow during traction. Axillary block is the anesthesia of choice for wrist arthroscopy because it causes complete muscle relaxation, makes the tourniquet better tolerated, and ensures
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Materials and Set-Up postoperative analgesia; it also makes it possible to keep the hospital stay short. A tourniquet is usually used to obtain a bloodless field even though some authors now advocate arthroscopy under local anesthesia without a tourniquet.1 The patient lies supine with the shoulder at 90° abduction. If a traction tower is used, it is placed on the arm table. The surgeon is at the head of the patient with the assistant beside or facing the surgeon. The arthroscopy column may be on the other side of the patient facing the surgeon, or sometimes facing the arm table (▶ Fig. 1.4). The image intensifier may be introduced from the distal side of the arm table, if needed, or facing the surgeon. These positions may be swapped to adapt to different steps of the procedure.
1.4 Conclusion Arthroscopic access to the wrist joint is particular due to its special anatomy characterized by small joint intervals. Adapted instruments and good setup enable safe surgery. Adequate time must be dedicated to proper setup, and appropriate instruments are mandatory for this surgery to go well.
Fig. 1.4 Diagram showing the position of the patient and the operators. The surgeon is at the head of the patient.
Reference [1] Ong MT, Ho PC, Wong CW, Cheng SH, Tse WL. Wrist arthroscopy under portal site local anesthesia (PSLA) without tourniquet. J Wrist Surg. 2012; 1(2):149–152
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2 Surgical Approaches 2.1 Introduction Arthroscopic surgery avoids the joint exposure that results from extensive surgical approaches. Conventional wrist surgery incisions are known to cause fibrosis and stiffness. Arthroscopic approaches are thus as small as possible. This chapter describes the main arthroscopic approaches, knowing that other possibilities exist, depending on the surgeon, the amount of exposure required, and variations in anatomic configuration.
2.2 General Principles of Approaches The incisions are horizontal, following the skin creases and left to granulate to achieve an aesthetically pleasing scar. A no. 15 blade is used; no. 11 blades are used for other joints such as the shoulder or the hip, but not for the wrist where noble structures, such as tendons, vessels, and nerves, lie just beneath the skin and risk being damaged (▶ Fig. 2.1). The steps for establishing an approach or portal are always as follow: ● Finger palpation of the zone ● Placement of a needle in the exact location of the portal, taking into account bony anatomy and the required angle ● Short incisions of 1 to 2 mm using the no. 15 blade ● Breaching of the skin and the capsule using a blunt mosquito clip to push away any noble structures without injuring them (▶ Video 2.1) The dorsal radiocarpal portals are named for the dorsal extensor compartments they are between, so that portal 3–4 lies between the 3rd and 4th compartments and portal 6R is radial to the 6th compartment, and so on.
2.3 Radiocarpal Portals
Fig. 2.1 Operative view of a 3–4 portal. The approach is a small horizontal skin incision allowing introduction of instruments and the scope.
The radiocarpal portals are named according to their positions in relation to the dorsal extensor compartments (▶ Fig. 2.2).
2.3.1 3–4 Radiocarpal Portal This portal is the real key to wrist exploration and the easiest one to locate. The first method of location uses the three circles technique: a circle is drawn over the tubercle of Lister, two identical circles of the same size are marked distally and the portal is located at the center of the third circle (▶ Video 2.2). In the second technique, the thumb is held vertically against the wrist so that the pulp feels the tubercle of Lister and the tip is at the distal end of the tubercle, the thumb is rolled toward the distal end of the wrist, second phalanx of the thumb (P2)
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Video 2.1 Video showing the sequence to establish an ulnar midcarpal portal (finger palpation, needle insertion, and introduction of the blunt clip followed by the arthroscope).
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Surgical Approaches passing from the vertical to the horizontal position, and the tip falls into the dip of the radial radiocarpal joint. The 3–4 portal is located just over the nail. Once the position is marked, the needle is inserted, respecting the radial slope from dorsal to palmar and from lateral to medial (▶ Video 2.3). Once the needle is correctly placed, i.e., felt freely inside the joint, the portal is established as usual using a blunt mosquito forceps (▶ Video 2.4).
complex (TFCC), the spot for the 6R portal is seen by transillumination. The correct position is verified using the needle in the joint (▶ Video 2.5).
2.3.3 4–5 Radiocapral Portal This portal is less frequently used, as the previous two portals are sufficient for wrist exploration. However, it may be useful for certain techniques.
2.3.2 6R Radiocarpal Portal This portal is easy to find once the 3–4 radiocarpal portal is established. The scope in portal 3–4 is directed ulnarward and when facing the triangular fibrocartilage
Video 2.2 Video showing the sequence for a 3–4 portal using the three circles technique.
Video 2.3 Video showing the sequence for a 3–4 portal using the flexed thumb technique. Fig. 2.2 Diagram showing the classic radiocarpal portals named according to their position relative to the dorsal extensor compartments.
Video 2.4 Video showing the introduction of a clip through the capsule, respecting the curve of the clip and the curve of the posterior rim of the radius: the clip rolls over the radial slope.
Video 2.5 Video showing the localization of the 6R portal: the scope is positioned in the 3–4 portal ulnarward and the needle is placed in the center of a circle of transillumination. The position of the needle is checked on the screen. The scope is held as a trigger, with the index applied against the skin to control the length of the scope introduced into the joint.
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Surgical Approaches With the scope in the 3–4 portal, a needle is used to locate this portal situated between the 4th and 5th compartments, 1 cm lateral to the 6R portal.
2.3.4 6U Radiocarpal Portal This portal was classically used for outflow. It is often associated with a direct foveal distal radioulnar portal for foveal reinsertion of the TFCC. The 6U radiocarpal portal is ulnar to the extensor carpi ulnaris tendon (ECU) on the medial aspect of the wrist. The scope in position 3–4 is pushed ulnarward and placed at the TFCC, facing the styloid recess. The intramuscular needle must emerge in the middle of the styloid recess. This approach is risky due to the association with the dorsal sensory branch of the ulnar nerve. Extra care is needed to avoid injury to this sensory nerve.
2.3.5 1–2 Radiocarpal Portal This portal is situated between the 1st and 2nd compartments above the radial styloid. The depression distal to the styloid is used to locate it, using the thumb and transillumination: the scope in 3–4 position is directed radially toward the styloid. The needle is placed respecting the radial slope and checked intra-articularly (▶ Video 2.6). The approach may be horizontal for a styloidectomy, or an extended vertical approach may be used to place an implant and avoid injury to the cutaneous sensory branches of the radial nerve.
2.4.1 Midcarpal Ulnar Portal The MCU is the simplest arthroscopic approach to the midcarpal joint. The midcarpal joint depression situated between the medial four wrist bones is easily palpable and is called the “crucifixion fossa.” An intramuscular injection needle helps locate the exact orientation of this portal. It should be placed following the slope of the first and second carpal rows, and directed from ulnar to radial (▶ Video 2.7).
2.4.2 Radial Midcarpal Portal This portal is not very simple to locate. It is situated about 1 cm distal to the 3–4 radiocarpal portal. The space between the scaphoid and the head of capitate is very tight, and the curve of the two bones is prominent. Lesions of the cartilage are not uncommon, if this is used as the primary approach to the midcarpal joint. After the MCU portal is established, it is easier to introduce the scope into the joint and direct it toward the dorsal aspect of the scaphoid just after the scapholunate joint to locate this portal by transillumination (▶ Video 2.8).
2.4.3 STT Midcarpal Portal This portal is situated between flexor carpi radialis (FCR) laterally and extensor carpi radialis (ECR) medially at the
2.4 Midcarpal Portals There are three classic midcarpal portals: the midcarpal ulnar (MCU) portal, the radial midcarpal (MCR) portal, and the scaphotrapeziotrapezoid (STT) portal (▶ Fig. 2.3).
Video 2.6 Video showing the sequence for the 1–2 radiocarpal portal, the scope is in 3–4, the camera toward the radial styloid, the needle is positioned at the center of a circle of transillumination with respect to the radial slope.
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Fig. 2.3 Diagram showing the classic midcarpal portals: STT: Scaphotrapezotrapezoid portal, MCR: radial midcarpal portal between compartments 3 and 4, and MCU: midcarpal ulnar portal classically between compartments 4 and 5 but sometimes crossing compartment 4.
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Surgical Approaches STT joint just radial to the index extensors (▶ Fig. 2.4). Localization is not simple. Transillumination may be used, directing the scope toward the STT joint (▶ Video 2.9). For this, the arthroscope must be introduced through the 3–4 portal following the medial aspect of the scaphoid distally until the STT.
2.5 Distal Radioulnar Portals There are three distal radioulnar portals: the distal radioulnar (DRU) portal, the direct foveal portal, and the proximal “distal radioulnar” portal.
2.5.2 Direct Foveal Portal This portal has been recently described by Atzei.1 It allows direct exploration of the foveal insertion of the TFCC. The supinated hand is placed under traction. The pit anterior to the ulnar styloid and above the ulnar head is palpated (▶ Fig. 2.5). The scope is placed in the DRU with the camera facing the fovea. A needle is then inserted through this depression until it becomes visible (▶ Video 2.11).
2.5.1 Distal Radioulnar Portal This portal is located below the TFCC precisely at the apex of an isoceles triangle the base of which is the line joining the 4–5 and the 6R portals. To find it, the scope is placed in 3–4 portal with the camera facing the TFCC. The needle must be inserted in the interval between the radius and the ulna and used to lift the center of the TFCC from below under direct vision (▶ Video 2.10). The deep side of the TFCC can be explored through this portal up to the foveal insertion and the sigmoid fossa of the radius.
Video 2.7 Video showing the sequence for the midcarpal ulnar portal. On the left, the thumb is seen localizing the “crucifixion” zone between the four medial carpal bones.
Video 2.8 Video showing the sequence for a radial midcarpal portal using transillumination.
Fig. 2.4 Diagram showing the two radial portals: the 1–2 radiocarpal and the STT midcarpal portal above between FPL and ECR.
Video 2.9 Video showing the making of the STT midcarpal portal, with the scope in MCR and the camera at the STT interval.
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2.5.3 Proximal “Distal Radioulnar” Portal This portal is situated 1 cm proximal to the DRU portal and is seldom used. It allows exploration of the proximal ulnar head and the proximal part of the ulnar notch.
2.6.2 Dorsal 1 Portal This portal is easy to locate using transillumination. The scope is inserted in the palmar 1 portal and the camera at the dorsal portion of the metacarpal joint (▶ Fig. 2.7).
2.6 Trapeziometacarpal Portal Exploration of the trapeziometacarpal joint is easy and safe; this portal can be used to treat arthritis of this joint.
2.6.1 Palmar 1 Portal This portal is located at the junction between palmar and dorsal skin on the TM joint. The needle is placed horizontally (▶ Fig. 2.6, ▶ Video 2.12). There are few risks at this location as it is far from the terminal radial nerve branches and no tendons cross it.
Video 2.11 Video showing the scope in distal radioulnar position (DRU) and the needle in the direct foveal portal. Intraarticular view showing the needle entry through the direct foveal portal and positioned at the fovea.
Video 2.10 Video showing the needle localization of the distal radioulnar portal: the scope in 3–4 is directed ulnarward with the needle below the TFCC to localize the ulnar head and to lift the TFCC under arthroscopic control.
Video 2.12 Video showing the palmar trapezometacarpal portal.
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Fig. 2.5 Diagram showing the two medial portals: the 6U radiocarpal portal and the direct foveal (DF). The direct foveal portal lies above the ulnar head and anterior to the ulnar styloid.
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Surgical Approaches
2.7 Palmar Portals It is sometimes necessary to use palmar portals to visualize the posterior components of the wrist joint. These portals are more perilous due to the increased depth of the anterior capsule under the skin and due to the close proximity of numerous noble structures, such as the median nerve, the radial artery, and the flexor tendons.
2.7.1 Radial Palmar Radiocarpal Portal This portal gives excellent access to view the dorsal ridge of the radius and the insertion of the dorsal radiocarpal (DRC) ligament.
Fig. 2.6 Operative view showing needle position to localize the palmar trapezometacarpal portal at the junction between palmar and dorsal skin.
It lies between the FCR medially and the radial pedicle laterally. The scope is inserted in 6R and a blunt trocar is placed through 3–4 passing through the radioscaphocapitate (RSC) and the long radiolunate (LRL) ligaments. It is pushed all the way to the skin, avoiding noble structures. A small cutaneous incision is made at its jutting end to exteriorize it (▶ Fig. 2.8a, b). The trocar is placed through a palmar approach using the trocar guide (▶ Fig. 2.9a, b). The guide is withdrawn and the scope is placed in the trocar.
2.7.2 Ulnar Palmar Radiocarpal Portal Rarely used, this portal is situated ulnar to the finger flexors, ulnar to the ulnar pedicle and the flexor carpi ulnaris. The scope is placed in position 3–4, and the blunt trocar
Fig. 2.7 Operative view showing needle position to localize the dorsal trapezometacarpal portal using transillumintaion.
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Fig. 2.8 (a) Operative view showing the blunt trocar pushed to the palmar skin from within. A small skin incision is made to exteriorize it. (b) Diagram showing the passage of the trocar.
Fig. 2.9 (a) Operative view showing the positioning of the trocar using the guide to enter the joint. (b) Diagram showing the intra-articular passage of the trocar onto the guide.
is pushed palmward in 6R, crossing the capsule at the depression of the pisotriquetral joint, and pushed all the way to the skin. The maneuver described earlier in section ‘Radial Palmar Radiocarpal Portal’ is used to place the scope.
2.7.3 Palmar Midcarpal Portal This portal is centrally located, at the anterior horn of the lunate between the median nerve, the palmaris longus
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(PL), the flexor pollicis longus (FPL) and the FCR radially, and the finger flexors ulnarly. Its proximity to the median nerve makes it a dangerous portal. The scope is placed through the ulnar midcarpal portal, the blunt trocar through the radial midcarpal portal, and at the level of the anterior horn of the lunate it is pushed through the capsule to the palmar skin. The capsule is breached at the medial part of the arcuate ligament, i.e., between the distal portion of the RSC ligament and the end of the LRL ligament radially, and
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Surgical Approaches procedure, such as palmar capsuloligamentous suture, is necessary, the approach is extended distally and proximally to allow retractors to be placed to protect the nerves and tendons.
2.8 Conclusion
Video 2.13 Video showing the trocar introduced through the radial midcarpal portal, positioned between the palmar ligaments anterior to the scapholunate interval.
Arthroscopic approaches are small by principle. They must respect the joint’s anatomy but especially that of the surrounding structures. It is paramount to respect the rules of entry, such as palpation, needle guidance, purely cutaneous incisions, and capsule entry, using a bluntended clip so as to avoid any injury to noble structures. Usually, these small incisions need no suture closure.
Reference the ulnocapitate (UC) ligament ulnarly (▶ Video 2.13). The skin incision varies according to the procedure. For a simple exploration, a classic small approach is used. If a
[1] Atzei A, Rizzo A, Luchetti R, Fairplay T. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability. Tech Hand Up Extrem Surg. 2008; 12(4):226–235
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3 Arthroscopic Anatomy of the Wrist 3.1 Introduction The anatomy of the wrist is now well-known, and many anatomical sources describe the components of this complex, functional, and well-organized joint. However, arthroscopic anatomy is particular in that the arthroscope provides vision “inside” the joint, and one must learn to analyze the view of the bones and ligaments from inside the wrist joint so that the brain can reconstruct the global wrist structure. The first step is to examine diagrams and dissections with the distal end of the wrist at the top of the page, as most arthroscopy procedures are performed with axis translation with the hand in the “American position,” i.e., the fingers pointing toward the ceiling. Another important particularity is that traction creates new anatomical spaces, allowing the arthroscope to enter the wrist (▶ Fig. 3.1, ▶ Fig. 3.2, ▶ Fig. 3.3).
3.2 Principles of Exploration Traction in the axis of the wrist creates space between the radius and the first carpal row—the radiocarpal space and between both carpal rows—the midcarpal space. Saline injection can help distend these potential spaces. (▶ Video 3.1) Entry into the joint is done using blunt ended clips so as not to injure the “noble structures” (i.e., nerves, veins, and tendons), using the classic arthroscopic portals.
Fig. 3.1 Diagram of first and second carpal rows, with traction on the wrist creating sufficient space to allow passage of the scope and instruments.
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Fig. 3.2 Diagram showing the dorsal extrinsic ligaments: dorsal intercarpal and dorsal radiocarpal.
Fig. 3.3 Diagram showing the palmar extrinsic ligaments. H, hamate; C, capitate; Td, trapezoid; Tm, trapezium; P, pisiform; T, triquetrum; L, lunate; S, scaphoid; U, ulna; R, radius. RSC, radioscaphocapitate ligament; LRL, long radiolunate ligament; SRL, short radiolunate ligament; UL, ulnolunate ligament; UT, ulnotriquetral ligament; UC, ulnocapitate ligament; TC, trapezocapitate ligament; SC, scaphocapitate ligament; PRU, volar part of the TFCC.
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Arthroscopic Anatomy of the Wrist
3.3 Radiocarpal Exploration We usually start through the 3–4 radiocarpal portal and immediately find the scapholunate ligament–a shiny valley between the 2 promontories of the lunate and scaphoid (▶ Video 3.2). We then push the scope to find the ligament of Testut at the junction between the palmar part of the scapholunate ligament and the anterior capsule of the wrist. The scope is directed laterally and the lateral distal part of the radiocarpal joint is visualized, i.e., the distal pole of the scaphoid above, and the scaphoid fossa and radial styloid below. The entire convexity of the scaphoid and radial cartilages can be assessed. If the scope is pushed forward, the anterolateral extrinsic ligaments can be seen: the scaphocapitate ligament RSC and the long radiolunate ligament LRL (▶ Video 3.3). These ligaments are better seen on arthroscopy than in cadaveric dissection since they are intracapsular and extrasynovial. Their tension can be tested either by moving the wrist in ulnar and radial deviation or by using a probe inserted through the 6R or 4–5 portal. The zone of origin of palmar wrist ganglia lies between these extrinsic ligaments.
The scope is then slid from lateral to medial following the scaphoid convexity to find the scapholunate ligament depression, a concave furrow extending from the cartilages of the two bones: the proximal pole of the scaphoid and the proximal aspect of the lunate. The scapholunate ligament can be visualized entirely, from its palmar aspect to its dorsal side. The radioscapholunate ligament of Testut should not be mistaken for pathological synovitis; it can be more or less vascularized (▶ Video 3.4). Not a real ligament; it is rather a vessel and proprioceptive nerve carrier for the SL ligament, with no stabilizer role. It is the direct prolongation of the anterior vessels and the anterior interosseous nerve. On the anterior aspect of the carpus, and just medial to the ligament of Testut, lies the short radiolunate (SRL) ligament, which is more difficult to see. By drawing the scope slightly backward, the distal surface of the radius can be assessed, with the scaphoid fossa laterally and the lunate fossa medially separated by a bony ridge related to the SL ligament. We then move medial to the radiocarpal joint. We follow the proximal surface of the lunate. The lunotriquetral
Video 3.1 Video showing the principles of traction on the wrist creating sufficient space to allow passage of the scope and instruments.
Video 3.2 Video showing radiocarpal arthroscopic view of an intact scapholunate ligament. Appearance of continuity between cartilages of the scaphoid and lunate.
Video 3.3 Video showing radiocarpal arthroscopic view of palmar extrinsic ligaments: radioscaphocapitate and long radiolunate.
Video 3.4 Video showing radiocarpal arthroscopic view of ligament of Testut.
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Arthroscopic Anatomy of the Wrist ligament can be seen above (▶ Video 3.5) as a valley between the lunate laterally and the triquetrum medially. The triquetrum is less often seen through 3–4 portal and the ulnocarpal ligament is also difficult to see. The key to assessing the medial radiocarpal joint is the triangular fibrocartilage complex (TFCC) exploration. The TFCC is a fibrocartilage disc, normally tense, with a medial insertion showing a regular anatomical perforation called the styloid recess (▶ Video 3.6). Its peripheral insertions on the palmar and dorsal capsule and on the radius can be assessed, as well as its foveal insertion on the ulnar head (▶ Fig. 3.4, ▶ Video 3.7). A hook introduced through the dorsal 6R portal can be used to assess all insertions and test the trampoline effect (the hook should spring briskly back when this ligament is stretched and tensed, and return to normal upon release). To complete the radiocarpal joint exploration and “see” certain zones, the scope position may be swapped (in 6R) with the instruments (3–4). The assessment of the triquetrum, the lunotriquetral ligament, and the lunate is easier in this position. This is the only approach by which to see the dorsal “cul de sac” between the reflection of the dor-
sal capsule and the first carpal row, especially the attachment of the dorsal portion of the scapholunate ligament to the dorsal capsuloligamentous septum–one of the first zones affected in scapholunate instability (▶ Fig. 3.5, ▶ Fig. 3.6, ▶ Video 3.8).
Video 3.6 Video showing radiocarpal arthroscopic view of the normal styloid recess at the insertion of the TFCC.
Video 3.5 Video showing radiocarpal arthroscopic view of the lunotriquetral ligament above left, triquetrum above right, and the TFCC below.
Video 3.7 Video showing radiocarpal arthroscopic view showing probe testing of the foveal insertion of the TFCC.
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Fig. 3.4 Anatomical cut showing the TFCC with its foveal insertion.
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Arthroscopic Anatomy of the Wrist
Fig. 3.6 Anatomical section showing the dorsal capsuloligamentous septum (DCSS), between the dorsal portion of the scapholunate and the dorsal capsule (DIC).
Fig. 3.5 Radiocarpal arthroscopic view showing the dorsal capsuloligamentous insertion of the scapholunate ligament (dorsal capsuloligamentous septum, DCSS).
3.4 Midcarpal Assessment The midcarpal joint is explored first through the ulnar midcarpal MCU portal; this is easily localized at the depression between the four medial bones. Because of the direction of the scope, the first zone visualized is the distal scapholunate space. Normally, this is an interval between the scaphoid laterally and the distal concave surface of the lunate medially (▶ Video 3.9). A probe is inserted through the radial midcarpal portal (RMC) to test this joint. The scope is slid medially in the midcarpal joint and the bony structures are assessed. Above, we can see the rounded cartilaginous surface of the capitate head, and medially the head of hamate and the interval between the two bones are also visible (▶ Video 3.10). We can follow the distal hamate medially. Below, we follow the concave aspect of the lunate as well as its two palmar and dorsal horns, and then the interval between the lunate and the triquetrum (▶ Video 3.11). The geometry of this joint depends on the shape of the lunate; this gives two possibilities: the surface is smooth between the two bones (Viegas 1), or shows a ridge on the distal medial part of the lunate forming a
Video 3.8 Video showing a radiocarpal arthroscopic view showing the dorsal capsuloligamentous insertion of the scapholunate ligament (dorsal capsuloligamentous septum, DCSS).
Video 3.9 Video showing midcarpal arthroscopic view showing the scapholunate interval between scaphoid and lunate. The capitate is visible at the top of the image.
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Arthroscopic Anatomy of the Wrist valley where the head of the hamate articulates (Viegas 2). The hamate does not form an inverted glenoid cavity but is more like a trochlear joint. It is possible to see the distal part of the great extrinsic palmar radiocarpal ligaments once the synovium is cleaned away to better distinguish the different ligaments. Laterally, we can see the scaphocapitate portion of the RSC ligament and medially the ulnotriquetro-capitate (UTC) ligament; both form the arcuate ligament, the rupture of which causes palmar midcarpal instability (▶ Fig. 3.7). Below and medially, we can see the RSC and the distal terminal part of the RLL ligament. Swapping the position of the scope to use the RMC shows the medial portion of this joint as well as the dorsal capsule, using the combined effect of the obliqueness of the camera and the triangulation effect. This is the only suitable approach to study the medial distal aspect of the scaphoid or the scaphotrapezotrapezoid joint (STT).
Moving the scope laterally and distally, we follow the scaphoid and the lateral aspect of the capitate medially to see the STT joint distally (▶ Video 3.12). The synovium can be debrided using a shaver through a 1–2 midcarpal portal. With the scope in this portal, and assisted by traction on the thumb, the STT can be entered and seen completely. We can then follow the distal dorsal medial portion of the joint, and check the dorsal aspect of the capitate up to the carpometacarpal joint.
3.5 Conclusion Knowledge of the classic anatomy is essential for understanding the arthroscopic anatomy of the wrist. Both the radial and midcarpal joints are complex. Although arthroscopy is no longer used exclusively for diagnostic exploration, the first step of every arthroscopy should be dedicated to analyzing the different anatomic structures, which can be directly seen perfectly. Furthermore, knowledge of this “arthroscopic” anatomy can bring to light new anatomical structures (e.g., dorsal capsuloscapholunate septum [DCSS]), help understand certain pathologies such as midcarpal instability, and allow certain procedures such as dorsal capsuloligamentous suture.
Video 3.10 Video showing midcarpal arthroscopic view showing the interval between the capitate and hamate.
Video 3.11 Video showing midcarpal arthroscopic view showing the upper part of the capitate and hamate, and the lower part of the lunotriquetral joint, and the distal aspect of the triquetrum.
Fig. 3.7 Midcarpal arthroscopic view showing, after cleaning and excision of the synovium, internal view of palmar extrinsic ligaments: the arcuate ligament formed by the union of the ulnocapitate ligament on the left and the radioscapholunate ligament on the right. Proximally, the long radiolunate ligament can be seen.
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Video 3.12 Video showing midcarpal arthroscopic view showing exploration of radial side, the scaphoid on the left and the capitate on the right until the dorsal aspect of the scaphotrapeziotrapezoid joint.
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4 Arthroscopic Treatment of Dorsal Wrist Ganglia 4.1 Introduction
4.3 Operative Technique
A dorsal wrist ganglion or synovial cyst is a benign tumor that often disappears spontaneously. Surgery is reserved for the rare painful ganglia, or large ones of cosmetic concern. The recurrence rate and postoperative complications of open surgery, such as stiffness in flexion and unattractive scars, are well known. Arthroscopic resection is a simple, minimally invasive technique, and has a recurrence rate similar to that following open surgery but without its complications.1
4.3.1 Patient Preparation This procedure is done as a day case surgery under regional anesthesia. The tourniquet is placed on the arm near the elbow to minimize the lever arm during upward traction. Counter traction is applied on the tourniquet.
4.2 Ligament Anatomy of the Dorsal Scapholunate Region The dorsal scapholunate (SL) region is a ligamentous complex composed of three distinct elements (▶ Fig. 4.1a, b): 1. The dorsal segment of the SL ligament 2. The dorsal intercarpal (DIC) ligament 3. The dorsal capsuloscapholunate septum (DCSS),2 which unites the SL ligament to the DIC ligament and contributes to the stabilization of the SL bony interval (▶ Fig. 4.2). The mucoid dysplasia, associated with ganglia, is intracapsular and extrasynovial and occurs at the level of this dorsal SL complex (▶ Fig. 4.3a–c, ▶ Video 4.1). Medially, the dysplasia herniates into the wrist joints, usually into the midcarpal joint (▶ Fig. 4.4). Laterally, the dysplasia extends by a pedicle between the DIC, or the radiolunotriquetral ligament (RLTL), either distally beneath the DIC or laterally toward the radial border of the radiocarpal compartment (▶ Fig. 4.5a–c).
Fig. 4.2 Arthroscopic view of the intact dorsal capsuloligamentous septum. The scope is placed in 6R portal, and directed toward the junction between the joint capsule and the dorsal portion of the SL ligament.
Fig. 4.1 (a) Sagittal cut of the wrist passing through the lunate and showing the dorsal SL complex. (b) Drawing showing the three components of the dorsal scapholunate complex: the dorsal portion of the scapholunate ligament in brown, the dorsal capsuloligamentous septum, DCSS, in blue, and the dorsal intercarpal ligament—the integrating part of the dorsal capsule—in white.
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Arthroscopic Treatment of Dorsal Wrist Ganglia
Fig. 4.3 (a, b) Photo and diagram showing the classic position of the dorsal wrist ganglion at the dorsal portion of the SL ligament in the midcarpal joint. (c) Drawing showing relations between the ganglion, the capsule, and the wrist extensors.
Video 4.1 Video showing the classic position of the dorsal wrist ganglion.
After exsanguinating and placing an upper limb sterile drape, traction is administered using a traction tower—it is possible to use the same one as used for shoulder arthroscopy. The required traction of 5 to 7 kg is applied using Chinese finger traps.
4.3.2 Assessment of the Size and Position of the Ganglion The first step is to locate the proximal and distal extent of the ganglion using a needle. The scope is inserted through
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Fig. 4.4 Drawing showing the normal relations between the ganglion and the midcarpal joint. The root of the ganglion is usually intra-articular at the SL interval.
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Arthroscopic Treatment of Dorsal Wrist Ganglia
Fig. 4.5 (a–c) Drawings showing three frequent possible locations of the ganglion in relation to dorsal ligaments.
Fig. 4.6 Operative view showing needle localization of the ganglion origin. (a) Locating the proximal ganglion location. (b) Locating the distal ganglion location.
the ulnar midcarpal portal and the exact limits of the capsule are identified (▶ Fig. 4.6a, b, ▶ Video 4.2).
4.3.3 Exploration of the Midcarpal Joint The ulnar midcarpal (MCU) portal is the simplest arthroscopic wrist approach. The blunt trocar is introduced, followed by the scope. Midcarpal exploration usually reveals a dorsal synovial bulge at the scapholunate interval corresponding to the intra-articular portion of the ganglion. Associated SL instability must be excluded.
Video 4.2 Video showing needle localization of the ganglion origin.
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Arthroscopic Treatment of Dorsal Wrist Ganglia
4.3.4 Resection of the Dorsal Mucoid Dysplasia at the Midcarpal Interval through a Transcystic Approach A needle is introduced through the ganglion into the midcarpal joint via the radial midcarpal portal (MCR). A direct transcystic MCR approach is established and an aggressive cutter, the shaver, is introduced through the ganglion into the joint (▶ Fig. 4.7a–c, ▶ Video 4.3). The dorsal pathological capsule, representing the mucoid dysplasia herniating into the midcarpal joint, is resected under vision, thanks to the scope angulation and triangulation effect. This resection is relatively easy compared to the resection of a healthy capsule. Sometimes, it is easier to use a basket grasper to resect some parts of the capsule. The DCSS and the continuity of the DIC ligament must be preserved. Electrocoagulation should be avoided for the risk of cartilage and extensor tendon lesions.
4.3.5 Resection of the Ganglion Wall It is now possible to bring out the scope from inside outward through the joint capsule at MCR. Vision is now obscured by the cyst wall. The shaver is always in MCR position but extra articular. This part of the procedure is more of an endoscopy
Video 4.3 Video showing operative view with the scope in MCU and the shaver in a transcystic position.
Fig. 4.7 (a) Operative view showing the scope in MCU and the shaver in a transcystic position. (b) Diagram showing scope and shaver positions. (c) Diagram showing the transcystic position of the shaver.
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Arthroscopic Treatment of Dorsal Wrist Ganglia than an arthroscopy (▶ Fig. 4.8, ▶ Video 4.4). Caution is required at this stage to avoid extensor tendon injury. It is easy to move the scope and the shaver from top to bottom to resect all the walls of the cyst, and immediately obtain a cosmetically perfect final result. The resection is done bit by bit with the shaver until the extensor tendons are visible at the end (▶ Video 4.5).
4.3.6 Closing and Postoperative Care
character of this condition and the frequency of its spontaneous disappearance by 6 months. Arthroscopic treatment of dorsal wrist ganglia is the gold standard of surgical treatment. The patient must be informed of the recurrence rate of 11%.1 Arthroscopic resection avoids the complications of open excision, especially unsightly scarring and joint stiffness. Care must be taken not to miss a dorsal wrist ganglion associated with scapholunate instability (▶ Fig. 4.9a, b).
Sutures are not needed, as Steri-Strips are used to close the skin. Immediate movement of the joint is encouraged, but without any forcing for 3 weeks.
4.4 Conclusion Conservative treatment is probably the best primary treatment for dorsal wrist ganglia owing to the benign
Video 4.4 Video showing arthroscopic view through MCR portal with the scope in MCU, the shaver resecting the cyst walls from inside out while the extensor tendons are protected.
Fig. 4.8 Diagram showing the scope position entering the MCU portal and exiting through the MCR to control the resection of the ganglion walls extra-articularly.
Video 4.5 Video showing arthroscopic view through MCR portal from inside out with the scope in MCU, showing the extensor tendons after the resection of the cyst wall.
Fig. 4.9 (a) Arthroscopic radiocarpal view with the scope in 6R radiocarpal portal showing a false dorsal synovial ganglion. (b) The probe testing shows a dorsal scapholunate lesion.
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Arthroscopic Treatment of Dorsal Wrist Ganglia
References [1] Gallego S, Mathoulin C. Arthroscopic resection of dorsal wrist ganglia: 114 cases with minimum follow-up of 2 years. Arthroscopy. 2010; 26(12):1675–1682
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[2] Overstraeten LV, Camus EJ, Wahegaonkar A, et al. Anatomical Description of the Dorsal Capsulo-Scapholunate Septum (DCSS)-Arthroscopic Staging of Scapholunate Instability after DCSS Sectioning. J Wrist Surg. 2013; 2(2):149–154
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5 Arthroscopic Dorsal Wrist Ganglion Excision with Colored Dye-Aided Stalk Resection Edward Wu, Jeffrey Yao
5.1 Introduction
5.2 Operative Technique
Ganglion cysts are the most common masses observed in the upper extremity. They are mucin-filled masses caused by synovial herniation, mucoid degeneration, and/or trauma. The dorsum of the wrist is the most common location, where cysts arise from the scapholunate joint. The annual incidence of ganglia in the wrist and hand is approximately 34 per 100,000 persons, with females twice as affected as males.1 Forty percent of ganglia resolve and disappear on their own with conservative management.2 Persistent ganglia may be treated with aspiration, though recurrence rates as high as 70% have been reported. Concomitant steroid injections have not been shown to produce better results.3 As such, surgical excision remains the most definitive treatment of wrist ganglia. Historically, excision via an open approach has been associated with recurrence rates of up to 40%.2–4 Further studies demonstrated the importance of defining and excising the entirety of the cyst’s stalk and deeper attachments, which has been associated with lower recurrence rates and less morbidity.4 In recent years, the arthroscopic excision of dorsal wrist ganglia has become increasingly popular due to its low recurrence rates and improved cosmesis. Arthroscopic excision has been associated with shorter recovery time, improved range of motion, fewer complications, and greater patient satisfaction.5–7 As with open techniques, the success of arthroscopic excision hinges on the adequate resection of the cyst stalk. Recurrence is often attributed to inadequate visualization of the stalk or occult cysts that remain unresected.8 Previous studies suggest that rates of visualization of the stalk emanating from the dorsal scapholunate ligament during wrist arthroscopy are highly variable.6,9,10 Yao and Trindade first presented a color-localization technique using an intralesional injection of Indigo Carmine dye to facilitate complete stalk visualization.11 A follow-up retrospective study demonstrated stalk identification in 100% of these arthroscopic dorsal wrist ganglion excision patients, with recurrence found in just one patient (3.7%) at 1-year follow-up.12 The intralesional injection of colored dye during arthroscopic dorsal wrist ganglion excision thus represents a safe and valuable technique to ensure the maximum visualization and resection of the cyst stalk. It has the potential to reduce conversion to open excision and its associated complications, and reduce recurrence rates.
5.2.1 Patient Preparation and Positioning The surgery is performed under a supraclavicular regional block. The patient is positioned supine with their arm extended on a hand table and a tourniquet placed on the upper arm. The extremity is placed in a standard wrist arthroscopy tower and 10 to 15 lb of longitudinal traction is applied to the index and long fingers. The ganglion is then demarcated with a skin marker, as it is often difficult to visualize and palpate once the surgery begins (▶ Fig. 5.1). The tourniquet is then inflated to 250 mmHg.
5.2.2 Surgical Steps The standard 6R portal is made radial to the extensor carpi ulnaris tendon, through which a 2.7 mm arthroscope is introduced. A diagnostic arthroscopy is performed to assess for any other potential causes of wrist pain. (▶ Video 5.1, ▶ Video 5.2) Next, the arthroscope is advanced radially and dorsally to evaluate the dorsal aspect of the scapholunate
Fig. 5.1 Set-up for the arthroscopic excision of a dorsal wrist ganglion. Longitudinal traction of 10 to 15 lb is applied through the index and long fingers using a standard wrist arthroscopy tower. The ganglion is marked on the skin before the surgery starts, as it is often difficult to visualize and palpate intraoperatively during arthroscopy.
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Arthroscopic Dorsal Wrist Ganglion Excision with Colored Dye-Aided Stalk Resection
Video 5.1 The dye is injected intralesionally. This video shows the view from the outside.
Video 5.2 The view inside the joint as the dye is injected intralesionally. Note the tissue turning blue as the dye is injected.
Fig. 5.3 The arthroscope is positioned radially and dorsally toward the dorsal portion of the SLIL. The 1:10,000 solution of indigo carmine is injected intralesionally into the cyst.
Fig. 5.2 Visualization of the ganglion stalk through the arthroscope placed in the 6R portal. Prior to intralesional injection of the indigo carmine dye, the ganglion stalk is faintly visible arising from the dorsal portion of the SLIL. The dorsal SLIL is to the left and the dorsal wrist capsule is to the right.
interosseous ligament (SLIL). This is the region from which the dorsal wrist ganglion stalk commonly originates (▶ Fig. 5.2). If the stalk is inadequately visualized, a 1:10,000 solution of Indigo Carmine is injected intralesionally into the ganglion cyst (▶ Fig. 5.3). Indigo carmine is an inert, water-soluble organic compound with wellestablished applications in obstetric and urologic surgery, and is safe when used intra-articularly. This stains the tissue within the ganglion cyst and provides a clear and improved visualization of the cyst walls and stalk (▶ Fig. 5.4). The distal 3–4 portal is then made under direct visualization and a 3.5 mm full-radius arthroscopic shaver is introduced. Following the areas colored blue by the dye, this is used to debride the ganglion, stalk, and capsular
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Fig. 5.4 Following the injection, the cyst and its stalk is more clearly delineated. The dorsal SLIL is to the left and the dorsal wrist capsule is to the right.
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Arthroscopic Dorsal Wrist Ganglion Excision with Colored Dye-Aided Stalk Resection
Fig. 5.5 The arthroscopic shaver is used to excise the cyst and stalk. The shaver’s teeth are always directed away from the dorsal SLIL (*). The dye may be seen entering the dorsal SLIL during excision (arrow).
attachment down to the level of the SLIL (▶ Fig. 5.5). The SLIL is protected at all times with the back of the shaver. After amputating the stalk at the level of the SLIL, the dye is followed along the stalk to ensure complete excision of the cyst, which often extends into the midcarpal joint. Once the cyst is excised, a 1 × 1 cm dorsal capsulectomy is created with the shaver to help prevent recurrence. Care must be taken while performing the capsulectomy as the dorsal extensor tendons lie directly on the opposite side of the capsule. The arthroscope can then be introduced through the 3–4 and radial midcarpal portals to confirm complete excision of the ganglion (▶ Fig. 5.6).
5.2.3 Closure and Postoperative Care After the instruments are removed, the portals are closed with 4–0 nylon suture. A soft dressing is applied. No splint is necessary and is preferable to avoid postoperative stiffness. Sutures are then removed 14 days postoperatively.
5.3 Conclusion Use of colored dye to enhance visualization is a safe and effective technique to improve the success of arthroscopic excision of dorsal wrist ganglia. Complete identification of the ganglion stalk is often challenging during standard wrist arthroscopy, and incomplete resection may lead to recurrence. Staining the ganglion and stalk with an intralesional injection of colored dye facilitates complete cyst
Fig. 5.6 Complete excision of the cyst and stalk. The stalk remnant is in the center. An extensor tendon can be seen through the capsulectomy to the right at the 2- to 3-o’clock position. The dorsal SLIL is to the left.
excision, thereby reducing the potential for recurrence and improving patient satisfaction and outcomes.
References [1] Janzon L, Niechajev IA. Wrist ganglia. Incidence and recurrence rate after operation. Scand J Plast Reconstr Surg. 1981; 15(1):53–56 [2] McEVEDY BV. The simple ganglion: a review of modes of treatment and an explanation of the frequent failures of surgery. Lancet. 1954; 266(6803):135–136 [3] Richman JA, Gelberman RH, Engber WD, Salamon PB, Bean DJ. Ganglions of the wrist and digits: results of treatment by aspiration and cyst wall puncture. J Hand Surg Am. 1987; 12(6):1041–1043 [4] Angelides AC, Wallace PF. The dorsal ganglion of the wrist: its pathogenesis, gross and microscopic anatomy, and surgical treatment. J Hand Surg Am. 1976; 1(3):228–235 [5] Aslani H, Najafi A, Zaaferani Z. Prospective outcomes of arthroscopic treatment of dorsal wrist ganglia. Orthopedics. 2012; 35(3):e365–e370 [6] Edwards SG, Johansen JA. Prospective outcomes and associations of wrist ganglion cysts resected arthroscopically. J Hand Surg Am. 2009; 34(3):395–400 [7] Osterman AL, Raphael J. Arthroscopic resection of dorsal ganglion of the wrist. Hand Clin. 1995; 11(1):7–12 [8] Gallego S, Mathoulin C. Arthroscopic resection of dorsal wrist ganglia: 114 cases with minimum follow-up of 2 years. Arthroscopy. 2010; 26(12):1675–1682 [9] Rizzo M, Berger RA, Steinmann SP, Bishop AT. Arthroscopic resection in the management of dorsal wrist ganglions: results with a minimum 2-year follow-up period. J Hand Surg Am. 2004; 29(1):59–62 [10] Kang L, Akelman E, Weiss AP. Arthroscopic versus open dorsal ganglion excision: a prospective, randomized comparison of rates of recurrence and of residual pain. J Hand Surg Am. 2008; 33(4):471–475 [11] Yao J, Trindade MC. Color-aided visualization of dorsal wrist ganglion stalks aids in complete arthroscopic excision. Arthroscopy. 2011; 27 (3):425–429 [12] Ahsan ZS, Yao J. Arthroscopic dorsal wrist ganglion excision with color-aided visualization of the stalk: minimum 1-year follow-up. Hand (N Y). 2014; 9(2):205–208
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6 Arthroscopic Excision of Volar Wrist Ganglia 6.1 Introduction Volar wrist ganglia are less common than dorsal ones. They occur mainly in the radiocarpal joint. Although rare, any occurrence in the midcarpal joint is the evidence of scaphotrapeziotrapezoid (STT) osteoarthritis. Their exact cause is still debated, but the result is capsule destruction across from the volar insertion of the scapholunate ligament. Similar to dorsal ganglia, these are benign tumors that can be treated using an open procedure; however, there is a risk of complications due to the proximity of the cyst with the radial artery and nerve. Arthroscopic resection is a simple and reliable procedure as long as the surgical technique is performed correctly, given that the intracapsular origin of the ganglion is far away from tendons, ligaments, and muscles.
6.2 Operative Technique 6.2.1 Patient Preparation and Positioning Surgery is performed on an outpatient basis under regional anesthesia. The patient is placed supine
with the arm resting on an arm board and a tourniquet placed at the base of the upper arm. A traction tower is used to make the procedure easier; 5–7 kg (11–15.5 lbs.) of traction is sufficient. The ganglion in the volar wrist crease below the thumb is outlined with a skin marker (▶ Fig. 6.1, ▶ Video 6.1). This documents the volume of the ganglion before starting the procedure; this information is used at the end of the procedure to make sure all the cyst fluid has been removed.
6.2.2 First Surgical Phase: Intra-articular Assessment The scope is typically placed in the 3–4 portal. After inspecting the various wrist compartments and making sure there are no other injuries, the position of the volar ganglion is determined from inside the joint. The scope is placed in front of the hiatus between the radioscaphocapitate (RSC) and long radiolunate ligaments (LRL) (▶ Fig. 6.2, ▶ Video 6.2). By gently pressing on the swollen volar structure with a finger, the volar ganglion’s poorly defined, frayed hypertrophic synovial membrane will bulge out between these two ligaments. The volar ganglion will be resected through this opening.
6.2.3 Second Surgical Phase: Identification and Resection of the Ganglion The scope is placed in the 3–4 portal and a shaver is inserted through the 1–2 portal. The assistant holds the camera and scope. The surgeon holds the shaver in one hand and uses the other hand to push the ganglion
Fig. 6.1 Intraoperative view of a volar wrist ganglion being outlined before resection is carried out.
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Video 6.1 Video showing intraoperative view of a volar wrist ganglion being outlined before resection is carried out.
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Arthroscopic Excision of Volar Wrist Ganglia toward the radiocarpal joint. The stalk of the ganglion can be resected by placing the shaver between the RSC and LRL ligaments (▶ Fig. 6.3). Once the capsule is breached, visibility will be reduced because of the inflow of mucus into the joint, which is proof of a broken ganglion wall. The resection can then be made, starting from inside the joint and carefully continuing deeper toward the volar
Fig. 6.2 Drawing of the scope inserted in the 3–4 portal to locate the stalk of the ganglion between the RSC and LRL ligaments.
Fig. 6.3 Drawing of the scope in the 3–4 portal and the shaver in the 1–2 portal being used to start resecting the foot of the ganglion cyst.
side. The shaver’s gradual progression must be continuously monitored through the resection window until all the abnormal synovial tissue is removed. Direct pressure can be placed on the skin over the ganglion to help with the resection (▶ Fig. 6.4, ▶ Video 6.3). It is not necessary to remove the entire cyst wall. The shaver should not be moved outside the joint because of the risk of damaging the radial artery and median nerve. During the last part of this procedure, the presence of fat fragments (visible as small yellowing flakes) indicates that the cyst has been opened. The resection opening will be clearly visible, as will the flexor tendons in some cases (▶ Fig. 6.5, ▶ Video 6.4). It is important to make sure that the ganglion has completely disappeared from the volar wrist crease below the thumb. This step can be performed by
Video 6.2 Video showing intra-articular view of the ganglion’s stalk between the RSC and LRL ligaments.
Fig. 6.4 Drawing of the hand and wrist viewed laterally with the scope in 3–4 portal and shaver in 1–2 portal. The surgeon’s index finger presses on the volar ganglion to make it easier to resect with the shaver.
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Arthroscopic Excision of Volar Wrist Ganglia
Video 6.3 Video showing the scope in the 3–4 portal and the shaver in the 1–2 portal being used to start resecting the foot of the ganglion cyst, helped by the surgeon’s index finger pressing on the volar ganglion to make it easier to resect with the shaver.
Video 6.4 Video showing intra-articular view of the flexor pollicis longus tendon after the cyst has been resected; the RSC and LRL ligaments remain intact.
Fig. 6.6 Drawing of the scope in the 6R portal and the shaver in the 3–4 portal, which is another possible configuration during resection. Fig. 6.5 Intra-articular view of the flexor pollicis longus tendon after the cyst has been resected; the RSC and LRL ligaments remain intact.
placing the scope in the 6R or 4–5 portal; the shaver is placed in the 3–4 portal so that it is directly over the dihedral space that separates the RSC and LRL ligaments (▶ Fig. 6.6).
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6.2.4 Closure and Postoperative Care The arthroscopy portal incisions do not need to be sutured closed, only covered with a dressing. Wrist motion is allowed immediately (▶ Fig. 6.7).
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Arthroscopic Excision of Volar Wrist Ganglia
Fig. 6.7 Patient at postoperative Day 3. (a, b) Range of motion is unlimited and the incisions, which were not sutured, have already closed.
6.3 Conclusion A wrist ganglion in the volar wrist crease below the thumb is a common and unremarkable finding. Surgical treatment is indicated only in cases where the ganglion causes pain or is unsightly. Arthroscopic resection is
feasible and effective. Its recurrence rate is similar to open resection, but without the risk of injuring tendons, ligaments, nerves, and muscles. Arthroscopic resection has become the gold standard for surgical techniques because it involves less scarring, minimal time away from work, and faster functional recovery.
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7 Arthroscopic Radial Styloidectomy 7.1 Introduction Radial styloidectomy is frequently associated with other procedures, such as treatment of scaphoid nonunion or chronic lesions of the scapholunate ligament. It is sometimes performed alone for the treatment of isolated radial chondropathy, especially in weight lifters, or as palliative treatment in some cases of scapholunate advanced collapse (SLAC) or scaphoid nonunion advanced collapse (SNAC).
7.2 Operative Technique 7.2.1 Patient Preparation
7.2.3 Styloidectomy through the 1–2 Radiocarpal Portal The scope is always stable in position 3–4 radiocarpal; the camera is directed toward the radial styloid. Using a needle, the 1–2 radiocarpal portal is identified and a shaver is installed in the joint to perform a synovectomy localized around the radial styloid. A 3.0 burr is then used to resect the entire zone of chondropathy all the way to the subchondral tissue. The styloidectomy is 4 to 5 mm deep, i.e., slightly greater than the size of the burr. The insertions of the extrinsic ligaments–RSC anteriorly and DRC posteriorly–must be respected (▶ Fig. 7.1, ▶ Fig. 7.2a, b, ▶ Video 7.1).
The surgery is done under regional anesthesia using an arm tourniquet. The arm is fixed to the table, applying 5 to 7 kg of traction in the axis of the arm, using Chinese traps.
7.2.2 Exploration of the Radiocarpal Joint The scope is placed through the 3–4 radiocarpal portal. After classic exploration of the radiocarpal joint, the camera is directed toward the radial part of the radiocarpal joint following the scaphoid fossa of the radius until the radial styloid. The zone of chondropathy is identified and one or more of the three techniques are chosen, according to its extent. More than one technique can be used during the same procedure.
Fig. 7.1 Drawing showing the scope through the 3–4 portal and the burr through the 1–2 portal.
Fig. 7.2 (a) Intra-articular view showing the burr at the beginning of a styloidectomy, placed at the zone of chondropathy of the radial styloid. (b) Intra-articular view showing the burr at the zone of styloidectomy.
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Arthroscopic Radial Styloidectomy
7.2.4 Styloidectomy through the 3–4 Portal
7.2.5 Styloidectomy through a Palmar Approach
Sometimes, when the zone of chondropathy is small, it is possible to use only the 6R and 3–4 radiocarpal portals. The scope is placed in position in the 6R portal and the camera is directed toward the radial styloid. The shaver is placed through the 3–4 portal and directed toward the zone of chondropathy. The resection is performed from the inside outward. Injury to healthy cartilage must be avoided by holding the burr firmly in the correct position (▶ Fig. 7.3a, b, ▶ Video 7.2).
The zone of chondropathy is often situated on the dorsal aspect of the styloid, and sometimes triangulation alone is not enough for good vision. The arthroscope is then placed in the palmar radial radiocarpal portal. The burr is placed either in position 3–4, or 1–2, so that resection of the zone of chondropathy can be adequately performed (▶ Fig. 7.4).
7.2.6 Closure and Postoperative Care These small incisions do not require closing. If the styloidectomy is isolated, a simple semi-compressive dressing is placed for a few days. Immediate movement of the joint is allowed (▶ Fig. 7.5a, b). If the styloidectomy is performed as an associated step, the postoperative care is that of the main procedure.
Video 7.1 Video showing arthroscopic styloidectomy by 1–2 and 3–4 portals.
Fig. 7.3 (a) Drawing showing the scope introduced through the 6R portal and the burr through the 3–4 portal. (b) Operative view showing the scope introduced through the 6R portal and the burr through the 3–4 portal.
Video 7.2 Video showing arthroscopic styloidectomy by 3–4 and 6R portals.
Fig. 7.4 Drawing showing the scope through the radial palmar radiocarpal portal and the burr through the 1–2 portal.
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Arthroscopic Radial Styloidectomy
Fig. 7.5 (a) Clinical case showing radial styloid arthritis SLAC 1 in a 65-year-old man following an old rupture of the scapholunate ligament. (b) The same case after styloidectomy, which was chosen as the sole treatment in this case, with immediate postoperative recovery of mobility.
7.3 Conclusion Radial styloidectomy is a simple procedure. Described by Barnard in the 1940s as a simple treatment for scaphoid nonunion, it was abandoned for many years due to its aggressiveness.1 The advent of wrist arthroscopy, which has simplified surgery and postoperative care, has led to this procedure regaining favor, sometimes performed
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on its own but most often associated with another procedure.
Reference [1] Barnard L, Stubbins SG. Styloidectomy of the radius in the surgical treatment of nonunion of the carpal navicular; a preliminary report. J Bone Joint Surg Am. 1948; 30A(1):98–102
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8 Anatomy of the TFCC: Current Concepts 8.1 Introduction
8.3 Anatomy
The triangular fibrocartilage complex (TFCC) is one of the intrinsic ligaments of the wrist. It is often injured due to a fall on an outstretched hand or in association with distal radius fractures, and central perforations are commonly seen in degenerative processes during aging. It contributes to the stability of the distal radioulnar joint and to that of the ulno-carpal joint. The nomenclature—Triangular Fibro Cartilage Complex—is apt because it reflects both structure and anatomical shape. Many recent cadaver and arthroscopic studies have elucidated its exact anatomy and function.1,2 This knowledge is of great help in understanding the biomechanical role of the TFCC and in the arthroscopic management of TFCC tears.2
The TFCC is located between the ulna and the proximal carpal row (opposite to the lunate and the triquetrum). It thus supports the distal radioulnar joint (DRUJ) in its proximal portion. The DRUJ is formed by the articulation between the concave sigmoid notch located on the medial aspect of the distal end of the radius and the articular surface of the ulnar head (▶ Fig. 8.1). The DRUJ is stabilized by dorsal and volar radioulnar ligaments, the TFCC, and the joint capsule. The TFCC consists of the following five parts: 1. The fibrocartilaginous disc and the meniscal homologue 2. The ulnocarpal ligaments on the volar aspect (the ulnolunate and the ulno triquetral ligaments) (▶ Fig. 8.2) 3. The dorsal and volar radioulnar ligaments (each with a superficial and deep part) (▶ Fig. 8.3a, b) 4. The ulnar collateral ligament 5. The floor of the fibrous 5th and 6th extensor compartments (▶ Fig. 8.4)
8.2 Histology The TFCC is composed of two histologically different types of tissues. The central fibrocartilage disc makes up for 80% of the area of the TFCC. It is avascular and comprised of collagen Type 1 fibers, which are oriented according to tensile forces and grouped in bundles, with fusiform chondrocytes in the matrix.3 This central disc attaches to the hyaline cartilage that covers the distal radius,4 and extends as a meniscus homologue. The peripheral 20% of the disc is vascularized, as are its extensions: the ulno-carpal ligaments (volar), and the sheath of the extensor carpi ulnaris (ECU) (dorsal). These structures are composed of loose vascularized connective tissue, with fibroblasts that secrete proteoglycans and extracellular matrix. They are interspersed in a gelatinous matrix composed of collagen fibers and elastin fibers. The TFCC is inserted on the fovea of the ulna by Sharpey’s fibers, which are vertically oriented. At the base of the ulnar styloid, the fibers are oriented horizontally. The ECU tendon subsheath is also firmly attached to the dorsal aspect of the fovea by Sharpey’s fibers.5 In contrast, the ulnocarpal ligaments do not have any Sharpey’s fibers. Thus, the TFCC is composed of two distinct parts: a vascularized portion and a non-vascularized portion. Vascularization is supplied from branches of the posterior interosseous artery, the ulnar artery, and medullary arteries of the head of the ulna at the fovea. This histological difference explains the pathophysiology of TFCC lesions. The central disc and its radial insertion are avascular and cannot heal spontaneously. The peripheral portion of the TFCC is well vascularized, and has a good healing potential. Macroscopically, it is often difficult to distinguish between the fibrocartilaginous and the ligamentous parts.
The central disc is a robust fibrocartilaginous structure extending between the ulna and the radius. The base of the disc is attached to the sigmoid notch of the radius, whereas the apex is attached to the fovea at the base of
Fig. 8.1 Schematic diagram of the distal radioulnar joint. S, scaphoid; L, lunate; T, triquetrum; Sig, sigmoid notch of radius; U, distal articular surface of the ulnar head.
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Anatomy of the TFCC: Current Concepts
Fig. 8.2 Drawing of the distal portion of the TFCC. D, disk; MH, meniscal homologue; UL, ulnolunate ligament; UT, ulnotriquetral ligament.
Fig. 8.4 Drawing of the dorsal and medial portion of the TFCC. ECU, extensor carpi ulnaris tendon; UCL, ulnar collateral ligament.
Fig. 8.3 (a) Drawing view of the distal portion of the TFCC. R, radius; D, disc; U, ulna; ARUL, anterior radioulnar ligament; PRUL, posterior radioulnar ligament. (b) Drawing section showing a portion of the radioulnar ligament composing the TFCC. DRUL, deep radioulnar ligament; SRUL, superficial radioulnar ligament.
the ulnar styloid on the head of the ulna. The foveal insertion of the TFCC is not seen during wrist arthroscopy using the standard radiocarpal portals. This important part of the TFCC is best visualized using the DRUJ portals. These fibers are part of the “iceberg” concept propagated by Atzei.2 The central fibrocartilaginous disc continues medially and volarly to merge with the ulnar collateral ligament and the ulnocarpal ligaments, respectively. The
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ulnocarpal ligaments (the ulnolunate and the ulnotriquetral ligaments) do not insert onto the ulna, but are derived from the anterior part of the TFCC, and they connect the carpus (lunate, triquetrum, and capitate3) to the ulna by the palmar portion of the radioulnar ligament at its origin—the fovea.6 The radioulnar ligaments (dorsal and volar) arise from the medial aspect of the distal radius. They insert at different points onto the ulna (the
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Anatomy of the TFCC: Current Concepts deep fibers insert onto the fovea, whereas the superficial fibers insert onto the styloid process). Palmer7 had a two-dimensional view of the TFCC. However, since the work of Nakamura,1,4,6 it is interesting to understand the dynamic function and analyze the TFCC in its threedimensional structure. One can, therefore, schematically separate the TFCC into three zones: a proximal zone corresponding to the insertion of the triangular foveal ligament, a distal region corresponding to the “hammock,” and an outer area corresponding to the ulnar collateral ligament (▶ Fig. 8.5).
8.4 Biomechanics The TFCC plays an important role in the biomechanics of the carpus and DRUJ.4,6 It stabilizes the DRUJ and the ulnocarpal joint. The TFCC allows the transmission and distribution of forces from the wrist onto the ulna and provides a gliding surface for the carpus during complex movements of the wrist. The central disc is important for the distribution of mechanical stresses on the proximal part of the triquetrum and the lunate. The TFCC and its components differentiate humans from primates and allow 6 degrees of movements at the wrist joint, namely flexion, extension, supination, pronation, ulnar, and radial deviation.
The proximal part of the TFCC stabilizes the DRUJ, whereas the distal portion, resembling a hammock, supports the ulnar carpus. During pronation and supination, the central disc deforms only slightly (▶ Fig. 8.6), whereas the triangular ligament twists significantly at its insertion on the fovea of the ulna. The ulnar collateral ligament is also deformed during pronation and supination. The relationship between the radius and the ulna changes with pronosupination: in supination, the head of the ulna is relatively volar to the radius, whereas, in pronation, it is dorsal to the distal radius. In fact, in supination, it is the radius that translates dorsally7 and causes certain fibers of the TFCC to tighten, namely the superficial fibers of the volar radioulnar ligament and the deep fibers of the dorsal radioulnar ligament.8 In pronation, conversely, the radius translates into the volar position: it is then the superficial fibers of the dorsal radioulnar ligament and deep fibers of the volar radioulnar ligament that are stretched out (▶ Fig. 8.7). It is, therefore, imperative to
Fig. 8.6 Drawing showing the dynamic changes of the disc during rotation of the wrist. P, pronation; S, supination; N, neutral, minor changes according to Nakamura.7
Fig. 8.5 Three-dimensional structure of the TFCC by Nakamura6 (concept of “hammock”) UCL, ulnar collateral ligament; U, ulna.
Fig. 8.7 Drawing showing the position of the fibers of radioulnar ligaments in wrist pronation. We note that the superficial fibers of the radioulnar ligament are stretched and posterior root fibers of the posterior ligament radioulnar are loose, whereas the reverse is true with the radio-ulnar ligament. ARUL, anterior radioulnar ligament; PRUL, posterior radioulnar ligament; S, superficial fibers; D, deep fibers; U, ulna; R, radius.
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Anatomy of the TFCC: Current Concepts move the DRUJ through the entire range of pronosupination when exploring the TFCC arthroscopically. The TFCC plays a key role in the intrinsic stability of the DRUJ. Extrinsic stability is provided by the ECU subsheath, the distal fibers of the interosseous membrane, and the pronator quadratus muscle. In extreme movements, the DRUJ capsule prevents dislocation of the joint.
in isolated proximal lesions, which differs from the hook sign (▶ Fig. 8.10).
8.6 Conclusion Knowledge of the histological differences of the TFCC components, especially with regard to their vascularization, is important in understanding the healing potential of different TFCC lesions. Understanding the complex
8.5 Arthroscopic Examination of TFCC Tears or Injuries The following three arthroscopic tests are used to check the type of TFCC lesion: 1. The “trampoline sign”: This test is used to assess for the overall loss of elasticity of the TFCC. Normally, the TFCC is as taut as a trampoline. A loss of the “trampoline” effect is seen in complete avulsion injuries of the proximal and distal portions of the TFCC. It may be negative in isolated proximal lesions and equivocal in partial distal lesions (▶ Fig. 8.8). 2. The “hook sign” (of Atzei2): While performing the “hook test,” a ripple effect can be seen by pushing the ulnar attachment of the TFCC toward the radius. It is positive in complete tears of the TFCC and negative in other cases. The hook probe is introduced at the foveal region. It then passes under the TFCC. The TFCC is then pulled up, applying traction with the hook probe from under the TFCC. In case of avulsion of its foveal insertion and of the superficial portion, the probe creates a ripple effect on the TFCC. The test is then considered positive (▶ Fig. 8.9 a–c, ▶ Video 8.1). 3. The “ghost sign” characterizes a “reverse trampoline sign” by inserting the hook into the DRUJ and seeking a “ghost” effect observed on the radiocarpal aspect of the TFCC. This indicates an avulsion of the deep fibers of the TFCC. It is negative in distal lesions and positive
Fig. 8.8 Drawing of the “trampoline sign” looking for an overall loss of elasticity of the TFCC. The probe is placed in the 6R portal and will test the resilience of the TFCC.
Fig. 8.9 (a) Drawing of the “hook sign” looking for a wave effect in repelling the ulnar attachment of the triangular complex to the radius. The probe introduced into 6R is positioned at the styloid recess and “pushes” the TFCC to the radial side. In case of a break, a raised ripple effect is visible. (b) Arthroscopic view showing the sensor positioned at the styloid recess. (c) Arthroscopic view showing the creation of the “ripple” when the probe pushes the TFCC toward the radius.
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Anatomy of the TFCC: Current Concepts
Video 8.1 Video showing the “hook sign.”
anatomy of the TFCC (its 3D structure and insertions) is helpful in identifying lesions, which were unknown or little understood before the advent of arthroscopy, especially avulsion of the TFCC at its foveal insertion on the head of the ulna.
References [1] Nakamura T, Yabe Y, Horiuchi Y. Functional anatomy of the triangular fibrocartilage complex. J Hand Surg [Br]. 1996; 21(5):581–586 [2] Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand Clin. 2011; 27(3):263–272 [3] Bednar MS, Arnoczky SP, Weiland AJ. The microvasculature of the triangular fibrocartilage complex: its clinical significance. J Hand Surg Am. 1991a; 16(6):1101–1105 [4] Nakamura T, Takayama S, Horiuchi Y, Yabe Y. Origins and insertions of the triangular fibrocartilage complex: a histological study. J Hand Surg [Br]. 2001; 26(5):446–454 [5] Joshi SS, Joshi SD, Jadhav SD, Athavale SD, Waghmode PS. Triangular fibrocartilage complex (TFCC) of wrist: some anatomical-clinical correlations. J Anat Soc India. 2007; 56:8–13
Fig. 8.10 Schematic of the “ghost sign,” looking for a “ghost” effect of the foveal side of the TFCC by inserting the hook into the RUD and pushing the probe up and down the radius. In case of an isolated fracture of the foveal insertion of the TFCC, a rising “ghost wave” can be seen.
[6] Nakamura Y, Makira A. The proximal ligamentous component triangular fibrocartilage complex the oh. J Hand Surg Am. 2000; 25B:479–486 [7] Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist–anatomy and function. J Hand Surg Am. 1981; 6(2):153–162 [8] Hagert CG. Distal radius fracture and the distal radioulnar joint–anatomical considerations. Handchir Mikrochir Plast Chir. 1994; 26(1): 22–26
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9 Arthroscopic Repair of Peripheral Tears of the TFCC 9.1 Introduction
9.2 Operative Technique
The triangular fibrocartilage (TFCC) is a fibro-cartilaginous structure located between the medial surface of the distal radius and ulnar head. The most common injury is a tear of the dorsal peripheral and medial part of the TFCC (Palmer Type IB1 or European Wrist Arthroscopy Society (EWAS) Atzei2) (▶ Table 9.1). This type of lesion is commonly seen in young active individuals and does not cause instability of the distal radioulnar joint (DRUJ). However, it often causes very annoying pain with any strenuous activities, especially sports (tennis, golf, fencing, basketball, etc.). Open repair often entails large incisions and results in stiffness, especially in pronosupination. Arthroscopy allows for better visualization and understanding of these lesions. It is easy to perform repairs of these peripheral lesions arthroscopically, resulting in less morbidity.
9.2.1 Patient Preparation and Set-Up The procedure is performed under local/regional anesthesia. The arm is fixed firmly to the arm table, and longitudinal traction is applied to the wrist for distraction of the wrist joint. The forearm is in supination with the ulnar styloid slightly dorsal. The TFCC lesion is therefore in a more dorsal position, i.e., opposite to the 6R portal rather than the 6U portal.
9.2.2 Exploration The arthroscope is introduced through the 3–4 radiocarpal portal. After routine examination of the radiocarpal joint, the arthroscope is directed toward the medial
Table 9.1 Atzei’s classification of TFCC tears
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Stage
Distal component
Proximal component
DRUJ stability
Treatment
1: Distal tear
Tear
Intact
No
Peripheral TFCC suture
2: Foveal desinsertion
Intact
Tear
Yes + /-
Foveal reinsertion
3: Complete tear
Tear
Tear
Yes
Foveal reinsertion ± peripheral TFCC suture
4: Massive rupture irreparable
Tear
Tear
Yes
Tendinous graft
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Arthroscopic Repair of Peripheral Tears of the TFCC aspect of the wrist toward the TFCC. Transillumination of the skin is helpful in easily locating the position of the 6R portal. A hypodermic needle is inserted to ascertain the correct position of the 6R portal, which is located about 3 or 4 mm distal to the peripheral insertion of the TFCC. A shaver is introduced through the 6R portal to excise the excess synovial tissue that is typically seen in these peripheral lesions. Using a hook probe, the following three tests are carried out: 1. The loss of the “trampoline” effect indicates a peripheral tear of the TFCC. The hook probe is pushed directly on the ligament, and a depression of the TFCC is noted without a spontaneous return to its original position. However, this classic test gives a false negative more frequently than is reported in the literature. In fact, painful small peripheral tears of the TFCC seldom have a loss of the “trampoline” effect. In addition, nontraumatic degenerative central perforations of the TFCC, frequently seen after the 4th decade, also demonstrate a loss of the “trampoline” effect. 2. The hook probe can be slid underneath the peripheral tear of the TFCC on the dorsal part (▶ Video 9.1). This sometimes has an altered appearance. Indeed, the scar tissue formed by the body’s natural healing process is not strong enough. When the peripheral insertion of the TFCC is intact, the probe follows the edge of the
TFCC to the collateral ligaments without causing any depression. In such situations, it is impossible to go underneath the TFCC because there are very strong attachments of the TFCC, at this level. In chronic peripheral lesions, the scar tissue often masks the injury. It is, however, very easy to pass under the TFCC by placing the probe between the TFCC and the collateral ligaments. This scarring is often why one can easily miss this type of lesion (▶ Fig. 9.1, ▶ Fig. 9.2). 3. The hook probe is then brought to the styloid recess and the “pull test” is performed by passing the probe from outside in underneath the TFCC. In isolated peripheral tears of the TFCC, the foveal insertion is intact and hence the “pull test” is negative.
Video 9.1 Video showing a distal peripheral lesion. The hook probe can be easily passed underneath the TFCC.
Fig. 9.1 Illustration showing an altered (pseudo-normal) appearance of the TFCC, the lesion being covered by a fibrous tissue. Red arrow simulates the movement of the probe on the TFCC.
Fig. 9.2 Illustration showing the probe in the tear zone.
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9.2.3 Creation of a DRUJ Portal To repair the TFCC, the suture must pass between the capsule and the TFCC. For this reason, a DRUJ portal is made. It is located approximately 1 cm proximal to the 6R portal lateral to the extensor carpi ulnaris. An obliquely upward directed needle is used to confirm the location of the portal under direct arthroscopic control. The needle must exit the TFCC at an appropriate point (▶ Fig. 9.3, ▶ Video 9.2). A small transverse incision is made. A hemostat is used to gently spread the tissue and avoid damage to the extensor tendons. The jaws of the hemostat forceps are gently opened and the tissue is spread until the dorsal capsule is reached.
9.2.4 Performing the Suture
on the size of the wrist. A suture loop is placed in a 21 gauge hypodermic needle and a straight suture is placed in another 21 gauge needle. First, the loop is passed via the DRUJ portal through the capsule and then forward and through the TFCC on the radial side of the tear (▶ Fig. 9.4). The needle is withdrawn leaving the suture loop in place within the joint (▶ Video 9.3). The second single suture is then passed through the capsule and at the medial portion of the TFCC, if possible through the foveal insertion, in order to strengthen the suture (▶ Fig. 9.5 a, b, ▶ Video 9.4). Using a fine hemostat forceps, both sutures are brought out through the 6R portal. (▶ Fig. 9.6, ▶ Video 9.5). On the outside, the single suture is passed through the loop (▶ Fig. 9.7, ▶ Video 9.6), and then the loop is pulled out of the DRUJ portal. In this manner, the single suture is pulled back across the TFCC and the articular capsule, so
A resorbable monofilament suture is used, either 4–0 or 3–0 polydioxanone sutures (PDS) (Ethicon), depending
Video 9.2 Video showing the technique to choose the right position of DRUJ portal.
Fig. 9.3 Operative view showing the location for the correct position of the DRUJ portal using a needle.
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Fig. 9.4 Drawing showing the passage of the loop in the most radial portion of the TFCC.
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Video 9.3 Video showing the passage of the loop in the intraarticular radial side of the lesion.
Video 9.4 Video showing the placement and the output of the second needle with the second suture, close to the first, after passing through the dorsal capsule and TFCC.
Fig. 9.5 (a) Drawing showing the positioning of the second wire. (b) View showing the operative position of the needle for the passage of the second suture. In this case, a clamp was used to spread the space between the compartments 5 and 6, to avoid the risk of catching an extensor tendon with the needle.
as to make a single intra-articular horizontal mattress suture, closing the peripheral TFCC tears (▶ Fig. 9.8 a, b, ▶ Video 9.7). Both strands of the absorbable suture are then brought out together through the DRUJ portal.
9.2.5 Securing the Final Suture After removing the traction, the wrist is placed in extension and ulnar deviation, the suture is placed under tension, and a surgeon’s knot is made between the two strands. The knot is then buried subcutaneously (▶ Fig. 9.9, ▶ Video 9.8). The portals are left open to heal by scar formation.
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Video 9.5 Video showing the recovery of two sutures at the same time.
Video 9.6 Video showing the passage of single suture in the loop outside of the wrist.
9.2.6 Postoperative Care Fig. 9.6 Operative view showing retrieval of the sutures from the 6R portal.
Fig. 9.7 Drawing showing the passage of the second suture through the loop of the first.
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The wrist is immobilized in extension and ulnar deviation in a below-the-elbow plaster cast for a period of 6 weeks. Rehabilitation is started at the sixth week. The suture usually resorbs within 3 to 6 months. It can sometimes cause temporary irritation and the patient should be informed about this.
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Fig. 9.8 (a) Drawing showing the passage of single suture thread at the radial part of the peripheral avulsion using the loop. (b) Surgical view showing the principle gestures to accomplish at this level of procedure. The assistant must securely hold the proximal portion of the second suture and unleash the distal portion so that it is driven by the loop to the first suture to bridge the TFCC injury.
Video 9.7 Video showing the principle of passage of final suture.
Video 9.8 Surgical view showing the technique of suturing.
9.3 Conclusion This simple technique of repairing peripheral tears of the TFCC avoids using an intra-articular knot, for which it is often difficult to adjust the tension leading to potential irritation. The outcomes of this technique are very good and most patients recover a functional and painless wrist without any loss of movement.
References [1] Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am. 1989; 14(4):594–606 [2] Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg Eur Vol. 2009; 34(5):582–591
Fig. 9.9 Drawing showing the completion of the final node.
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10 “Double Loop” Suture Repair in Large Dorsal Tears of the TFCC 10.1 Introduction Anatomical and histological studies have allowed a better understanding of the three-dimensional structure of the triangular fibrocartilage complex (TFCC). There are three components: a proximal portion that inserts into the fovea, a distal “hammock-like” structure, and extrinsic ligamentous insertions forming the ulnar collateral ligament. The most common injuries of the TFCC are peripheral tears involving the distal component. However, we sometimes see large TFCC tears, extending from the styloid process and comprising of a complete detachment along the dorsal aspect of the TFCC up to its insertion on the radius. These cases of massive peripheral lesions are often associated with distal radioulnar joint (DRUJ) instability, even though the foveal insertion is intact. In such cases, traditional techniques of TFCC repair are ineffective and insufficient. Herein, we propose a technique called “double loop” suture technique for these extensive dorsal TFCC tears.
to determine where the distal radioulnar portal should be created. A distal radioulnar portal is then made. This portal is usually located 1 cm proximal to the 6R portal. A loop of a 3–0 resorbable monofilament suture is passed through the needle and then through the capsule and into the middle of the TFCC at its dorsal insertion. The suture loop is retrieved using a fine mosquito forceps inserted through the 6R portal (▶ Fig. 10.2, ▶ Video 10.2). A second hypodermic needle is inserted radial to the first needle through the same distal radioulnar portal and in the same direction, to exit near the radial insertion of the TFCC. A simple absorbable suture (3–0 or 4–0 absorbable monofilament, depending of the wrist size) is passed through the needle and retrieved through the 6R portal (▶ Fig. 10.3, ▶ Video 10.3). A third ulnar-directed hypodermic needle is then placed through the distal radioulnar portal to exit close to the styloid recess. The robust repair is achieved by
10.2 Operative Technique 10.2.1 Patient Preparation The procedure is performed on an ambulatory basis under local anesthesia. The patient is supine with the arm resting on a table with a pneumatic tourniquet. Vertical traction of 5 to 7 kg is applied to the hand.
10.2.2 Exploration The arthroscope is introduced into the wrist joint through the 3–4 radiocarpal portal. A probe is inserted through the 6R portal. The massive tear of the dorsal aspect of the TFCC is identified (▶ Fig. 10.1, ▶ Video 10.1). The “trampoline test” and “hook test” are performed. The “trampoline test” evaluates the tension of the TFCC. It is considered positive when the TFCC becomes loose, indicating a peripheral lesion. The trampoline sign is positive in massive dorsal tears of the TFCC. The “hook test” is performed by exerting a pull on the TFCC by passing the probe into the styloid recess. It is considered positive when the TFCC can be raised and indicates a foveal avulsion. It is negative in isolated peripheral lesions. A full radius shaver is then used to perform a synovectomy and debride the torn part of the TFCC.
Fig. 10.1 Drawing of a large dorsal TFCC tear extending from the styloid recess and up to the dorsal level of the radial insertion of the TFCC.
10.2.3 TFCC Repair A hypodermic needle is introduced obliquely through the capsule and directed toward the center of the TFCC tear
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Video 10.1 Video showing the wide tear of the TFCC.
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“Double Loop” Suture Repair in Large Dorsal Tears of the TFCC passing the suture through the foveal insertion of the TFCC. A simple absorbable suture is then passed through the needle and retrieved through the 6R portal (▶ Fig. 10.4, ▶ Video 10.4). With a little practice, it is possible to recover the three sutures in a single pass so as to avoid soft tissue entrapment between the sutures.
Video 10.2 Video showing retrieval of the loop.
Fig. 10.2 Drawing showing the passage of the loop in the middle of the TFCC and retrieved by a clamp introduced through the 6R portal.
Video 10.3 Video showing the single suture in the ulnar position. The first loop in seen in the center of the lesion.
Fig. 10.3 Illustration showing the passage of a single suture through the dorsal ulnar portion of the TFCC, and retrieval through the 6R portal.
Fig. 10.4 Drawing showing the passage of a single suture through the radial part of the TFCC, and retrieval through the 6R portal.
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“Double Loop” Suture Repair in Large Dorsal Tears of the TFCC At this stage, we have two single sutures (one radial and the other ulnar) and the suture loop in the center passing through the DRUJ portal into the capsule and the TFCC, to emerge through the 6R portal (▶ Fig. 10.5). The two single sutures are then passed through the central loop (▶ Fig. 10.6 a, b, ▶ Video 10.5). The loop is then pulled at the DRUJ portal so that the other two sutures pass through the TFCC (▶ Video 10.6), and out through the DRUJ portal to form two loops (“double loop”), one loop securing the lateral portion of the TFCC and the other loop securing the medial portion of the TFCC to the dorsal capsule (▶ Fig. 10.7, ▶ Video 10.7). The axial/vertical traction is then released and the suture knot is tied subcutaneously, while placing the wrist in extension and in ulnar deviation (▶ Fig. 10.8, ▶ Video 10.7).
10.2.4 Postoperative Care A volar/palmar splint is applied for 6 weeks, with the wrist in slight extension and ulnar deviation. Rehabilitation is started at 6 weeks.
Video 10.4 Video showing the radial suture retrieved through the 6R portal; the other suture has already been retrieved, and the loop at the center of the lesion. Fig. 10.5 Intra-operative view showing the principle of the suturing. The loop is in the center; the two single sutures, one on the radial side and one on the ulnar side of the TFCC tear, enter through DRUJ portal and exit through the 6R portal.
Fig. 10.6 (a) Drawing showing the passage of two single sutures through the loop. (b) Intra-operative view showing the two single sutures passed through the loop.
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Video 10.5 Video showing the passage of two single sutures through the loop.
Video 10.6 Video showing the loop pulling the sutures on the radial and ulnar sides of the tear.
Video 10.7 Video showing the completion of the suture on the radial side. The suture knot is buried subcutaneously at the DRUJ. It is easier to tie the knot after releasing the traction and by placing the wrist in extension and ulnar deviation. Arthroscopic view showing the final suture.
Fig. 10.7 Drawing showing the two sutures exiting at the DRUJ portal.
10.3 Conclusion TFCC lesions are not always as simple as described in conventional descriptions. Large tears of the entire dorsal aspect of the TFCC are not so rare. These injuries are often associated with tears of the dorsal capsule-ligamentous septum—a structure connecting the dorsal capsule and the dorsal intercarpal ligament to the dorsal portion of the scapholunate ligament. These types of TFCC tears can cause mild distal radioulnar instability even though the foveal insertion is still intact. The “double loop” suture technique allows a complete repair which is simple and easy to perform.
Fig. 10.8 Drawing showing the final position of sutures to complete the repair of a wide dorsal avulsion.
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11 Arthroscopy-Assisted Foveal Reinsertion of the TFCC with an Anchor 11.1 Introduction The triangular fibrocartilage complex (TFCC) is the primary stabilizer of the distal radioulnar joint (DRUJ). Recent histological and functional studies1 have elaborated the three-dimensional structure of the TFCC and identified three components: (1) the proximal triangular ligament, (2) the distal ligament “hammock,” and (3) the ulnar collateral ligament (UCL), attached to the deep part of the sheath of the extensor carpi ulnaris tendon. This distal hammock-like structure and the UCL form the “distal TFCC,” while the proximal ligament is considered the “proximal TFCC” (▶ Fig. 11.1). Within this structure lie
both “arms” joining the anterior and posterior ulnar fovea and the edges of the distal radius—the “real” stabilizers of the DRUJ. These two main structures may be injured independently of each other and result in a specific clinical picture and the DRUJ instability. Several arthroscopyassisted trans-osseous repair techniques have been described—either at the ulnar metaphyseal region as described by Nakamura et al.,2 or at the DRUJ itself as described by Atzei.3 The only all-arthroscopic technique that has been previously described, by William Geissler,4 using three portals, requires expensive disposable instrumentation. We describe two simple, reliable, and reproducible techniques.
11.2 Operative Technique 11.2.1 Patient Preparation The procedure is performed on an ambulatory basis under local anesthesia. The patient is supine with the arm resting on a table with a pneumatic tourniquet. Vertical traction of 5 to 7 kg is applied to the hand.
11.2.2 Exploration
Fig. 11.1 Schematic illustration of the two portions of the triangular ligament. Distal peripheral portion (D-TFCC) and the proximal portion that inserts into the fovea of the ulnar head (P-TFCC). UCL, ulnar collateral ligament.
The arthroscope is introduced through the 3–4 radiocarpal portal allowing visualization of the radiocarpal joint. In isolated foveal avulsion of the TFCC (stage 2 Atzei EWAS), the appearance of the TFCC is usually normal. The “hook test,” which is performed by placing the probe at the styloid recess and applying a radial and distal pull, will raise the TFCC, indicating an avulsion of the TFCC from the fovea (▶ Fig. 11.2a, b, ▶ Video 11.1). In cases where the foveal avulsion is associated with a peripheral tear (stage 3 Atzei - EWAS), there will also be a loss of the “trampoline” effect, considered a positive “trampoline test.”
Fig. 11.2 (a) Drawing showing a foveal avulsion associated with a peripheral tear. The probe at the styloid recess raises the TFCC (hook test). (b) Arthroscopic view showing a positive hook test, reflecting the foveal TFCC avulsion.
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11.2.3 Extending the Medial Incision With the arthroscope inserted through the 3–4 radiocarpal portal, a needle is first inserted through the 6U portal medial to the ulnar styloid and distal to the TFCC. The arthroscope is then introduced through the DRUJ portal, located approximately 1 cm proximal to the 6R portal underneath the TFCC. The view is often distorted at the zone of injury. A hypodermic needle is inserted through the direct foveal portal, to identify the avulsion of the TFCC at the fovea. This portal is located anterior to the ulnar styloid and on top of/distal to the ulnar head, with the forearm in supination (▶ Video 11.2). An incision of about 1 cm is then made joining the two needles, while identifying and protecting the dorsal cutaneous branch of the ulnar nerve. First, a blunt mosquito forceps is used to identify the direct foveal portal (▶ Video 11.3).
11.2.4 Exploration and Debridement of the Distal Radioulnar Joint A full radius shaver is introduced and under arthroscopic control, the area of the foveal insertion of the TFCC is cleaned and debrided (▶ Video 11.4). This area is often not visualized clearly at first because of the scar tissue and ligament remnants. Progressive cleaning allows better visualization (▶ Fig. 11.3).
11.2.5 Insertion of the Anchor Keeping the arthroscope in the same position while still viewing the foveal insertion of the TFCC, a drill is used to create a hole in the head of the ulna at the fovea (▶ Fig. 11.4a, b). Sometimes a blunt forceps is introduced through the foveal portal and its jaws are opened to place the drill between the forceps allowing better
Video 11.1 Video showing the peripheral avulsion of the TFCC.
Video 11.2 Video showing the first step of the realization of Direct Foveal portal (DF).
Video 11.3 Video showing the second step of the realization of Direct Foveal portal (DF).
Video 11.4 Video showing the DRUJ exploration and cleaning.
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Arthroscopy-Assisted Foveal Reinsertion of the TFCC with an Anchor visualization (▶ Video 11.5). An anchor is then inserted, through the direct path foveal portal (▶ Video 11.6). We prefer to use a bioabsorbable anchor. With the anchor in place at the foveal insertion of the TFCC on the ulnar head, the sutures are left outside through the medial portal.
11.2.6 TFCC Suture
Fig. 11.3 View showing the probe at the cleaned fovea.
The arthroscope is then reintroduced into the radiocarpal joint through the 3–4 radiocarpal portal, so as to visualize the radiocarpal aspect of the TFCC. The distal end of one of the sutures of the anchor is passed through a hypodermic needle. The needle is then passed through the direct foveal portal through the TFCC directed dorsally or volarly (▶ Video 11.7). Using a fine mosquito forceps, the suture passed through the TFCC is retrieved through the 6U portal (▶ Fig. 11.5, ▶ Video 11.8). This suture is pulled outside and then passed through a loop created at its exit from the anchor and its point of entry into the TFCC (▶ Fig. 11.6, ▶ Video 11.9). The second suture is passed and retrieved in a similar manner at the dorsal or palmar portion of the TFCC, depending on the position Fig. 11.4 (a) Intraoperative view showing the drill passing through the DF portal. (b) Arthroscopic view showing the tip of the drill at the fovea.
Video 11.5 Video showing the use of the drill to create a hole into the ulna at the foveal insertion of the TFCC.
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Video 11.6 Video showing the installation of the anchor through the DF portal into the hole at the foveal insertion of TFCC.
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Video 11.7 Video showing the passage of one strand of suture in an intramuscular needle, and through the portion of the dorsal ulnar insertion of TFCC.
Video 11.8 Video showing the recovery of the wire placed in the dorsal ulnar portion of the TFCC using forceps entry through the first 6U portal.
Fig. 11.5 Drawing showing the recovery of the wire placed in the dorsal ulnar portion of the TFCC to the forceps inlet through first 6U portal.
Fig. 11.6 Drawing showing the yarn passed through the dorsal ulnar portion of the TFCC, recovered by a clamp, exteriorized through the first 6U portal, and passed through the loop created between the fastener on the anchor and the passage through the TFCC.
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Video 11.9 Video showing the wire passed through the loop and how the wire placed in the dorsal portion of the ulnar TFCC is tense after completing a passage through its own loop.
Video 11.10 Video the second suture strand passing through the portion of the ulnar volar TFCC.
Fig. 11.7 Drawing showing the second strand of suture passed through the ulnar volar portion of the TFCC, recovered by a clamp, exteriorized through the first 6U portal, and passed through the loop created between the attachment of the anchor and the passage in the TFCC.
Fig. 11.8 Drawing showing the suture passing through the ulnar volar portion of the TFCC, recovered by a clamp, exteriorized through first 6U portal, and passed through the loop.
of the first suture (▶ Fig. 11.7, ▶ Video 11.10). The second strand is retrieved by a blunt forceps (▶ Video 11.11) and then passed in its own loop, as was done for the first strand (▶ Fig. 11.8, ▶ Video 11.12). This allows us to suture the dorsal and palmar parts of the TFCC back to its insertion into the fovea with
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one single suture. The final knot is made after releasing the traction and with the wrist in slight extension and ulnar deviation (▶ Fig. 11.9a, b, ▶ Video 11.13). One or two sutures are used to close the ulnar incision and are removed at the first dressing change 1 week later.
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Video 11.11 Video showing the principle of recovery of the wire placed in the palmar portion of the ulnar TFCC using forceps inserted through first 6U portal.
Video 11.12 Video showing the suture passing through the ulnar volar portion of the TFCC, recovered by a clamp, exteriorized through first 6U portal, and passed through the loop.
Fig. 11.9 (a) Drawing showing the foveal reinsertion of the TFCC suture with the palmar and dorsal portion of the ulnar insertion of the TFCC, by suturing the two strands with a single suture through the implementation of two loops. (b) Arthroscopic view showing the appearance of the foveal TFCC after rehabilitation.
11.3 Conclusion Isolated foveal avulsions of the TFCC, or those associated with a peripheral lesion, cause distal radioulnar instability. Arthroscopic repair of such tears is effective. The dorsal branch of the ulnar nerve must be protected. A small 1 to 2 cm incision on the ulnar aspect of the wrist allows us to identify and protect the nerve.
References Video 11.13 Video showing the embodiment of the surgical knot, and the end of the suture.
11.2.7 Postoperative Care A volar, below-the-elbow splint is applied with the wrist in extension and ulnar deviation. The splint is continued for 6 weeks at the end of which rehabilitation is started.
[1] Nakamura T, Yabe Y, Horiuchi Y. Functional anatomy of the triangular fibrocartilage complex. J Hand Surg [Br]. 1996; 21(5):581–586 [2] Nakamura T, Ikegami H, Sato K, Nakamichi N, Okuyama N, Takayama S. Arthroscopic repair of the ulnar tear of the TFCC. Riv Chir Mano. 2006; 43(3):291–293 [3] Atzei A, Rizzo A, Luchetti R, Fairplay T. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability. Tech Hand Up Extrem Surg. 2008; 12(4): 226–235 [4] Geissler WB Arthroscopic knotless repair TFCC ulnar side. Hand Clin. 2011; 27(3):273–279
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12 Arthroscopic-Assisted Foveal Reinsertion of the TFCC Toshyiasu Nakamura
12.1 Introduction When the radioulnar ligament (RUL), proximal component of the TFCC, is ruptured or detached at the fovea where the main inserting point of the RUL to the ulna is located, it results in severe distal radioulnar joint (DRUJ) instability readily. The RUL should be reattached to the fovea in such patients. This chapter describes arthroscopic-assisted refixation method of the TFCC including the RUL to the fovea using wrist targeting guide.
12.2 Operative Technique 12.2.1 Patient Preparation The procedure is performed on an inpatient basis under general anesthesia. The patient is supine positioned with a pneumatic tourniquet on the upper arm. The forearm is vertical in position with traction tower and 2–3 kg weight is applied on the upper arm for counter traction.
12.2.2 Exploration
After the foveal detachment of the TFCC is confirmed, the original target device (▶ Fig. 12.3) Wrist Drill Guide (Arthrex, Naples, FL) was set through 4–5 or 6R portal and an approximately 1 cm longitudinal incision was made on the ulnar side of the ulnar cortex (▶ Fig. 12.4), 10–15 mm proximal from the tip of the ulnar styloid, with the periosteum elevated. Small spike on the target device is set on the ulnar half of the TFCC. Two separate small holes are made from the ulnar cortex of the ulna with 1.2 mm K-wire to the ulnar half portion of the TFCC (▶ Fig. 12.5). DRUJ arthroscopy may be helpful to confirm precise hole-making at the fovea. The 21 gauge needle, in which the loop nylon 4–0 stitch was set, is passed through one tunnel from the outside (▶ Fig. 12.6, ▶ Video 12.1), and then is repeated through the other bone tunnel (▶ Fig. 12.7). From 4–5 or 6R portal, both two loop stitches are once pulled out by mosquito forceps (▶ Fig. 12.8), then two non-absorbable 3–0 polyester stitches (Ticron, Covidien, Mansfield, MA) are introduced from the RC joint to the ulnar cortex of the ulna by loop stitches (▶ Fig. 12.9) to make outside-in pullout suture of the TFCC to the fovea (▶ Fig. 12.10). The TFCC is tightly anchored to the ulnar fovea with this technique (▶ Fig. 12.11).
Radiocarpal arthroscopy can only demonstrate loss of trampoline effect as well as loss of peripheral tension in the disc in the patients with foveal disruption, since the TFCC is not continuously connected to the ulna. DRUJ arthroscopy can directly visualize the fovea lesion (▶ Fig. 12.1). In case of foveal detachment of the TFCC, joint space of the DRUJ can be widely expanded because the RUL is loose. When the TFCC is attached completely to the ulna without any DRUJ instability, the fovea area is difficult to be visualized with DRUJ arthroscopy. Therefore, the DRUJ arthroscopy can be a diagnostic tool for foveal detachment of the TFCC. When the ligament tissue can be seen in the RUL area, it is a candidate for arthroscopic-assisted foveal refixation, whereas severe scar tissue occupies the fovea area, open exploration will be recommended.
12.2.3 Arthroscopic-Assisted Foveal Refixation of the TFCC Basic concept of this technique is based on the anatomical characteristics of the TFCC, where the line between the ulnar half area of the TFCC and 10–15 mm proximal point on the ulnar surface of the ulna from the ulnar styloid must pass through the center of the fovea (▶ Fig. 12.2).
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Fig. 12.1 DRUJ arthroscopy offers direct vision of the ulnar head, radial sigmoid notch, proximal surface of the TFCC, fovea, and RUL.
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Fig. 12.2 Basic concept of the arthroscopic transosseous repair of the TFCC. The line between the point on the ulnar cortex of the ulnar shaft 10–15 mm proximal from the tip of the ulnar styloid and ulnar half of the TFCC passes through the fovea theoretically.
Fig. 12.3 Wrist drill guide.
12.2.4 Postoperative Care Two weeks of long arm casting, then 3 weeks of short arm casting are applied with the wrist and forearm in neutral position. After removal of the cast, rehabilitation is started. The patient may be back to normal sports activity level 6 months after the surgery.
Fig. 12.4 Setting of the targeting device.
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Fig. 12.5 Inserting K-wire to create tunnel through the ulna and the TFCC. (a) Actual picture. (b) Drawing.
Fig. 12.6 21G needle with loop stitch (a) is passing through the TFCC (RC arthroscopy) (b). (c) Drawing of 21G needle passing through the ulna to the TFCC.
Video 12.1 Video indicates transosseous refixation of the TFCC. The K-wire is passing from the ulnar cortex to the ulnar half of the triangular fibrocartilage two times to create parallel bone tunnels. The 21G needle with the loop lasso inside is passing into the bone tunnel. The other needle is set to the different site on the disc. Two loops are grabbed simultaneously with the mosquito forceps inserted through the 6R portal, then once retracted outside the wrist. The loops introduce main stitches into the TFCC to create outside-in refixation of the TFCC anchored to the ulnar fovea.
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Fig. 12.7 (a) Two 21G needles are set through the TFCC. (b) Outside picture of two 21G needle setting.
Fig. 12.8 Drawing indicates that mosquito forceps, which is introduced into the radiocarpal joint through 6R portal, picks up two loop stitches simultaneously.
Fig. 12.9 Two loops were introduced outside through 6R portal, because the working space for repair is wide compared with inside the joint.
Fig. 12.10 (a) Two 3–0 polyester stitches are introduced from the RC joint to the ulnar cortex of the ulna by loop stitches. (b) Actual picture of two non-absorbable 3–0 polyester stitches being introduced to the ulnar cortex of the ulna by loop stitches.
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Fig. 12.11 (a) Diagram of arthroscopic transosseous repair of the TFCC. (b) Outside view of after refixation of the TFCC. (c) Arthroscopic view after transosseous repair of the TFCC. Note that the detached TFCC is tightly anchored.
12.3 Conclusion The presenting technique is a very easy and reliable refixation technique of the avulsed TFCC (RUL) to the fovea.
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The targeting wrist guide is useful and time saving to create two parallel bone tunnels to reattach the RUL to the precise anchoring point.
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13 Arthroscopic Reconstruction of the TFCC Using a Free Tendon Graft 13.1 Introduction Instability of the distal radioulnar joint (DRUJ) results from injury or laxity of the ligaments responsible for stabilizing the joint. Of these, the triangular fibrocartilage complex (TFCC) plays a crucial role in maintaining DRUJ stability. Sometimes, it may be impossible to repair the TFCC due to degenerative changes in the TFCC; or the repair might be inadequate in maintaining DRUJ stability if the extrinsic stabilizers are also torn (e.g., radioulnar ligaments and interosseous membrane). In such cases, DRUJ reconstruction is possible provided that there are no arthritic changes in the DRUJ. This technique, using a free tendon graft, was first described by Mansat in 1983,1 and then modified and popularized by Adams and Berger in 2002.2 The aim of this procedure is to reconstruct the ligament and restore function, thus providing multidirectional stability. This procedure uses a tendon graft, preferably Palmaris Longus (PL), which is woven through transosseous tunnels in the distal radius, converging at the fovea through a distal ulnar transosseous tunnel. This procedure can be performed as an open surgery or as minimally invasive arthroscopy-assisted surgery. The arthroscopic technique uses several incisions. The length of these incisions depends on the experience of the surgeon in protecting the underlying structures; a more experienced surgeon will be able to successfully use a shorter incision.
13.2 Operative Technique 13.2.1 Patient Preparation The procedure comprises two steps: (1) harvesting the tendon graft and (2) reconstruction of the TFCC. The first step will be carried out with the hand flat on the table arm. The second stage of the procedure is performed with 5 to 7 kg axial traction applied to the hand using Chinese finger traps. A pneumatic tourniquet is applied, and the arm is fixed to the table. The entire procedure is carried out under regional anesthesia (▶ Video 13.1).
flexion crease of the wrist joint at the base of the carpal tunnel. A tendon stripper is utilized to harvest the graft (▶ Fig. 13.1). A grasping suture is applied to the two ends of the tendon graft using 4—0 Ethilon 4.0 or similar nonbraided suture material. The suture is passed several times (Krackow suture), about 1.5 cm on both ends of the tendon graft in order to create a strong grasping suture construct, and the ends of the suture are left long for retrieval while passing the tendon graft through the transosseous tunnels (▶ Video 13.2).
13.2.3 Making the Radial Tunnel and Passing the Tendon through In this step, axial traction is applied to the wrist. The incision used for harvesting the tendon graft is extended proximally on the volar aspect to expose the ulnar corner of the distal radius, and retractors are positioned to improve the exposure. A second incision is made at the same level on the dorsoulnar aspect of the wrist to expose the ulnar and distal edge of the dorsal surface of the radius. A guide wire is inserted from dorsal to palmar using a protective sleeve. Care is taken to protect the soft tissues and particularly the median nerve. The guide wire is inserted several millimeters proximal to the lunate fossa and radial to the articular surface of the sigmoid notch. The wire is inserted parallel to the articular surfaces of the distal radius and the sigmoid notch. Fluoroscopic views confirm proper guide wire position, and the tunnel is made with a cannulated drill, exiting through the palmar incision. A 2.5 mm cannulated drill bit usually suffices (▶ Video 13.3). Then, the tendon graft is introduced from the dorsal side and retrieved through the volar side (▶ Fig. 13.2, ▶ Video 13.4).
13.2.2 Harvesting the Tendon Graft The tendon graft must be strong and long enough to stabilize the DRUJ, and thin enough to pass through the bone tunnels. Usually, a PL tendon graft suffices. However, in case the PL is absent, a hemi flexor carpi radialis or a plantaris tendon graft may be harvested. The PL tendon graft is harvested through a small incision at the distal
Video 13.1 Video showing the major DRUJ instability.
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Video 13.2 Video showing the technique to harvest the PL tendon with a tendon stripper.
Video 13.3 Video showing how to perform the radial tunnel.
Fig. 13.1 Drawing showing the harvest of a PL tendon graft: the severed distal end of the tendon is secured by a suture passed through the eyelet of the tendon stripper. When tension maintained on the tendon, the tendon stripper is pushed down subcutaneously to the musculotendinous junction to harvest a full-length graft without requiring another incision.
13.2.4 Preparation of the Graft Area in the TFCC In this step, the TFCC is visualized arthroscopically. Debridement is performed using a “shaver” and basket punch forceps, to visualize the fovea and the ulnocarpal articulation clearly. The scope is introduced through the 3–4 radiocarpal portal, and the 6R or the 4–5 portal is
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Fig. 13.2 Drawing of the tendon passing through a tunnel in the distal radius.
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Video 13.4 Video showing the passage of tendon graft into the radial tunnel.
Video 13.5 Video showing the cleaning of foveal insertion of the TFCC.
Video 13.6 Video showing how to perform the ulnar head tunnel.
the ulna. Arthroscopic control helps verify the correct entry and exit of the guide wire at the fovea.
Fig. 13.3 Drawing showing the positioning of the guidewire being positioned in the center of the fovea.
used for the shaver (▶ Video 13.5). Once the fovea is cleared of scar tissue and is well visualized, the forearm is supinated and a small incision is made slightly proximal to the 6U portal. A 1 to 1.5 cm incision is required to identify and protect the dorsal sensory branch of the ulnar nerve. A periosteum elevator is used to clear the soft tissue on the medial aspect of the ulna through the incision.
13.2.5 Creating the Ulnar Tunnel A guide wire is inserted in the ulna obliquely and distally toward the fovea (▶ Fig. 13.3). This is most often done in a proximal to distal direction. Alternatively, the guide wire can also be passed through the 6R portal in a distal to proximal direction. A targeting device facilitates this step. A cannulated 3.2 mm drill bit is used from proximal to distal to create the tunnel (▶ Video 13.6). The size of the tunnel is critical and care must be taken not to fracture
13.2.6 Passing the Graft through the Ulnar Tunnel Once the bone tunnel is drilled under arthroscopic control, joint lavage is performed. A fine straight mosquito forceps is inserted through the tunnel from proximal to distal. The two ends of the PL graft are introduced into the joint. The volar end of the tendon graft is passed through a small hole created in the capsule, ulnar, and distal to the radial tunnel at the radial insertion of the TFCC. The space is slightly distal to the edge of the radius, and the suture ends are introduced into the joint. The suture is retrieved with a fine mosquito forceps and passed through the ulnar bone tunnel. The tendon end is then pulled into the joint. It is important to first pass the volar end of the tendon graft before passing the dorsal end, otherwise the dorsal stump might block the arthroscopic visualization (▶ Fig. 13.4). Next, a window is created: a small hole is made in the dorsal capsule, distal, and ulnar to the radial bone tunnel, and the dorsal end of the tendon graft is introduced into the joint while grasping the suture ends with a fine mosquito forceps. The suture is then passed into the bone
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Video 13.7 Video showing the passage of tendon graft into the ulnar head tunnel.
Fig. 13.4 Drawing showing the volar end of the tendon graft being passed through the ulnar tunnel at the fovea.
tunnel through the distal ulna in the same manner (▶ Video 13.7).
13.2.7 Passage and Fixation of the Graft Both ends of the tendon are inserted into the joint and the suture ends are pulled through the bone tunnel. It is easier to pass both ends of the tendon graft at the same time. Sometimes, it might be necessary to pass one end at a time (▶ Fig. 13.5). Once both ends of the tendon graft are inserted into the bone tunnel and retrieved on the medial aspect of the ulna, traction is applied to stabilize the tendon under tension. The axial traction applied to the wrist is released and the graft is fixed under tension using an interference screw (▶ Fig. 13.6). One can also fix the tendon to the distal ulna or mere suture is performed in between the two tendinous extremities. This technique requires a long tendon graft (▶ Video 13.8).
13.2.8 Closure and Postoperative Care All incisions are sutured with interrupted sutures. Postoperatively, a sugar-tong splint is applied to prevent pronosupination of the forearm and flexion-extension of the wrist joint for 6 weeks. Elbow flexion-extension can be performed. After removal of the splint, physiotherapy is initiated. Strenuous work and lifting weights is prohibited for another 6 weeks.
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Fig. 13.5 Drawing showing the two ends of the tendon passing through the ulnar bone tunnel. The two bands of the tendon graft then reconstruct the palmar and dorsal portions of the TFCC, and the entry into the bone tunnel re-creates the foveal insertion.
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Video 13.8 Video showing the final fixation of tendon graft.
Fig. 13.6 Drawing showing fixation of the tendon ends by an interference screw.
arthritic changes have not set in. This technique is difficult and has a steep learning curve. With rare indications, it should be performed by surgeons experienced in arthroscopic surgery of the wrist. Nevertheless, when well done, this technique provides good stabilization of the DRUJ, while maintaining good mobility of the wrist in all directions.
References 13.3 Conclusion Arthroscopic reconstruction of the TFCC is the method of choice to stabilize the DRUJ in chronic injuries of the TFCC, when repair is no longer possible and
[1] Mansat M, Mansat Ch, Martinez Ch. L’articulation radio-cubitale inférieure. pathologie traumatique. Le Poignet, ed Masson, Paris, 1983: 187–195 [2] Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg Am. 2002; 27(2):243–251
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14 Arthroscopic Distal Ulnar Resection 14.1 Introduction
14.2 Operative Technique
Ulnar impaction syndrome is a common but often an unrecognized cause of pain on the ulnar side of the wrist. Although it can be congenital in nature (due to a long ulna), it is most often secondary to a distal radius fracture with axial subsidence, especially in the elderly. This proximal shift in the radial epiphysis leads to the appearance of a “long ulna,” which translates to positive ulnar variance (▶ Fig. 14.1a-c). Pain is often exacerbated during forced radial deviation, which causes the lunate to slide toward the ulnar head. The resulting injuries appear in succession over time: perforation of the radioulnar disk of the triangular fibrocartilage complex (TFCC) ligament, impingement between the distal ulna and medial aspect of the proximal lunate, and eventually lunotriquetral instability or even chondromalacia of the head of the hamate (▶ Fig. 14.2a, b, ▶ Video 14.1). Several treatments are possible, such as ulnar shortening, radial reconstruction osteotomy, and ulnar head resection. Arthroscopic distal resection of the ulnar head is a simple surgical technique that eliminates the impingement without requiring wrist immobilization.
14.2.1 Patient Preparation and Positioning The procedure is performed under regional anesthesia with the patient supine and the arm abducted to 90° and resting on a hand table. A tourniquet is placed at the base
Video 14.1 Video showing injuries resulting from ulnar impaction syndrome.
Fig. 14.1 (a) Drawing of the typically normal relationship between the ulnar head and distal radius (neutral ulnar variance). (b) Drawing of a positive ulnar variance where the ulna is longer than the radius. (c) Drawing of a negative ulnar variance where the ulna is shorter than the radius.
Fig. 14.2 (a) Drawing of the most common injuries resulting from ulnar impaction syndrome: the central TFCC perforation, ulnar head chondromalacia, chondromalacia of the medial aspect of the lunate, often associated with triquetral chondromalacia and lunotriquetral instability. (b) Drawing of these same injuries before the TFCC perforation.
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Arthroscopic Distal Ulnar Resection of the arm and secured to the table. The elbow is flexed to 90° and 5 to 7 kg (11–15.5 lbs.) of traction is applied using finger traps.
ablation probe can also be used to make this step easier. Any chondromalacia of the ulnar head is now visible (▶ Video 14.2).
14.2.2 Exploration and Synovectomy of the Radiocarpal Joint
14.2.4 Distal Ulnar Resection
The arthroscope is introduced through the 3–4 radiocarpal portal; the 6R radiocarpal portal is used to pass instruments. The first exploratory step always consists of debridement of the inflamed synovial membrane with a shaver. This provides good exposure of the TFCC ligament and ensures that no synovial remains will be interposed in front of the scope or interfere with the resection step.
14.2.3 Preparation of TFCC Ligament The second step consists of debridement of the central part of the TFCC ligament. Extensive debridement may not be necessary if the central portion is already significantly perforated, either due to the chronic nature of the impingement or the degenerative nature of the perforation in an elderly patient. This central perforation, which is usually present, is widened using basket forceps, and then evened out with a shaver to provide good exposure of the ulnar head cartilage (▶ Fig. 14.3). A radiofrequency
The next step is the bone resection itself. Using a burr, the entire visible portion of the ulnar head jutting out above the radius is resected (▶ Fig. 14.4a, b). Note that the ulnar head is not completely spherical but rather oval-shaped. As a consequence, the surgical assistant must pronate and supinate the wrist during the burring. The surgeon continues the resection as new bulges appear (▶ Fig. 14.5a, b, ▶ Video 14.3). During this resection step, it is absolutely essential that the distal radioulnar joint be preserved (▶ Fig. 14.6a-c, ▶ Video 14.4). At the end of this step, the articular surface has undergone a helicoidally oblique osteotomy. Fluoroscopy can be used to verify the outcome (▶ Fig. 14.7a, b).
14.2.5 Ulnar Head Resection when the TFCC Is Intact In rare cases, mainly in young patients, the TFCC will be intact. A subligament approach can be used to avoid perforating the TFCC when exposing the ulnar head. The scope is placed in the distal radioulnar portal. The shaver is inserted through the direct foveal portal. Resection is carried out as described earlier, with the assistant pronating and supinating the wrist. It can be useful to reverse the scope and burr positions to put the finishing touches on the osteotomy (▶ Fig. 14.8a, b).
14.2.6 Closure and Postoperative Care At the end of the procedure, the small portal incisions are left open under the dressing. Wrist mobilization can start immediately.
Fig. 14.3 Drawing of central debridement of the TFCC using basket forceps. Care must be taken to not injure the peripheral structures because they stabilize the TFCC.
Video 14.2 Video showing the damaged ulnar head cartilage through the central TFCC perforation.
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Fig. 14.4 (a) Drawing of the position of the burr in the 6R portal and initial resection of the ulnar head through the visible central portion. (b) Diagram of the view from above of the same configuration seen in (a).
Fig. 14.5 (a) Diagram of the view from above showing continued resection of the ulnar head during wrist pronation. (b) Diagram of the view showing continued resection of the ulnar head during wrist supination.
Fig. 14.6 (a) Drawing of the preserved distal radioulnar joint after the ulnar head has been resected. (b) Arthroscopic view of the intact radioulnar joint after ulnar head resection.
Video 14.3 Video showing the resection of ulnar head and the intact radioulnar joint after ulnar head resection.
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Video 14.4 Video showing the ulnar head cartilage articulating with the sigmoid fossa of the intact radius.
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Fig. 14.7 (a) Diagram of the view from above showing the final appearance of the resected ulnar head: not level; it is rather oblique and helicoidal. (b) Postoperative radiograph showing the degree of ulnar resection and removal of the impingement with preservation of the entire distal radioulnar joint.
Fig. 14.8 (a) Drawing of ulnar head resection when the TFCC is intact. The scope is placed in the distal radioulnar portal and the shaver inserted through the direct foveal portal so that it lies under the TFCC. The probe (or skin hook), inserted through the 6R portal, is used to lift the TFCC. (b) Arthroscopic view of the shaver under the TFCC.
Fig. 14.9 (a) Radiograph of ulnar impaction syndrome secondary to radius fracture. (b) Radiograph showing the final result after ulnar head resection; the distal radioulnar joint is intact.
14.3 Conclusion Arthroscopic resection of the distal ulna is now the preferred technique for ulnar impaction syndrome in cases where the ulnar variance does not exceed 4 mm. The
outcomes are excellent as long as the integrity of the distal radioulnar joint is preserved (▶ Fig. 14.9a, b). Postoperative recovery is much simpler, as the patient can immediately use their wrist.
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15 Arthroscopic Hamatum Head Resection for HALT Syndrome Jan Ragnar Haugstvedt
15.1 Introduction Hamate arthritis lunotriquetral instability is often called “HALT syndrome.” Anatomical studies of the carpus have revealed different shapes of the lunate in the midcarpal joint; the lunates being called type I and type II. More than 50% of the specimens have been shown to have a medial facet articulating with the hamate; this type has been called type II lunate, whereas the lunates with only one facet are called type I (▶ Fig. 15.1a, b). The medial facet found in type II lunate is from 1 to 6 mm wide, and in approximately half of these specimens, cartilage erosions are found on the distal part of the lunate (▶ Fig. 15.2a-c). This is not typically found in the type I lunate. The four-corner kinematics of the wrist are
different between the two types of lunate. It is thought that repeated impingement between the hamate and the lunate, when the hand is in ulnar deviation, is the mechanism for the development of chondromalacia in type II. There has also been shown different influence of the different form and contribution of the triquetrohamate and triquetrocapitate ligaments in the different wrists. A longitudinal force transmission in a positive ulnar variance wrist might also contribute to the pathology; you will see changes of the triangular fibrocartilage complex (TFCC) with erosions of the ulnar head together with changes on the proximal part of the lunate and/or the triquetrum (▶ Fig. 15.3). HALT syndrome (▶ Fig. 15.4) is often a missed diagnosis and could be an unidentified cause of ulnar sided wrist pain.
Fig. 15.1 In a lunate type I, there is one distal facet on the lunate articulating with the capitate (a); whereas, in a lunate type II, there is also one medial facet articulating with the hamate (b).
Fig. 15.2 (a–c) In anatomical studies of the lunate, approximately 50% of the specimens are found to have erosions between the lunate and the hamate in the type II lunate. These changes could be seen on regular radiographs as well as on MRI scans.
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Fig. 15.3 In a positive ulnar variance wrist, the TFCC may have degenerative changes from contact with the bones of the proximal carpal row, which in turn might also have chondral injuries.
15.2 Operative Technique 15.2.1 Patient Preparation and Positioning The arthroscopy could be performed under local or regional anesthesia; however, we prefer to have the patient under general anesthesia using a tourniquet on the arm. After preparation for surgery, the arm is placed in a traction tower. We establish the 3–4 and 6R portals and examine the radiocarpal joint before establishing the midcarpal radial (MCR) and midcarpal ulnar (MCU) portals. We prefer using “dry” arthroscopy; however, we will have a syringe with fluid and a shaver available for flushing and cleaning the joint whenever necessary.
15.2.2 Exploration of the Bones In the radiocarpal joint, we examine the TFCC to look for signs of ulnar impaction syndrome. This could be a degenerative central tear, signs of a chondral lesion of the ulnar head (confirmed by viewing the ulnar head directly through a TFCC tear or through an arthroscopy of the distal radioulnar joint), but we will always also enter the scope through the 6R portal to have a better view of the proximal articular surfaces of the lunate and the triquetrum as well as the lunotriqueral (LT) ligament. The diagnosis is confirmed by midcarpal arthroscopy. When passing the scope toward the ulnar side of the midcarpal
Fig. 15.4 If further pressure is exerted over the ulnocarpal joint, changes might occur in the LT interval and the midcarpal joint. These changes, together with the change in kinematics in the lunate type II wrists, might lead to changes in the midcarpal joint, a condition called HALT.
joint, we will notice the type of the lunate (type I or type II) and inspect the distal articulate surfaces of the lunate and the triquetrum as well as the proximal articulate surface of the hamate. In a HALT syndrome, the erosions of the cartilage (▶ Fig. 15.5) are easily seen (▶ Video 15.1). If there are no other pathologies that can explain the ulnar sided wrist pain, we will prepare for the treatment.
15.2.3 Resection of the Tip of the Hamate With the scope in the MCR portal we introduce a shaver in the MCU portal. We start with shaving off the soft tissue and the cartilage before using a burr to resect the proximal tip of the hamate (▶ Video 15.2). The goal is to prevent contact between the proximal tip of the hamate and the lunate and triquetrum. A fluoroscope could be used to control the resection; however, it could also be very well controlled using the arthroscope (▶ Video 15.3, ▶ Video 15.4). After the resection, we clean out the joint. A radiograph will verify the resection (▶ Fig. 15.6).
15.2.4 Closure and Postoperative Care We end the surgery by closing the small transverse incisions with strips. We deposit local anesthesia for postoperative pain relief and then put on a sterile bandage
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Fig. 15.5 Arthroscopic view from the midcarpal joint where chondral changes on both sides of the joint are seen.
Video 15.2 Resection of the proximal tip of the hamate. The view is through the scope from the MCR portal, while the burr is entering through the MCU portal.
Video 15.4 The resection of the tip of the hamate as shown in a different case.
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Video 15.1 Examination of the midcarpal joint. (In this case, wet arthroscopy is used.) The scope is in the MCR portal. The scope is between the scaphoid and the capitate, moving toward the scaphotrapeziotrapezoid (STT) joints before turning ulnarly to show the SL interval, which is being tested. The examination is then continued toward the ulnar side of the wrist and a lunate type II is verified. There are chondral changes of the distal lunate as well as the triquetrum. When viewing at the proximal part of the distal row, there is no cartilage on the proximal part of the hamate, while the cartilage of the capitate is normal.
Video 15.3 The resection has been performed and there is no longer contact between the tip of the hamate and the bones of the proximal row.
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Arthroscopic Hamatum Head Resection for HALT Syndrome before a soft dressing is added. We will usually recommend resting the wrist for some days before exercises are started and then allow full activity.
15.3 Conclusion HALT syndrome is often missed as a cause of ulnar-sided wrist pain. In a patient with a type II lunate, the changes are seen in the ulnar side of the midcarpal joint. The articular changes involving the cartilage and the bone are shaved/resected, and the patients are allowed immediate motion. It is our experience that this treatment gives good pain relief (if no other pathologies are found in the joint).
Fig. 15.6 A radiograph showing the resection of the hamate.
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16 Anatomy of the Scapholunate Complex 16.1 Introduction
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Scapholunate joint stability is ensured not only by the scapholunate interosseous ligament (SLIL), but also by a group of intrinsic and extrinsic elements called the scapholunate complex. A good understanding of this complex, based on technical advances and recent anatomical studies, is essential for providing timely, specialized care when it is injured and, thus, giving it the best chance of healing. To accomplish this, however, we must have pertinent information about the various structures involved. The goal of this chapter is to precisely describe the topographic and arthroscopic anatomy of the scapholunate complex and the use of a hook probe to test the integrity of its various structures.
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16.2 Applied Anatomy and Biomechanics of the Carpal Ligaments The proximal and distal interosseous ligaments, together with the volar and dorsal extrinsic ligaments, are directly involved in scapholunate stability. During wrist flexion or extension, both rows of carpal bones flex or extend collectively, but to differing degrees. The primary flexion and extension lines (where the joint is most mobile) cross at the scapholunate ligament. Distal carpal compression is the greatest at the capitate. As the pressure is transmitted to the proximal row, it tends to separate the scaphoid from the lunate.
16.2.1 Intrinsic Ligament: Scapholunate Interosseous Ligament The SLIL joins the scaphoid and lunate together. Its fibers are asymmetrical. The ligament consists of three separate, macroscopically continuous parts, at least before agerelated degeneration sets in (▶ Video 16.1):
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Dorsal: acts as a dorsal ligament between the posterior horn of the lunate and the scaphoid Volar: thinner, but still strong Proximal (intermediate): little to no vascularity, thus cannot be repaired (similar to central part of the triangular fibrocartilage complex [TFCC]); fibrocartilage between the articular surfaces of the scaphoid and lunate (▶ Fig. 16.1a, b)
The dorsal portion is the strongest because of its thick, fibrous nature. It is considered the main scapholunate joint stabilizer.
16.2.2 Extrinsic Ligaments Some of the extrinsic wrist ligaments provide additional stabilization to the scapholunate joint: ● The dorsal intercarpal (DIC) ligament seems to be the second most important stabilizer. The proximal portion of the DIC is also call the dorsal scaphotriquetral ligament. Spanning the distal scaphoid and the triquetrum, it combines with the dorsal radiocarpal
Video 16.1 Video showing an intact scapholunate ligament in a young patient. It is hard to distinguish the ligament from the articular surfaces of the lunate and scaphoid as they are seamlessly integrated; the scapholunate ligament can be detected only by the depression between the two bones.
Fig. 16.1 (a) Anatomical study on a fresh cadaver showing the first row flexed 90° toward the radius after having removed all of the dorsal extrinsic ligaments (Pagliei). The intrinsic SLIL is located between the proximal pole of the cartilage-covered scaphoid (upper left) and the lunate. (b) Drawing of the three portions of the SLIL, in which red is the thick dorsal portion, blue is the thin, non-vascularized proximal (intermediate) portion, and green is the volar portion.
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Anatomy of the Scapholunate Complex (DRC) ligament to form the “dorsal V” described by Senwald and Segmüller. It is unique in that it has multiple insertions onto the lunate and the scaphoid (▶ Fig. 16.2).1 This ligament complex, which restricts intracarpal supination and ulnar translation of the carpus, has a particularly high number of nerve endings. Together, this “dorsal V” and the dorsal portion of the SLIL form a genuine crossroads of dorsal ligament attachments.2 Although its resulting length varies, it is always under tension, whether the wrist is in flexion or in extension.3
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In a recent cadaver study, the author’s showed that this scapholunate confluence plays a major stabilizing role; we called this structure “dorsal capsulo-scapholunate septum” (DCSS).2 It consists of a thickening of the capsule itself that connects the dorsal capsule with the dorsal portion of the scapholunate ligament (▶ Fig. 16.3a, b). The volar radioscaphocapitate (RSC) ligament spans the radius and the capitate (▶ Fig. 16.4a–c). It inserts deeply on the anterior side of the scaphoid’s waist (isthmus). It restricts intracarpal pronation and stops dorsal translation of the proximal pole. It makes up the radial branch of the “distal palmar V.”1 The scaphotrapezial (ST) ligament stabilizes the radiovolar side of the ST joint. It is extremely strong and rarely tears.
Stability of the scapholunate joint is ensured by a combination of structures that comprise an actual ligament complex. The peripheral ends of the flexor and the extensor carpi radialis and ulnaris tendons provide the additional stabilization of this complex by surrounding the carpus.
16.3 Arthroscopic Testing of Scapholunate Stability—New Classification System 16.3.1 Arthroscopic Testing of Predynamic Instability Fig. 16.2 Drawing of the two dorsal extrinsic ligaments: DIC ligament and DRC ligament. DIC, dorsal intercarpal; DRC, dorsal radiocarpal.
Predynamic or occult instability is the evidence of an incomplete tear that can be detected by arthroscopy. The procedure is performed on an outpatient basis under regional anesthesia. The patient lies supine. Upward
Fig. 16.3 (a) Section of a cadaver wrist passing through the scapholunate ligament near the scaphoid. On the dorsal side, the DCSS is clearly visible between the dorsal capsule and the dorsal potion of the scapholunate ligament. (b) Arthroscopic view of an intact DCSS located between the capsule and dorsal portion of the scapholunate ligament.
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Fig. 16.4 (a) Cadaveric dissection showing the DCSS. (b) Drawing showing the DCSS ligament structure composed of three arches uniting the dorsal capsule to the dorsal scapholunate ligament. (c) Drawing of all the extrinsic volar ligaments. H, hamate; C, capitate; Td, trapezoid; Tm, trapezium; P, pisiform; T, triquetrum; L, lunate; S, scaphoid; U, ulna; R, radius. RSC, radioscaphocapitate ligament; LRL, long radiolunate ligament; SRL, short radiolunate ligament; UL, ulnolunate ligament; UT, ulnotriquetral ligament; UC, ulnocapitate ligament; TC, trapezocapitate ligament; SC, scaphocapitate ligament; PRU, volar part of the TFCC.
Table 16.1 Arthroscopic EWAS classification for scapholunate instability7 Stage
Arthroscopic findings
Stage I
Probe cannot enter scapholunate (SL) joint
Stage II
Tip of probe enters SL joint, without joint space widening
Proximal (membranous) part of SLIL
Stage IIIA
Partial volar widening of SL joint space on dynamic instability testing from MC joint
Volar and proximal portions of SLIL with or without RSC/LRL injury
Stage IIIB
Partial dorsal widening of SL joint space on dynamic instability testing from MC joint
Dorsal and proximal portions of SLIL with complete tear of an extrinsic structure (DIC or RSC/LRL)
Stage IIIC
Complete widening of SL joint space during dynamic testing
Complete tear of SLIL (dorsal, prox., and volar) with complete tear of one extrinsic structure (DIC or RSC/LRL)
Stage IV
Spontaneous opening of SL joint space that allows scope to move from MC to RC joint
Complete tear of SLIL (dorsal, prox., and volar) with complete tear of extrinsic structures (DIC and RSC/LRL)
Stage V
SL diastasis visible on X-rays (dynamic or static)
Complete tear of SLIL, DIC, LRL, RSC and at least one other ligament (TH, ST, and DRC)
traction (5–7 kg or 11–15.5 lbs.) is applied to the arm and a support pad is placed against the upper arm. A 30° scope is used for radial or midcarpal arthroscopy. A blunt trocar is essential to avoid damaging the cartilage. It is inserted into portals once they have been located with needles. The standard radiocarpal (RC) (3–4 and 6R portals) and ulnar (MCU) or radial midcarpal (MCR) portals are typically sufficient to assess proximal row stability. A hook probe is a critical tool for the testing. Geissler and Dautel4,5 separately proposed classification systems for arthroscopic predynamic scapholunate instability based on midcarpal testing with a probe. This method was modified and improved by a European Wrist Arthroscopy Society (EWAS) group led by Messina.6 The basic concept rests on determining if the scapholunate joint opens spontaneously or can be opened with a probe.
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Associated injuries
16.3.2 EWAS Classification for Scapholunate Instability ▶ Table 16.1 provides the EWAS classification system for scapholunate instability. Stage I corresponds to a stable scapholunate joint; the probe cannot be inserted into the scapholunate joint space (▶ Fig. 16.5). Stage II corresponds to a joint space which opens just enough to insert the probe, but does not rotate it. Stage III corresponds to a larger opening of the joint space, which can be further widened by turning the probe, either on the volar side of the joint (IIIa) (▶ Fig. 16.6), its dorsal side (IIIb) (▶ Fig. 16.7), or in its entirety (IIIc). In stage IV, the joint opens spontaneously, which allows the scope to be moved from the midcarpal to the radiocarpal joint (▶ Fig. 16.8). Stage V corresponds to major diastasis, visible on X-rays, with the scaphoid becoming horizontal.6 Any opening of
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Fig. 16.5 Drawing of stage I scapholunate instability, viewed from above. The probe cannot be inserted between the scaphoid and lunate.
Fig. 16.7 Drawing of stage IIIb scapholunate instability, viewed from above. The probe can be inserted between the scaphoid and lunate on the dorsal side; this is the evidence of an isolated tear of the dorsal portion of the scapholunate ligament.
Fig. 16.6 Drawing of stage IIIa scapholunate instability, viewed from above. The probe can be inserted between the scaphoid and lunate, but only on the volar side; this is the evidence of an isolated tear of the volar portion of the scapholunate ligament.
Fig. 16.8 Drawing of stage IV scapholunate instability, viewed from above. There is enough space between the scaphoid and lunate for the scope to pass easily between the two bones.
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Anatomy of the Scapholunate Complex the scapholunate joint indicates an injury to the SLIL and that the extrinsic ligaments are acting as secondary scapholunate joint stabilizers. An isolated SLIL tear does not result in scapholunate instability unless an extrinsic ligament is also torn.
16.4 Arthroscopic Testing of Extrinsic Ligaments—Injury Classification 16.4.1 Classification for Extrinsic Ligament Injury Testing of extrinsic ligaments is performed under the same conditions as the testing for scapholunate stability in the midcarpal joint described earlier. Injuries are uncovered by visually inspecting the integrity of the structures and using the probe to determine how tight they are. In some cases, the synovial membrane will have to be reflected or resected. Four injury stages have been described:7 in stage 0, the ligament is perfectly taut with all fibers continuous; in stage 1, the ligament is stretched and palpably lax, with more than 50% fiber continuity; in stage 2, the ligament is stretched and lax with partial degeneration and less than 50% fiber continuity; in stage 3, the ligament is completely torn or no longer present (▶ Table 16.2).
16.4.2 Method for Arthroscopic Testing of Extrinsic Ligaments The testing sequence has been standardized and applies to all the dorsal and volar ligaments that can be accessed in the radiocarpal and midcarpal joints. Most of the time, testing requires the four standard portals (3–4, 4–5, MCR, and MCU) due to the scope angle and triangulation. In rare cases, other portals may need to be used: scaphotrapeziotrapezoid (STT) to visually confirm the DIC testing, or 6U to visually confirm the DRC testing. The surgeon must be especially careful while using these latter portals
Table 16.2 Arthroscopic classification of extrinsic ligament injuries
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Stage
Arthroscopic findings
Stage E0
Ligament is perfectly taut with all fibers continuous
Stage E1
Ligament is stretched and palpably lax with more than 50% fiber continuity
Stage E2
Ligament is stretched and palpably lax with less than 50% fiber continuity
Stage E3
Ligament completely torn or no longer present
because of the presence of the radial artery and sensory branch of the ulnar nerve.
Extrinsic Ligaments Visible in the Radiocarpal Joint The following ligaments are palpated sequentially in the radiocarpal joint with the scope in 3–4 and probe in 6R portal: RSC, long radiolunate (LRL), short radiolunate (SRL), ulnolunate (UL), ulnotriquetral (UT), and DRC (▶ Fig. 16.5). The RSC and LRL ligaments are easily palpated through the space between ligaments. The SRL can be palpated on the ulnar side of the ligament of Testut or radioscapholunate (RSL) ligament but is often hidden by synovium. The RSL has no mechanical role. The UL ligament is palpated immediately in front of the TFCC’s radial insertion. The UT ligament is palpated immediately in front of the distal ulnar and palmar insertions of the TFCC. The DRC is palpated by sliding the probe onto the proximal surface of the triquetrum and hooking the ligament’s dorsal insertion on the triquetral bone. The DCSS is assessed by placing the scope in 6R portal and probe in 3–4 portal (▶ Fig. 16.9). With the scope, the dorsal capsule is followed over the SLIL until the DCSS is located; this is the ligamentous structure between the dorsal capsule and the dorsal portion of the SLIL. If the DCSS is intact, the probe will stop and remain in the radiocarpal joint (negative push test) (▶ Fig. 16.10a, b, ▶ Video 16.2). If the DCSS is torn, the probe will breach the space between the dorsal capsule and the dorsal portion of the scapholunate ligament, and end up in the dorsal part of the midcarpal joint (positive push test, ▶ Video 16.3, ▶ Video 16.4, ▶ Video 16.5).
Extrinsic Ligaments Visible in the Midcarpal Joint With the scope in the MCU portal and probe in the MCR portal, the scapholunate and triquetrolunate joints are evaluated within the midcarpal joint. The scope is then introduced in the MCR portal and the probe in the MCU to sequentially test the ST ligament, midcarpal portion of the RSC, triquetrocapitate (TC) ligament, and then the DIC ligament. The ST is palpated by placing the scope in MCR portal and the probe in the MCR or STT portals. The probe crosses and passes over the scope inside the joint. It slides along the distal surface of the scaphoid and pushed deep into the radial side of the STT joint. By following alongside the scaphoid, the scope can be advanced far enough to provide a direct view of the ligament in most cases. The midcarpal portion of the RSC is located in front of the scapholunate joint and often covered by synovium. The UC is the largest ligament in the anterior plane of the midcarpal joint. It is located in front of the triquetrolunate joint. To palpate the DIC, the probe is slid from volar
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Video 16.2 Video showing a testing of an intact DCSS.
Video 16.3 Video showing a testing of a torn DCSS.
Fig. 16.9 Intraoperative view of instrument positioning used for the DCSS testing. The scope is in the 6R portal and the probe in 3–4.
Video 16.4 Video showing a testing of a torn DCSS associated with a complete dorsal capsule rupture.
Fig. 16.10 (a) Arthroscopic view during testing of an intact DCSS. The probe cannot go beyond the DCSS. (b) Drawing of the DCSS testing with a probe. The red arrow stimulates the pressure from proximal to distal on the DCSS with the probe.
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Anatomy of the Scapholunate Complex stabilizers is taken into account while determining the arthroscopic classification of “predynamic” scapholunate instability. Arthroscopic testing of extrinsic ligaments supplements the diagnosis of scapholunate instability, while specifying the time frame of the injury through well-defined criteria. From that point on, the choice of repair methods can be qualified. Given the information presented, it seems necessary to diagnose each injury and treat as many stabilizing structures as possible when caring for patients with nonarthritic scapholunate instability. Video 16.5 Video showing an arthroscopic radiocarpal and midcarpal exploration of complete scapholunate ligament torn stage (EWAS 4).
to dorsal on the distal surface of the proximal third of the scaphoid. By pulling the scope almost out of the joint, the dorsal edge of the scaphoid can be viewed directly. The probe can hook the DIC at this location and test both its scaphoid and lunate attachments. However, this latter ligament is the hardest to test through the standard midcarpal portals and may require use of the STT portal.
16.5 Conclusion Scapholunate stability is effectively ensured by a complex associating the dorsal and volar portions of the SLIL, the DIC ligament, the DRC ligament, the RSC ligament, the ST ligament, and the DCSS. The integrity of these various
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References [1] Senwald G, Segmüller G. Base anatomique d’un nouveau concept de stabilité du carpe. Int Orthop. 1986; 10:25–30 [2] Overstraeten LV, Camus EJ, Wahegaonkar A, et al. Anatomical Description of the Dorsal Capsulo-Scapholunate Septum (DCSS)-Arthroscopic Staging of Scapholunate Instability after DCSS Sectioning. J Wrist Surg. 2013; 2(2):149–154 [3] Mitsuyasu H, Patterson RM, Shah MA, Buford WL, Iwamoto Y, Viegas SF. The role of the dorsal intercarpal ligament in dynamic and static scapholunate instability. J Hand Surg Am. 2004; 29(2):279–288 [4] Geissler WB. Arthroscopic management of scapho-lunate instability. Chir Main. 2006(25):187–196 [5] Dautel G, Merle M. [Dynamic arthroscopic tests for the diagnosis of scaphoid-lunar instabilities]. Ann Chir Main Memb Super. 1993; 12 (3):206–209 [6] Messina JC, Van Overstraeten L, Luchetti R, Fairplay T, Mathoulin CL. The EWAS Classification of Scapholunate Tears: An Anatomical Arthroscopic Study. J Wrist Surg. 2013; 2(2):105–109 [7] Van Overstraeten L, Camus EJ. A systematic method of arthroscopic testing of extrinsic carpal ligaments: implication in carpal stability. Tech Hand Up Extrem Surg. 2013; 17(4):202–206
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17 Dorsal Capsuloligamentous Repair of the Scapholunate Ligament Tear 17.1 Introduction Scapholunate interosseous ligament (SLIL) tears are one of the most serious injuries associated with wrist trauma. Although open surgical repair can be performed, it is not indicated in the initial stages because of the resulting joint stiffness. Wrist arthroscopy has completely changed how these injuries are diagnosed and treated. The injury can be evaluated in its initial stage, before the ligament is completely torn and the scaphoid becomes horizontal. The dorsal portion of the scapholunate (SL) ligament and its attachment to the dorsal capsule through a dorsal capsuloscapholunate septum (DCSS) are the keys to SL stability. This dorsal complex can be repaired arthroscopically using capsule-to-ligament suturing, thereby preventing the stiffness typically observed with open procedures.1–3
A push test is performed to assess the DCSS, which is an anatomical structure located between the dorsal intercarpal (DIC) ligament and the dorsal portion of the SL ligament. The probe is placed in the dorsal recess under scope guidance, using the angulation and triangulation effects. If the DCSS is intact, it will be completely visible and the probe will not be able to go any further. If it is not, the probe can subsequently move into the midcarpal joint without being hindered by the DCSS (positive push test) (Chapter 16).
17.2 Operative Technique 17.2.1 Patient Preparation and Positioning The procedure is performed on an outpatient basis under regional anesthesia. The patient is placed supine, with the arm resting on an arm board with an attached tourniquet. Upward traction of 5 to 7 kg (11–15.5 lbs.) is applied to the hand.
17.2.2 Radiocarpal Exploration The arthroscope and sheath are inserted through the 3– 4 radiocarpal portal to visualize the SLIL. However, the dorsal portion of SLIL can be seen only with the scope in the 6R portal. A shaver is introduced into the 6R portal to clean out the joint and perform a synovectomy. The shaver and arthroscope are reversed to finish the synovectomy, particularly at the dorsal recess. A probe is used to assess the nature of the SL ligament injury (Chapter 16). The scope can be used to follow the volar portion of the SLIL to its dorsal insertion. Usually, the SLIL is avulsed from the scaphoid. The ligament stump that is attached to the lunate can easily be lifted with the probe. The dorsal portion of the SLIL and the DCSS are then evaluated at the dorsal recess. More often than not, the ligament is torn, with ligament stumps remaining attached to the scaphoid and lunate (▶ Fig. 17.1, ▶ Video 17.1). This technique can only be performed under these circumstances.
Fig. 17.1 Drawing of a torn scapholunate ligament. The probe indicates a positive push test with the torn DCSS. The repair can be performed only if the SLIL remnants are attached to the lunate and scaphoid.
Video 17.1 Video showing a torn scapholunate ligament with a positive push test.
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17.2.3 Exploration of the Midcarpal Joint
are then inserted parallel to the first into the SLIL stump attached to the lunate (▶ Fig. 17.5a, b, ▶ Video 17.3).
The arthroscope and sheath are introduced through the midcarpal ulnar (MCU) portal. The shaver is introduced through the midcarpal radial (MCR) portal to carry out a synovectomy. In cases of dorsal intercalated segment instability, there will be a step-off between the scaphoid and lunate. The probe is inserted between the scaphoid and lunate to determine the dissociation stage (Chapter 16).
17.2.5 Tying the First Knot
17.2.4 Performing the Dorsal Capsuloligamentous Suture The scope is introduced into the 6R portal to inspect the gap between the lunate and the dorsal capsule. An absorbable monofilament suture (3–0 or 4–0 depending on the patient’s size) is passed through a needle. This needle is inserted through the skin via the 3–4 portal, then shifted slightly distally so as to cross the joint capsule (▶ Fig. 17.2, ▶ Video 17.2). The needle is located inside the joint through the scope and then pushed through the SLIL stump on the scaphoid side. The needle is oriented dorsal to volar and angled proximal to distal, allowing it to enter the midcarpal joint (▶ Fig. 17.3). If the 3–4 portal is not exactly overlying the SLIL, the assistant can pull on the skin on the medial side of the wrist to shift the 3–4 portal and avoid having to make a larger opening (▶ Fig. 17.4). A second needle and suture
Fig. 17.2 Drawing of SL ligament suture repair to the dorsal capsule. A suture is passed through a needle. The needle is inserted through the capsule and then through the dorsal portion of the scapholunate ligament that remains attached to the scaphoid.
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The scope is returned to the MCU portal. The two needles are located inside the midcarpal joint, after they have passed between the scaphoid and lunate (▶ Video 17.4). A hemostat is introduced through the MCR portal to retrieve the two sutures (▶ Fig. 17.6, ▶ Video 17.5). The needles are removed, and the hemostat is used to externalize both sutures. A knot is tied between the two sutures (▶ Video 17.6). Traction is applied to both sutures through the 3–4 portal to pull the first knot into the midcarpal joint and seat it between the scaphoid and lunate (▶ Fig. 17.7, ▶ Video 17.7). The knot is positioned volar to
Video 17.2 Video showing the first step of dorsal capsuloligamentous repair.
Fig. 17.3 Arthroscopic view of the needle passing through the capsule and dorsal portion of the SLIL. The needle is angled dorsal to volar and proximal to distal so that it can penetrate into the midcarpal joint.
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Video 17.3 Video showing intraoperative view of the position and alignment of the two needles at this point in the procedure.
Video 17.4 Video showing arthroscopic view of the two needles inside the midcarpal joint, between the scaphoid and lunate.
Fig. 17.4 Intraoperative view of a technical trick: by pulling on the skin on the medial side of the wrist, the 3–4 portal is shifted medially so that it lies overtop of the SLIL.
Fig. 17.5 (a) Drawing of the position of the two needles passing through the dorsal capsule into the two stumps of the dorsal portion of the SLIL. (b) Arthroscopic view of the position of the needles inside the joint.
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Video 17.5 Video showing intraoperative view of the position of the hemostat introduced through the MCR portal to retrieve the two sutures.
Fig. 17.6 Drawing of suture retrieval using a hemostat introduced through the MCR portal.
Video 17.6 Video showing intraoperative view of the knot being tied between the two sutures while outside the wrist. The proximal suture ends have emerged from the 3–4 portal.
Fig. 17.7 Drawing of traction placed on the proximal suture ends to bring the knot back into the joint.
the remaining dorsal portions of the SLIL. The degree of reduction in the SL gap is determined by maintaining tension on the sutures and slightly releasing wrist traction. If reduction is satisfactory, the ligament is sutured to the dorsal capsule. If reduction is insufficient, K-wires will need to be added to stabilize the SL joint and potentially the scaphocapitate joint.
17.2.6 K-Wire Fixation of the SL Joint (Optional) Video 17.7 Video showing intraoperative view of traction on the proximal suture ends.
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K-wire fixation of the SL is challenging because of the small size of these bones. In some cases, a large dissociation must be reduced. A blunt trocar guide is inserted through the MCR portal and then positioned under the
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Dorsal Capsuloligamentous Repair of the Scapholunate Ligament Tear capitate; the blunt tip will extend beyond the anterior edge of the proximal pole of the scaphoid. The scaphoid is reduced onto the lunate using a lever action, like when using a tire iron (▶ Fig. 17.8). The SL joint is secured while maintaining this position. When the blunt guide is removed, the scaphoid shifts back to its initial position and pulls the lunate back up. Scaphocapitate fixation may also be needed in cases of substantial dissociation (▶ Fig. 17.9).
17.2.7 Tying the Second (Last) Knot The scope is returned to the 6R portal before the last knot is made. To make sure the dorsal capsule-to-ligament suture is properly positioned, the dorsal capsule is
Fig. 17.8 Intraoperative view of significant scapholunate dissociation being reduced with a blunt trocar guide placed between the capitate and scaphoid, and then moved proximally using a “tire iron” leverage principle.
pressed with the thumb while keeping the sutures taut— this will roughly duplicate the final knot’s action. Closing the gap recreates the DCSS. A probe introduced through the 3–4 portal cannot go any further distally. After the hand is released and the wrist is extended, the last knot is tied subcutaneously (▶ Fig. 17.10a, b, ▶ Video 17.8).
17.2.8 Large SL Ligament Tear with Instability (EWAS 4) In some cases, the instability is significant (EWAS 4) and simple dorsal capsuloligamentous suturing is not sufficient. In this case, we use a special trick: we catch a large part of the dorsal capsule, proximally and dorsally, to constrict the capsule and reduce the SL space. Proximally, the two needles pass through two different points on the capsule approximately 1 cm apart. It is sometimes necessary to extend the 3–4 radiocarpal portal to protect the extensor tendons. Distally, the radiomidcarpal portal is also extended. Two different openings 1 cm apart will be needed to pass the mosquito forceps (▶ Fig. 17.11). The distal knot stays outside the dorsal capsule. With the final knot, constriction of the dorsal capsule avoids the need for K-wires (▶ Fig. 17.12, ▶ Video 17.9).
Fig. 17.9 Drawing of the K-wire fixation step; when significant reduction is needed, two K-wires are inserted through the scaphoid and lunate and one through the scaphoid and capitate.
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Fig. 17.10 (a) Drawing of the suturing between the SL and dorsal capsule with one intra-articular knot located in front of the dorsal portion of SLIL and one extraarticular subcutaneous dorsal knot located behind the dorsal capsule. (b) Section through a cadaver wrist showing the thickness of the repair after the ligament and dorsal capsule have been sutured.
Video 17.8 Video showing the final step of procedure with the final knot between the SL and dorsal capsule.
Fig. 17.12 Drawing of the final knot with a constriction of dorsal capsule helping to reduce the scapholunate dissociation.
Fig. 17.11 Drawing of the special trick in case of large scapholunate dissociation, catching a large part of the dorsal capsule, proximally and distally.
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Video 17.9 Video showing the special trick in case of large scapholunate dissociation, catching a large part of the dorsal capsule, proximally and distally, with the constriction of dorsal capsule helping to reduce the scapholunate dissociation.
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17.2.9 Large SL Ligament Detachment without Ligament Stump on the Scaphoid In other cases, the SL ligament detachment is very severe, with no SL ligament stump left on the dorsal proximal pole of the scaphoid. In these cases, an anchor is inserted into the dorsal distal part of the proximal pole (▶ Fig. 17.13, ▶ Fig. 17.14). The suture in the anchor is
Fig. 17.13 Drawing of cleaning of avulsion area of dorsal scapholunate ligament attachment on dorsal proximal pole of scaphoid.
Fig. 17.15 Drawing showing the passage of second suture used to catch a large part of the dorsal capsule.
used as the first suture for dorsal capsuloligamentous repair. Another suture is added, like in the classic technique, and used to catch a large part of the dorsal capsule to achieve reduction, as described above (▶ Fig. 17.15, ▶ Fig. 17.16, ▶ Video 17.10). In such cases, K-wires are typically needed to stabilize the SL reduction (▶ Video 17.11).
Fig. 17.14 Drawing of insertion of an anchor into the dorsal distal part of the proximal pole of the scaphoid.
Fig. 17.16 Drawing of the final knot between the suture from the anchor into the scaphoid, and the second suture through the remnant part of scapholunate ligament attached to the lunate.
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Video 17.10 Video showing the use of anchor into the proximal pole of scaphoid when the scapholunate ligament is avulsed from the scaphoid.
17.2.10 Postoperative Care The portal incisions are not closed. The wrist is immobilized in extension (45–60°) with an anterior splint for 6 weeks in cases of suture repair only, and for 8 weeks in cases of associated K-wire fixation. The K-wires are removed after 8 weeks. Rehabilitation starts immediately after the immobilization period ends.
17.3 Conclusion Arthroscopic repair of the SLIL has drastically changed how SL injuries are treated. The resulting repairs are excellent. This method avoids the stiffness typically associated with open procedures. Athletes are able to return to preinjury performance levels. Nevertheless,
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Video 17.11 Video showing the pinning of scapholunate space in non-sufficiently reduced of scapholunate space after the knot.
its use is limited to cases where the stump of the dorsal portion of the SLIL is still attached to the scaphoid. Arthroscopy and comprehensive clinical assessments can provide early diagnosis of SL tears, leading to early treatment.
References [1] Wahegaonkar AL, Mathoulin CL. Arthroscopic dorsal capsulo-ligamentous repair in the treatment of chronic scapho-lunate ligament tears. J Wrist Surg. 2013; 2(2):141–148 [2] Mathoulin C. Treatment of dynamic scapholunate instability dissociation: Contribution of arthroscopy. Hand Surg Rehabil. 2016; 35(6): 377–392 [3] Mathoulin CL. Indications, techniques, and outcomes of arthroscopic repair of scapholunate ligament and triangular fibrocartilage complex. J Hand Surg Eur Vol. 2017; 42(6):551–566
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18 Arthroscopic-Assisted Box Reconstruction of Scapholunate Ligament with Tendon Graft Pak Cheong Ho, Siu Cheong Jeffrey Justin Koo
18.1 Introduction
18.2 Operative Techniques
Scapholunate (SL) dissociation is the most common carpal instability.1 Numerous surgical techniques have been described to restore or improve the stability of the SL joint and retard and prevent the progression to arthritis. Most methods provide only dorsal and uniplanar reconstructions. Recurrent or persistent gapping, tendon loosening, technical difficulty, limited motion and grip strength, and fracturing of or through drill holes have been reported.2–11 Many studies have emphasized on the importance of the volar ligaments.12–15 But Yi et al. used a palmaris longus (PL) tendon to pass through drill holes in the anteroposterior plane of the scaphoid and the lunate. The SL diastasis was effectively reduced to normal, and the scaphoid and lunate contact pressure on the radius and the scaphoid-to-lunate contact ratio were significantly improved after the reconstruction.16 Zdero used bovine tendons passing through double bone tunnels of the scaphoid and lunate in 19 cadaveric wrists and found no difference in the mechanical property from the normal wrists.17 It is logical and more ideal to restore both the dorsal and volar component of the SL ligament. Dobyns used a portion of tendon to pass through anteroposterior bone tunnels in the proximal pole of the scaphoid and lunate to reconstruct the SL linkage. Stability was obtained by tightly looping the tendon graft across the scaphoid and lunate.18 However, creating drill holes across poorly vascularized areas of bone in an open fashion severely compromised their blood supply and resulted in fractures and avascular necrosis. Marcuzzi et al. reconstruct both the palmar and dorsal parts of the SL interosseous ligament through a combined palmar and dorsal approach in six patients produced very good clinical outcomes.19 In 2002, authors developed an arthroscopic-assisted technique to reconstruct both the dorsal and volar SL ligament simultaneously using a free tendon graft in a boxlike structure without violating the major blood supply to the scaphoid and soft tissue envelope (▶ Fig. 18.1). The indication is subacute and chronic SL dissociation of 6 weeks or beyond with reducible SL diastasis and dorsal intercalated segmental instability (DISI) deformity confirmed arthroscopically and radiologically.
18.2.1 Patient Preparation and Positioning The surgery is performed under general anesthesia or regional block with patient in supine position and operated arm is in 90° shoulder abduction resting on hand table. Elbow joint is flexed to 90° and the affected hand is subjected to 10 to 13 lbs. digital traction through the plastic finger traps by using a sterilizable Wrist Traction Tower (ConMed Linvatec Corp., Goleta, CA). The tourniquet was not initially inflated. The 2% lignocaine with 1:200,000 adrenaline was injected in the portal sites to reduce bleeding. Continuous saline irrigation of the joint was achieved with a bag of 3 L of normal saline instilled under gravity.
18.2.2 Exploration of Radiocarpal Joint and Midcarpal Joint A 1.9-mm or 2.7-mm arthroscope is used. Radiocarpal joint arthroscopy is performed initially through the 3–4 and 4–5 portals with 6U as outflow portal, followed by midcarpal joint (MCJ) arthroscopy through the midcarpal radial (MCR) and midcarpal ulnar (MCU) portals.
Fig. 18.1 Simultaneous reconstruction of the dorsal and palmar SL ligaments anatomically with the use of tendon graft in a boxlike structure.
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Arthroscopic-Assisted Box Reconstruction of Scapholunate Ligament with Tendon Graft Synovectomy and radial styloidectomy are performed at the same time if necessary using a 2-mm shaver and 2.9-mm burr. Intra-articular fibrosis is resected with a shaver to improve the wrist motion and facilitate subsequent reduction of the SL mal-alignment and the DISI deformity.
18.2.3 Preparation of Dorsal and Volar Tunnel Wound The tourniquet is then inflated. A 2-cm transverse incision is extended from slightly radial to the 3–4 portal toward the 4–5 portal (▶ Fig. 18.2a). The extensor retinaculum is split along its oblique fibers. The extensor digitorum communis (EDC), extensor carpi radialis brevis (ECRB), and the extensor carpi radialis longus (ECRL) are identified. Lunate can be exposed by retracting the EDC or going through EDC tendon interval ulnarly, whereas ideal scaphoid tunnel position can be spotted between ECRB and ECRL (▶ Fig. 18.2b). Volarly, a transverse incision is made along the proximal wrist crease from the ulnar border of the PL to the ulnar border of the flexor carpi radialis (FCR) tendon (▶ Fig. 18.3a, b). PL free graft is harvested with a tendon stripper. The anterior forearm fascia was incised. The palmar cutaneous branch of the median nerve needs to be dissected, isolated, and safeguarded. The interval between the FCR tendon, the finger flexor tendons and median nerve is entered to reach the volar wrist joint capsule. Both the volar and dorsal wrist joint capsules are preserved without violation.
18.2.4 Correction of the DISI Deformity and Stabilization of Scaphoid and Lunate Position The DISI deformity needs to be corrected before drilling the bone tunnel. The hand is examined under the fluoroscope. The extended lunate can be corrected by wrist flexion and the lunate position can be maintained by transfixing the radiolunate (RL) joint with a 1.6-mm Kirschner wire (Kwire), which is inserted percutaneously through the dorsum of distal radius. The RL pin should be aimed at the ulnar half of the lunate to avoid conflict with the lunate bone tunnel (▶ Fig. 18.4a, b). Flexion deformity of scaphoid and restoration of normal SL angle is then achieved by passive wrist extension. The wrist is now ready for bone tunnel preparation.
18.2.5 Preparation of Lunate Bone Tunnel Lunate bone tunnel is created through the dorsal tunnel incision. With EDC tendons retract ulnarly, dorsal portion of lunate can be visualized. A 1.1-mm guide pin was inserted into the lunate perpendicular to the long axis of the lunate, i.e., parallel to the line joining the tip of the volar and dorsal lips of the lunate, under fluoroscopic guidance. The guide pin should be 2–3 mm away from the bone margin to avoid iatrogenic blow-out fracture and drill guide should be used to protect the soft tissue.
Fig. 18.2 (a) Through a dorsal incision, (b) the extensor tendons are retracted, exposing the dorsal wrist capsule.
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Fig. 18.3 (a) Through a volar incision, (b) the PL graft can be harvested with the use of a tendon stripper. FCR, flexor carpi radialis; PL, palmaris longus.
Fig. 18.4 (a) Drawing showing the DISI deformity of lunate. (b) Drawing showing the lunate reduction by the Linscheid maneuver. The radiolunate joint is transfixed with a 1.6-mm K-wire with the lunate in a neutral position.
With the flexor tendons and median nerve, including the palmar cutaneous branch, carefully retracted ulnarly, the lunate tunnel guide pin perforate the volar cortex of the lunate and exit through the volar wound (▶ Fig. 18.5).
18.2.6 Preparation of Scaphoid Bone Tunnel Another guide pin was inserted through dorsal tunnel wound onto the scaphoid in the interval between the ECRB and ECRL tendons. It provide counter-rotational force on the scaphoid to correct the flexion deformity
when the guide pin trajectory is slightly directed proximally and volarly (▶ Fig. 18.6). With the FCR tendon retracted radially, the scaphoid guide pin exited through the volar tunnel wound. Caution to keep the scaphoid tunnel at least 2-3 mm from all articular margins of the proximal scaphoid. Both the lunate and scaphoid bone tunnel are subsequently enlarged and bored using 2.0 and 2.4-mm cannulated drill bits. It must be bear in mind that the bone tunnel should not be too large as there is a risk of iatrogenic fracture or avascular necrosis or not too small, which will cause jamming of tendon graft inside the tunnel causing graft avulsion when forcefully pulled the tendon graft through the tunnel.
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Fig. 18.5 Drawing showing another K-wire positioned to prepare the lunate tunnel with a cannulated drill from a dorsal to volar direction.
18.2.7 Passing the PL Tendon Graft through the Scaphoid and Lunate Bone Tunnel The free PL tendon graft is delivered through the bone tunnels with a 2-mm arthroscopic grasper. With the grasper passing from the dorsal side to volar aspects of scaphoid and lunate, the two ends of tendon graft are grasped and passed from the volar side of the scaphoid and lunate to dorsal (▶ Fig. 18.7a-d). The tendon graft is passed outside the capsule to cross the SL interval so that the reconstruction also helps to tighten the capsule and the extrinsic ligaments, which confer added stability to the SL joint (▶ Fig. 18.8b, c).
18.2.8 Assessment through Midcarpal Joint Arthroscopy and Scapholunate Interval Reduction with PL Tendon Graft The MCJ was then inspected through either the MCR or MCU portal. Any interposed tissue in the SL interval that blocks reduction is excised arthroscopically. The RL pin is then withdrawn from the lunate so that the lunate becomes mobile. With manual traction of the two ends of
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Fig. 18.6 Drawing showing the preparation of the scaphoid tunnel with a cannulated drill and a K-wire inserted through the dorsal capsule from dorso-distal to volar-proximal direction.
the tendon graft, any SL gapping or step-off is corrected. The reduction is facilitated by using a large bone reduction clamp between the scaphoid and triquetrum. The tendon graft is maximally tensioned and tied in a shoelace manner over the dorsal capsule and secure with 2–0 nonabsorbable braided sutures (▶ Fig. 18.8). SL stability is confirmed arthroscopically and fluoroscopically. The tendon graft is then tied once more and sutured. Two K-wires, which are cut short and buried underneath the skin, are inserted through a small incision in the anatomic snuffbox region to transfix the scaphocapitate (SC) joint to protect the reconstructed ligament during the healing process. Additional suture anchors can be placed at the dorsal bone tunnels for the scaphoid and lunate for additional graft fixation. The RL pin is then advanced to maintain the lunate reduction if necessary. The tendon knot is then sutured to the adjacent dorsal joint capsule and the extensor retinaculum is repaired (▶ Fig. 18.9, ▶ Video 18.1).
18.3 Closure and Postoperative Care The wound is closed with absorbable sutures. Bulky dressing and scaphoid plaster slab are applied with wrist in a neutral position and the thumb in neutral palmar abduction.
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Fig. 18.7 (a) Operative view of PL tendon graft delivered through the wrist capsule and the bone tunnels to reduce the two bones in a boxlike fashion. (b) Drawing showing the position of tunnels before passage of tendon graft and before reduction. (c) Drawing showing the passage of tendon graft from scaphoid, volarly to the volar capsule and trough the lunate before final suture. (d) Drawing showing the reduction of both tunnels after tensioning of the PL graft.
Fig. 18.8 (a) The tendon graft is knotted and sutured under maximal tension on the dorsal surface of the SL joint extracapsularly in shoelace manner. (b) Note the reduction of the SL interval on X-ray.
Fig. 18.9 Drawing showing the final dorsal suture dorsally to the dorsal capsule.
Video 18.1 Video summarizing the different steps of the complete operation.
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Arthroscopic-Assisted Box Reconstruction of Scapholunate Ligament with Tendon Graft The wrist is immobilized in a short arm thumb spica cast for 6 weeks. The RL pin is removed at the beginning of the third week. The cast is then changed to a thumb spica splint for an additional 2 weeks, at which time gentle wrist mobilization is allowed out of the splint. The SC pins are removed at the beginning of the ninth week. The splint is worn at nighttime for another 4–6 weeks. Gradual wrist range-of-motion exercises, under physiotherapy supervision, are started after the pin removal. Gradual strengthening exercises are started at the beginning of the 13 week after surgery.
18.4 Conclusion In our series of 17 patients with chronic SL instability, there were three Geissler grade 3 and 14 grade 4 instability cases. The average preoperative SL interval was 4.9 mm (range 3–9 mm). The DISI deformity was present in 13 patients. Six patients had stage 1 SLAC wrist change, radiologically. Concomitant procedures were performed in four patients. The average follow-up was 48.3 months (range 11–132 months). Thirteen returned to their preinjury job level. Eleven patients had no wrist pain, and six had some pain on either maximum exertion or at the extreme of motion. The average extension range improved for 13%, flexion range 16%, radial deviation 13%, and ulnar deviation 27%. Mean grip strength was 32.8 kg (120% of the preoperative status, 84% of the contralateral side). The average SL interval after reconstruction was 2.9 mm (range 1.6–5.5 mm). Recurrence of a DISI deformity was noted in four patients but remain asymptomatic. Ischemic change of proximal scaphoid was noted in one case without symptoms or progression. There were no major complications. All patients were satisfied with the procedure and outcome.
References [1] Daniels JM, II, Zook EG, Lynch JM. Hand and wrist injuries: Part I. Nonemergent evaluation. Am Fam Physician. 2004; 69(8):1941–1948 [2] Moran SL, Ford KS, Wulf CA, Cooney WP. Outcomes of dorsal capsulodesis and tenodesis for treatment of scapholunate instability. J Hand Surg Am. 2006; 31(9):1438–1446
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[3] Linscheid RL, Dobyns JH. Treatment of scapholunate dissociation. Rotatory subluxation of the scaphoid. Hand Clin. 1992; 8(4):645– 652 [4] Almquist EE, Bach AW, Sack JT, Fuhs SE, Newman DM. Four-bone ligament reconstruction for treatment of chronic complete scapholunate separation. J Hand Surg Am. 1991; 16(2):322–327 [5] Brunelli GA, Brunelli GR. A new technique to correct carpal instability with scaphoid rotary subluxation: a preliminary report. J Hand Surg Am. 1995; 20(3 Pt 2):S82–S85 [6] Van Den Abbeele KL, Loh YC, Stanley JK, Trail IA. Early results of a modified Brunelli procedure for scapholunate instability. J Hand Surg [Br]. 1998; 23(2):258–261 [7] Talwalkar SC, Edwards ATJ, Hayton MJ, Stilwell JH, Trail IA, Stanley JK. Results of tri-ligament tenodesis: a modified Brunelli procedure in the management of scapholunate instability. J Hand Surg [Br]. 2006; 31(1):110–117 [8] Chabas JF, Gay A, Valenti D, Guinard D, Legre R. Results of the modified Brunelli tenodesis for treatment of scapholunate instability: a retrospective study of 19 patients. J Hand Surg Am. 2008; 33(9): 1469–1477 [9] Garcia-Elias M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique. J Hand Surg Am. 2006; 31(1):125–134 [10] Glickel SZ, Millender LH. Ligamentous reconstruction for chronic intercarpal instability. J Hand Surg Am. 1984; 9(4):514–527 [11] Taleisnik J. Wrist anatomy function and injury. American Academy of Orthopaedic Surgeons Instructional Course Lectures. Vol. 27. St Louis: Mosby; 1978:61–87 [12] Mayfield JK. Patterns of injury to carpal ligaments. A spectrum. Clin Orthop Relat Res. 1984(187):36–42 [13] Meade TD, Schneider LH, Cherry K. Radiographic analysis of selective ligament sectioning at the carpal scaphoid: a cadaver study. J Hand Surg Am. 1990; 15(6):855–862 [14] Dunn MJ, Johnson C. Static scapholunate dissociation: a new reconstruction technique using a volar and dorsal approach in a cadaver model. J Hand Surg Am. 2001; 26(4):749–754 [15] Short WH, Werner FW, Sutton LG. Dynamic biomechanical evaluation of the dorsal intercarpal ligament repair for scapholunate instability. J Hand Surg Am. 2009; 34(4):652–659 [16] Yi IS, Firoozbakhsh K, Racca J, Umeda Y, Moneim M. Treatment of scapholunate dissociation with palmaris longus tendon graft: a biomechanical study. Univ Pa Orthop J. 2000; 13:53–59 [17] Zdero R, Olsen M, Elfatori S, et al. Linear and torsional mechanical characteristics of intact and reconstructed scapholunate ligaments. J Biomech Eng. 2009; 131(4):041009 [18] Dobyns JH, Linscheid RL, Chao EYS, Weber ER, Swanson GE. Traumatic instability of the wrist In Instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Vol. 24. St. Louis: C. V. Mosby; 1975: 182–199 [19] Marcuzzi A, Leti Acciaro A, Caserta G, Landi A. Ligamentous reconstruction of scapholunate dislocation through a double dorsal and palmar approach. J Hand Surg [Br]. 2006; 31(4):445–449
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19 Arthroscopic-Assisted Reconstruction of LT-Ligament Jan Ragnar Haugstvedt, István Zoltán Rigó
19.1 Introduction Injuries of the lunotriquetral (LT-) ligament are less common than injuries of the scapholunate (SL-) ligament. The LT ligament lesion is often being part of a perilunate dissociation and the injury is probably often missed and overlooked. In an acute injury, the diagnosis should be verified by arthroscopy and the treatment is reduction of any displacement followed by the fixation (Kirschner wire [K-wire]) of the bones and immobilization in a cast for at least 6 weeks. Late diagnosed injuries are more difficult to treat. The patient will suffer from ulnar sided wrist pain, the testing of the LT interval reveals pain and once again an arthroscopic examination will confirm the diagnosis with instability over the LT joint. The options for treatment are ligament repair, ligament reconstruction, or arthrodesis of the LT joint.1 For the late treatment, it has been shown that arthrodesis has more secondary procedures and complications than ligament reconstruction.2 We have performed open ligament reconstruction for many years; however, for this procedure, we need a wide-open exposure with the potential of damaging ligaments, nerves, and thus proprioception. We have therefore developed an arthroscopic-assisted technique for this procedure.
19.2.3 Preparation of the Tendon Slip and the Bones We make a longitudinal skin incision over the distal part of the extensor carpi ulnaris (ECU) tendon, identifying the tendon and avoiding crossing nerves. We identify the tendon proximal of the wrist where we make one or two small transverse incisions in the skin; aim for a length of
19.2 Operative Technique 19.2.1 Patient Preparation and Positioning We usually perform wrist arthroscopy with the patient under general anesthesia, the arm is prepared and placed in a traction tower, and we use a tourniquet. We establish the 3–4, 6R as well as the midcarpal radial (MCR) and midcarpal ulnar (MCU) portals, using the technique of “dry” arthroscopy. We will have a shaver available for flushing and cleaning the joint whenever necessary.
19.2.2 Exploration of the Ligament and the Bone We confirm the diagnosis of a LT-lig tear and instability from the radiocarpal (RC) as well as the midcarpal (MC) joints (▶ Fig. 19.1, ▶ Video 19.1 and ▶ Video 19.2). We also establish the 1–2 portal for the arthroscope to have a view of the SL interval (that can also be viewed from the 6R portal). Having confirmed that the bone, the cartilage, and the other ligaments are fine, we can decide to go on with the planned procedure.
Fig. 19.1 With the arm in the traction tower, we test the LT interval through the MC portals.
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Video 19.1 When using a probe on the triquetrum, a motion is seen over the LT interval.
Video 19.2 The probe is in the LT interval and an instability of the LT ligaments is confirmed.
Fig. 19.2 (a, b) Preparation of part of the ECU tendon is performed through two small skin incisions.
14–16 cm for the tendon slip (▶ Fig. 19.2a, b), and using a pre-prepared homemade device made of a cerclage wire, we insert this through the ECU tendon sheath from a distal and in a proximal direction to harvest the tendon slip. We use a size of the tendon that will match the drill-hole (usually 3 mm), cut the part of the tendon that will be used and pull the tendon slip in the distal direction into the wound around the insertion of the ECU tendon, where the tendon slip is prepared. Through the 3–4 portal, we drill a hole through the lunate (▶ Fig. 19.3). We view the entrance point of the Kwire from the 1–2 portal (or from the 6R portal) and using a fluoroscope in a horizontal position such that we can identify the correct direction for the K-wire, which should be toward the pisiform. Thus, the K-wire should be running from a radial dorsal position in a palmar and ulnar direction through the lunate. After having drilled the K-wire through the lunate, we verify the position using fluoroscope (▶ Fig. 19.4), we correct the position by entering another K-wire if necessary, and then we use a 2.8-mm cannulated drill (or a 3.0 mm drill, if the patient is a male) to make a bony hole through the lunate (▶ Fig. 19.5, ▶ Video 19.3 and ▶ Video 19.4).
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Fig. 19.3 Through the 1–2 portal, we view the entrance point for the K-wire into the lunate. We aim for the pisiform with the K-wire running in a more or less horizontal direction.
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Fig. 19.5 When the position of the K-wire is good, we drill a hole through the lunate using a cannulated drill. Fig. 19.4 The position of the K-wire is checked using a fluoroscope. If the position is not correct, we can enter another K-wire through the drill-guide (see ▶ Fig. 19.3).
Video 19.4 The hole in the lunate is seen from the 1–2 portal.
Video 19.3 We view the position of the drill guide while the hole is drilled through the lunate.
The next step will be to establish the tunnel through the triquetrum, the tunnel running from a dorsal, ulnar position on the triquetrum in a palmar and radial direction to come out on the palmar side in the LT interval, where the hole through the lunate exits. We place the tip of a drill guide into the hole already prepared in the lunate, whereas the sleeve of the drill guide is placed where the K-wire should be inserted on the triquetrum (▶ Fig. 19.6a, b). After having confirmed the correct position using fluoroscopy, we drill the K-wire through the triquetrum (▶ Fig. 19.7a, b). If everything looks good, we make a 2.8 (or 3.0) mm hole through the triquetrum. To avoid problems while passing the tendon slip through the
bones, we use a small curette in both tunnels to smoothen the surfaces; most attention is paid on the palmar side (that we do not see, but where the tendon should pass from one bone to the other in an almost 90° angle).
19.2.4 Passing the Tendon Slip through and Securing the Graft in the Bones We now enter the slip of the ECU tendon into a tendon passer, while we pass a wire loop from the 3–4 portal through the lunate and pull it out through the triquetrum to the dorsal side of the bone (▶ Fig. 19.8). Using the wire loop, we pull the end of the tendon shuttle through the bones (the triquetrum and the lunate) (▶ Fig. 19.9a, b and ▶ Fig. 19.10a, b). If a volar intercalated segmental
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Fig. 19.6 (a, b) When the hole through the triquetrum is drilled, we place one arm of the drillguide into the lunate, whereas the other is placed on the dorsal side of the triquetrum. We use a K-wire to go through the triquetrum.
Fig. 19.7 (a, b) We check the position of the K-wire using fluoroscope, and again use the cannulated drill for the final hole.
Fig. 19.8 To pass a wire loop through the lunate and the triquetrum is challenging. We enter the wire loop into the lunate, whereas a grasper or a hook is used to pull the wire loop through the triquetrum. With the wire loop on the dorsal side of the triquetrum, we can enter the tendon loop into the wire loop before pulling the tendon graft through the bones.
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instability (VISI) or a malposition is present, we will reduce the VISI by performing Linscheid’s maneuver and place a K-wire securing the reduction. At this point, we carry out arthroscopy of the MC joint. We visualize the LT interval and by pulling the tendon graft we can verify that the LT interval closes (▶ Fig. 19.11, ▶ Video 19.5). We secure the tendon graft by entering a PEEK screw (Tenodesis screw, PEEK, Vented, 3X8 mm; Arthrex Co., Naples, FL, USA) into the dorsal triquetrum, making sure the tendon is fixed in the bone (▶ Fig. 19.12a, b). Following this, we will fix the tendon in the lunate, and by viewing from the 1–2 portal, we can verify the exit of the tendon from the lunate while through the 3–4 portal we enter another tenodesis screw into the lunate, while tensioning the tendon graft (▶ Fig. 19.13a, b). At this point, the tendon graft should be brought back to the triquetrum on the dorsal side of the carpus. From the entry point of the tendon graft on the dorsal side of the triquetrum, we pass a mosquito extracapsular, but palmar to the extensor tendons, to the 3–4 portal (▶ Fig. 19.14 and ▶ Fig. 19.15). When this space has been
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Fig. 19.9 (a, b) It could be easier to use a suture through the tendon shuttle to pull the suture through the holes before the tendon shuttle and the graft is pulled through the bones.
Fig. 19.10 (a, b) The tendon shuttle is pulled through the bones.
Video 19.5 While viewing from the 1–2 portal, we can see when the tendon shuttle with the tendon attached is pulled through the carpal bones to exit through the lunate and the 3–4 portal.
Fig. 19.11 When pulling the graft through the bones, the LT interval will tighten.
established, we pass the tendon graft from the 3–4 portal to the triquetrum and secure the tendon graft by passing it around the distal part of the ECU slip itself and fix it with non-resorbable sutures (▶ Fig. 19.16). The LT interval is now stable as verified by midcarpal arthroscopy (▶ Video 19.6).
At this point, the reconstruction is finished; however, we usually proceed with reinforcing the dorsal radiocarpal ligament (DRC lig). This runs from the dorsal part of the radius to the dorsal side of the triquetrum. The remaining part of the tendon slip, after having been secured to itself, is tunneled under the extensor digiti minimi tendon in a proximal-radial direction to the distal part of the radius. We verify the position using a fluoroscope and use a bone anchor that we insert into the dorsal edge of the radius. We tighten the tendon graft to this bone anchor, the wrist in a neutral position (▶ Fig. 19.17, ▶ Fig. 19.18, ▶ Fig. 19.19, ▶ Fig. 19.20).
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Fig. 19.12 (a, b) While traction of the tendon graft is maintained, a PEEK screw is inserted into the triquetrum to secure the position of the graft.
Fig. 19.13 (a, b) Through the arthroscope, we check the reduction of the LT interval. Then, a second PEEK screw is inserted into the lunate through the 3–4 portal to secure the tendon transfer.
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Fig. 19.15 The tendon graft is brought back to the dorsal side of the triquetrum.
Fig. 19.14 We establish a room for the tendon graft outside the capsule, however palmar of the extensor tendons.
Video 19.6 At the end of the procedure, the LT interval is tested. It is no longer possible to enter the probe into the interval.
Fig. 19.16 The tendon graft is secured to itself by nonresorbable sutures.
Fig. 19.17 We use the remaining part of the ECU tendon slip to reinforce the DRC ligament by passing the tendon slip in a proximal direction to the dorsal, ulnar side of the radius.
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Fig. 19.18 The tendon slip is fixed to the radius using a bone anchor.
19.3 Closure and Postoperative Care We finalize the surgery by closing all wounds and applying sutures to the bigger wounds and strips to the smaller incisions. We apply an above-elbow cast that we leave on for 2 weeks, then we change the dressings and give the patient a below-elbow cast where we include the epicondyles to prevent rotation of the forearm. The wrist is immobilized for 8 weeks before the hand therapist sets up a rehabilitation program. Full weight-bearing and normal activity is allowed after 5 months.
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Fig. 19.19 The exposure of the wrist is used while performing an open reconstruction of the LT ligament.
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19.4 Conclusion Reconstruction of the LT lig with an open repair has been our treatment of choice for chronic LT lig lesions causing pain and reduction of daily activities for patients. The open procedure leaves big scars and necessitates going through the ligaments with the potential of injuring the nerves. We think the arthroscopic-assisted technique could be a better way to treat these patients.
References [1] Haugstvedt JR. LT tears and arthroscopic repair. In: Piñal Fd, Mathoulin C, Nakamura T eds. Arthroscopic management of ulnar pain. Berlin; New York: Springer; 2012:213–36 [2] Shin AY, Battaglia MJ, Bishop AT. Lunotriquetral instability: diagnosis and treatment. J Am Acad Orthop Surg. 2000; 8(3):170–179
Fig. 19.20 The wounds after an arthroscopic assisted LT ligament reconstruction.
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20 Arthroscopic-Assisted Fixation of Trans-Scaphoid Perilunate Dislocation Wendong Xu
20.1 Introduction Trans-scaphoid perilunate dislocation (TSPD) is a highenergy trauma, which usually occurs in young patients.1 The characteristic features of the TSPD are scaphoid fracture, dislocation of the capitate from the lunate, and lunotriquetral ligament injuries (▶ Fig. 20.1a, b). Percutaneous fixation under fluoroscopic guidance is a popular option for the treatment of acute TSPD.2 In the clinical practice, it is not uncommon that the TSPD could not be successfully reduced without open surgery. Thus, open reduction and internal fixation are often recommended.3,4 However, aggressive surgical interventions, which involve inevitable soft-tissue dissection, can adversely affect the carpus. This chapter introduces a less invasive technique of arthroscopic-assisted fixation of irreducible TSPD.
scaphoid space. The 1–2 portal is used to pass instruments. After debridement of the synovium, the distal part of scaphoid is found shifting dorsally to the proximal part (▶ Fig. 20.4, ▶ Video 20.1).
20.2.3 Midcarpal Arthroscopy and Exploration The radiocarpal arthroscopy is initiated through the midcarpal radial (MCR) and the midcarpal ulnar (MCU) portals. The lunate could not be found among the scaphoid, capitate, and triquetrum, which would be filled with synovium (▶ Fig. 20.5). Synovectomy of the midcarpal joint is performed with shaver and radiofrequency probe.
20.2 Operative Technique 20.2.1 Patient Preparation and Positioning Brachial plexus regional anesthesia is performed with the patient in a supine position. The arm is abducted to 90°, with the elbow flexed to 90°, and resting on a hand table. A tourniquet is used at the proximal part of the arm. After a traction tower is applied with finger traps, closed reduction is attempted, but quite often, the fluoroscopy shows that the closed reduction failed (▶ Fig. 20.2). Palpation shows that lunate is absent among the scaphoid, capitate, and triquetrum (▶ Fig. 20.3).
20.2.2 Radiocarpal Arthroscopy and Synovectomy The radiocarpal arthroscopy is initiated through the 3–4 portal, and lots of red synovium is found in radial
Fig. 20.2 The fluoroscopy shows that the closed reduction failed.
Fig. 20.1 (a) Lateral view of trans-scaphoid perilunate dislocation (TSPD). (b) Frontal view of the TSPD.
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Fig. 20.4 Arthroscopic view from the 3/4 portal. The distal part of scaphoid (blue arrow) was found shifting dorsally to the proximal part (red arrow).
Fig. 20.3 Palpation shows that lunate was absent among the scaphoid, capitate, and triquetrum.
Video 20.1 Video showing the different steps of treatment of trans-scaphoid perilunate dissociation.
20.2.4 Dissection of the Volar Capsule After the synovectomy of the midcarpal joint, with the scope in the MCU portal, a probe is inserted into the MCR portal to dissect the volar capsule of scaphoid and lunate, and push out the RSC ligament (▶ Fig. 20.8a, b). During the dissection, the carpal bones reduce gradually. Then, the scaphoid could reduce without the blocking of the RSC ligament (▶ Fig. 20.9a, b). Fig. 20.5 View from the MCR portal. Lunate could not be found among the scaphoid, capitate (blue arrow), and triquetrum, which was filled with synovium (red arrow).
Volar capsule rupture could be found after debridement, whereas the arc ligament might be still intact (▶ Fig. 20.6a, b). Nevertheless, radioscaphocapitate (RSC) ligament could be stuck in the scaphoid fracture site, which would be blocking reduction (▶ Fig. 20.7a, b).
20.2.5 Assessment of Intercarpal Ligaments Stability With the scope in the MCR portal, a probe is inserted into the MCU portal to assess the stability of scapholunate and lunotriquetral ligaments. During the assessment, the traction should be temporally reduced. It could be found that the probe could be easily inserted into, which indicates a complete rupture of lunotriquetral ligaments (▶ Fig. 20.10a, b, ▶ Fig. 20.11a, b).
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Fig. 20.6 (a) Arthroscopic view from the MCR portal showing the scaphoid insertion of the arc ligament. (b) Arthroscopic view from the MCR portal showing the triquetrum insertion of the arc ligament.
Fig. 20.7 (a) Arthroscopic view from the MCR portal showing that the radioscaphocapitate ligament (blue arrow) could be stuck in the scaphoid fracture site. (b) Arthroscopic view from the midcarpal ulnar portal (MCU) showing that the radioscaphocapitate ligament (blue arrow) could be stuck in the scaphoid fracture site.
Fig. 20.8 (a) Arthroscopic view showing dissection of the volar capsule (view from the MCU portal) and the debridement of the scaphoid fracture site. (b) Arthroscopic view showing dissection of the volar capsule (view from the MCU portal) pushing out the RSC ligament from the scaphoid fracture site.
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Fig. 20.9 (a) Arthroscopic view from the MCR portal showing the dislocation of scaphoid fracture reduced after debridement. (b) Arthroscopic view from the MCU portal showing the dislocation of scaphoid fracture reduced after debridement.
Fig. 20.10 (a) Arthroscopic view from the MCU portal, showing the assessment of intercarpal ligaments stability, the probe could not be inserted between scaphoid and lunate. (b) Arthroscopic view from the MCR portal, showing the assessment of lunotriquetral stability, indicating a complete rupture.
Fig. 20.11 (a) Arthroscopic view from the 3–4 radiocarpal portal showing the assessment of scapholunate stability and intact scapholunate ligament. (b) Arthroscopic view from the 6R radiocarpal portal showing the assessment of lunotriquetral stability with a complete rupture.
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20.2.6 Screw Fixation of Scaphoid A guidewire is inserted from the distal volar tubercle of scaphoid to the proximal pole. The proximal tip of the guidewire could be seen by the arthroscope via radiocarpal 6R portal. The scaphoid is then prepared using a cannulated drill. With the guidance of the wire, a cannulated screw is inserted into the scaphoid. Then, the guidewire is removed.
20.2.7 K-Wire Fixation of Lunotriquetral Joint Two K-wires are drilled from the ulnar side of the triquetrum to fix the lunotriquetral joint, after verified by fluoroscopy (▶ Fig. 20.12a, b).
20.2.8 Assessment of Stability after Fixation After the reduction and fixation of the carpal bones, the assessment of stability was performed again. The scope was inserted into the MCU portal, and a probe was inserted into the MCR portal to check the scaphoid and lunotriquetral space. The scaphoid fracture showed an excellent stability (▶ Fig. 20.13), and so did the lunotriquetral ligament (▶ Fig. 20.14).
20.2.9 Closure and Postoperative Care The portals used could be closed with sterile stripes. A splint is used for four weeks, and passive exercise begins. The K-wires should be removed after 6 weeks. Fig. 20.12 (a) Radiograph showing lateral view after fixation. (b) Radiograph showing frontal view after fixation.
Fig. 20.13 Arthroscopic view from the MCU portal showing the scapholunate stability after the reduction and fixation of the scaphoid.
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Fig. 20.14 Arthroscopic view from the MCR portal showing the lunotriquetral stability after the reduction and fixation of the lunotriquetral space.
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20.3 Conclusion The arthroscopic-assisted fixation of the TSPD is a minimally invasive procedure for irreducible TSPD. The exploration of the ligament blocking is the key for a successful reduction. The assessment of ligament injuries is also essential to determine the treatment options for the surrounding structures.
References [1] Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J. Perilunate dislocations and fracture-dislocations: a multicenter study. J Hand Surg Am. 1993; 18(5):768–779 [2] Chou YC, Hsu YH, Cheng CY, Wu CC. Percutaneous screw and axial Kirschner wire fixation for acute transscaphoid perilunate fracture dislocation. J Hand Surg Am. 2012; 37(4):715–720 [3] Knoll VD, Allan C, Trumble TE. Trans-scaphoid perilunate fracture dislocations: results of screw fixation of the scaphoid and lunotriquetral repair with a dorsal approach. J Hand Surg Am. 2005; 30(6):1145– 1152 [4] Lutz M, Arora R, Kammerlander C, Gabl M, Pechlaner S. [Stabilization of perilunate and transscaphoid perilunate fracture-dislocations via a combined palmar and dorsal approach]. Oper Orthop Traumatol. 2009; 21(4–5):442–458
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21 Volar Capsuloligamentous Suture as Treatment of Volar Midcarpal Instability 21.1 Introduction Midcarpal instability, as described by Lichtman in 1981,1 is a rare condition that occurs mainly in young people after a sport-related accident. Testing of the midcarpal joint provokes significant painful clicking due to midcarpal pivot shift.2 In most patients, the pathophysiology of volar midcarpal instability is secondary to volar capsuleligament injury due to stretching or avulsion of the arcuate ligament (the triquetrohamatocapitate [THC] and radioscaphocapitate [RSC] ligaments) and the long radioulnar (LRL) ligament (▶ Fig. 21.1a, b and ▶ Fig. 21.2a, b, ▶ Video 21.1). Imaging reveals dorsal intercalated
segment instability (DISI) tilting of the second row of carpal bones along with volar intercalated segmental instability (VISI) tilting of the first row.2 Treatment of volar midcarpal instability continues to be challenging, as no method has shown to be effective. Conservative procedures, such as open ligament reconstruction or capsulodesis, not only stabilize the joint, but also cause significant stiffness.3,4 Palliative procedures have severe functional consequences, even though they are typically used as a last resort for these injuries. Arthroscopic thermal volar capsulorrhaphy has been described but its use is limited to partial tears.5
Fig. 21.1 (a) Drawing of the extrinsic volar ligament complex in a right wrist. The tears result in volar midcarpal instability. UC, ulnocapitate or ulnotriquetrocapitate ligament; LRL, long radiolunate ligament; RCS, radioscaphocapitate ligament. (b) Arthroscopic view of the midcarpal area of a left wrist showing an intact extrinsic ligament complex after synovectomy; UC ligament is on the left, RCS on the right, and distal end of LRL in the lower-middle part.
Fig. 21.2 Drawings of frontal (a) and lateral (b) views of torn and stretched volar extrinsic ligaments at the volar midcarpal joint, leading to volar midcarpal instability.
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Video 21.1 Video showing the torn and stretched volar extrinsic ligaments at the volar midcarpal joint, leading to volar midcarpal instability
21.2 Operative Technique 21.2.1 Patient Preparation and Positioning
Fig. 21.3 Drawing of a stretched volar ligament complex (UC, RSC, and LRL) when tested with a hook probe.
Surgery is generally performed on an outpatient basis under regional anesthesia. The patient is placed supine, with the arm resting on an arm board with an attached tourniquet. A standard traction tower (5–7 kg or 11–15.5 lbs.) is used during the arthroscopic procedures.
21.2.2 First Phase: Arthroscopic Exploration Using a dorsal approach with the scope in the 6R portal and hook probe in 3–4 portal, arthroscopic radiocarpal joint exploration reveals loosening of the extrinsic volar ligament complex, especially the RSC and long radioulnar (LRL) ligaments. Probe testing of these structures reveals significant loss of tension. The midcarpal radial (MCR) and midcarpal ulnar (MCU) portals are used next. The volar aspect is often hidden under a thick synovial membrane that must be removed to inspect the volar ligaments. The volar arcuate ligament complex, which consists of the THC (ulnar limb of arcuate ligament) and RSC (radial limb) ligaments, will often be avulsed or stretched (▶ Fig. 21.3, ▶ Video 21.2). All of the ligaments are identified and their insertions abraded with a shaver.
21.2.3 Second Phase: Volar Ulnar Approach The volar ulnar (VU) approach is carried out through a 2cm longitudinal incision along the ulnar side of the flexor digitorum tendons over the proximal wrist crease (▶ Fig. 21.4, ▶ Video 21.3).6 The flexor tendons are reflected to the radial side. A needle is inserted into the
Video 21.2 Video showing a stretched volar ligament complex (UC, RSC, and LRL), when tested with a hook probe.
midcarpal joint at the level of the arcuate ligament under visual guidance with the scope placed in the MCR portal. This step can be facilitated by using an inside-out VU approach (▶ Fig. 21.5a, b, Chapter 2).
21.2.4 Third Phase: Volar CapsuleLigament Suturing The scope is placed in the MCR portal. Using the VU incision, a 3–0 (polydioxanone) PDS suture is inserted through a needle into the ulnar limb of the arcuate ligament (the THC ligament) (▶ Fig. 21.6). A second 3–0 PDS suture and needle are then introduced into the distal limb of the arcuate ligament (RSC ligament) through the same incision. A third PDS suture is then inserted into the proximal part of the midcarpal joint where the LRL
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21.2.5 Postoperative Care The wrist is immobilized in neutral position after the surgery with a removable volar splint used for 6 weeks. Hand-intensive activities can be reinitiated starting 2 months after surgery.
21.3 Conclusion Treatment of volar midcarpal instability is challenging; the surgeon must sometimes resort to extensive palliative methods. With wrist arthroscopy, the extent of the injuries can be accurately assessed and volar capsule and ligament suturing performed in the same manner as with scapholunate dissociation (Chapter 15). The initial results are encouraging, but a longer follow-up, with a greater number of patients, is needed to validate this promising surgical technique.
Video 21.3 Video showing the volar midline incision used to reflect flexor tendons and median nerve and access the volar side of the articular capsule
Fig. 21.4 Intraoperative view of the volar midline incision used to reflect flexor tendons and median nerve and access the volar side of the articular capsule; in this particular patient, an Henry anterior approach was also performed to remove a radius plate.
Fig. 21.5 (a) Intraoperative view of a blunt trocar inserted through the MCR portal and pushed forward at the volar capsuleligament injury site to help localize the volar midline incision. (b) Arthroscopic view of a blunt trocar guide passing through the midcarpal joint.
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Fig. 21.6 Drawing of the first outside-in suture passing through one of the torn ligament components.
Fig. 21.7 Drawing of three outside-in sutures passing through the volar aspect and capturing the three ligaments (UC, RSC, and LRL).
Fig. 21.8 (a) Arthroscopic view of the three sutures tied together outside the joint before volar traction is applied. (b) Drawing of the volar knot flattened against the intraarticular surface of the three ligaments.
Video 21.4 Video showing the three sutures in the midcarpal joint.
Video 21.5 Video showing the three sutures tied together outside and the volar knot flattened against the intra-articular surface of the three ligaments.
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Video 21.6 Video showing the last volar knot being tied.
Fig. 21.9 Drawing of last volar knot being tied; this knot will close the gap between the three torn ligaments.
Video 21.7 Video showing the end of surgical procedure.
Fig. 21.10 (a, b) Drawings of final suture placement between the three ligaments on the frontal and lateral views with VISI deformity reduced.
References [1] Lichtman DM, Schneider JR, Swafford AR, Mack GR. Ulnar midcarpal instability-clinical and laboratory analysis. J Hand Surg Am. 1981; 6 (5):515–523– eng [2] Lichtman DM, Wroten ES. Understanding midcarpal instability. J Hand Surg Am. 2006; 31(3):491–498– eng [3] Lichtman DM, Bruckner JD, Culp RW, Alexander CE. Palmar midcarpal instability: results of surgical reconstruction. J Hand Surg Am. 1993; 18(2):307–315– eng
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[4] Hwang MD, Klinefelter R. Palmar midcarpal instability. J Hand Surg Am. 2013; 38(3):565–568– eng [5] Mason WT, Hargreaves DG. Arthroscopic thermal capsulorrhaphy for palmar midcarpal instability. J Hand Surg Eur Vol. 2007; 32(4):411– 416– eng [6] Slutsky DJ. The use of a volar ulnar portal in wrist arthroscopy. Arthroscopy. 2004; 20(2):158–163– eng
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22 Arthroscopic-Assisted Fixation of Intra-Articular Distal Radius Fractures 22.1 Introduction Intra-articular fractures of the distal radius need to be anatomically reduced, but this is often very difficult to achieve using standard open surgical techniques. Knirck and Jupiter1 showed the importance of complete reduction; any persistent step-off of 2 mm or more will likely lead to the development of arthritis. Wrist arthroscopy has changed how these fractures are treated. It can be used to ensure the fracture is completely reduced and gives the surgeon the ability to view and treat any associated injuries. In addition, new plates with distal locking screws have streamlined the fixation process.
22.2 Operative Technique (J. M. Cogent) 22.2.1 Patient Preparation and Positioning The patient lies supine with the arm abducted to 90° and resting on a hand table. The procedure is typically performed with regional anesthesia. The surgeon stands at the patient’s head, and the assistant stands across from the surgeon; the fluoroscopy unit is placed at the patient’s feet and the arthroscopy tower is located on the side of the non-operated arm (▶ Fig. 22.1). Traction must be able to be applied and removed as many times as necessary during this procedure; thus, the use of a sterile wrist traction tower or sterile finger traps is recommended.
Fig. 22.1 Drawing of the relative position of the surgical team: the surgeon is at the patient’s head, and the assistant is across from the surgeon.
All of the standard arthroscopy portals may be used during arthroscopic-assisted distal radius fracture fixation. The anterior portals can be useful for some fractures located on the posterior margins.
22.2.2 First Surgical Phase: Provisional Fixation There is no specific instrumentation for arthroscopicassisted fixation of intra-articular distal radius fractures. Surgeons are free to use their preferred instrumentation. Provisional fixation aims to achieve acceptable reduction–stabilization based on intraoperative fluoroscopy controls, while allowing the fixation to be subsequently altered based on arthroscopic findings. The use of locking plates simplifies fracture fixation and ensures good distal stability. Screw fixation is used only in cases of isolated lateral radial styloid fractures (▶ Fig. 22.2). K-wires are used from time to time to hold the articular fragments or prop up the articular surface. The Henry anterior approach passes between the radial neurovascular bundle laterally and flexor carpi radialis medially. After identifying the flexor pollicis longus (FPL), a Beckmann retractor is placed between the radial neurovascular bundle and the flexor digitorum superficialis, flexor digitorum profondus, and flexor pollicis longus tendons. The pronator quadratus is detached from its radial insertion and abraded with a rasp. The extra-articular portion of the fracture site is exposed. The fracture can be initially reduced by pulling the distal radius along its main axis and, if needed, by using a thin bone rasp
Fig. 22.2 Drawing of the fixation of an isolated radial styloid fracture using a cannulated screw after reduction performed under arthroscopic control.
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Video 22.1 Video showing the first step of surgical procedure with the placement of the volar plate.
is to evaluate reduction quality, cartilage damage, and intrinsic and extrinsic ligament involvement. Fig. 22.3 Drawing of the placement of a volar buttress plate secured with a single screw in the oval slot; this allows the position of the plate to be adjusted as needed later on in the procedure.
(3 mm) to consolidate the bone fragments. A volar locking plate is secured through its oval slot to the volar side of the radius with a non-locking screw (▶ Fig. 22.3, ▶ Video 22.1). If the fragments are displaced posteriorly, one or two K-wires are manually inserted into the dorsal side of the distal radius through the fracture line and pushed into the radial shaft. The quality of the reduction is verified by fluoroscopy. One or two locking screws are inserted into the epiphyseal portion of the plate over the areas that show the best reduction on the fluoroscopy images. The posterior K-wires (if they were used during the reduction) are then removed so as to not interfere with the arthroscopy phase. If volar plate fixation is being used, not every epiphysis screw should be inserted right away. If any of these screws have to be changed after the arthroscopy inspection, the profusion of bone tunnels will negatively affect the construct’s stability.
22.2.3 Second Surgical Phase: Arthroscopic Evaluation Traction is placed on the wrist with the forearm pointing upwards. The elbow is flexed to 90° and 5 to 7 kg (11– 15.5 lbs.) of traction is applied. The arthroscopy portals may be difficult to identify because of fracture-related edema. The scope is introduced into the 3–4 portal and the shaver into 4–5 or 6R portal. The hemarthrosis associated with an intra-articular distal radius fracture will interfere with the view of the joint; a lavage step is performed before starting the exploration to remove the accumulated blood. The goal of arthroscopic exploration
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Fracture reduction and fixation Several scenarios may exist: ● The fracture is completely reduced and the ligaments are not injured; fracture fixation must be finalized. Postoperative recovery will be similar to that for extraarticular distal radius fracture. ● The fracture is not anatomically reduced and there is an articular step-off or subsidence: reduction maneuvers must be performed under arthroscopic control. Any large fragments can be reduced using a spatula or hook probe (▶ Fig. 22.4 and ▶ Fig. 22.5, ▶ Video 22.2 and ▶ Video 22.3). In cases of central subsidence (die-punch fracture), the fragment can usually be lifted up with a hook probe. Stabilization can then be achieved with small K-wires or locking screws that prop up the articular fragments. If the fracture is comminuted, the joystick method can be used to move the various fragments around and reduce them. A K-wire is drilled into one of the fragments that need to be reduced. The surgeon can use the proximal end of the K-wire to manipulate this fragment, reduce it, and then stabilize it by driving the K-wire further in. If needed, a K-wire or small tendon rasp can also be inserted into the metaphysis through a small incision over the fragment that needs to be reduced. The scope may need to be moved, depending on which area has beenimpacted. If the subsidence affects the dorsal part of the scaphoid fossa, reduction will be impossible with the scope in the 3–4 portal – it must be moved to a volar portal or the 6R portal. If the subsidence affects the lunate fossa, the scope may be placed in 1–2 or 6R. ● The fracture cannot be reduced because the central articular fragment is overly affected; indirect reduction can be attempted. A dorsal incision is made proximal to Lister’s tubercle to carry out a shortened corticotomy. A small diameter osteotome (5 mm) is inserted through the corticotomy and tapped with a hammer to lift the
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Fig. 22.4 Drawing of intra-articular fragments being reduced with a probe. The lateral fragment has been temporarily fixed with a dorsal K-wire.
Fig. 22.5 Drawing of locking plate fixation of the reduced fragments after the temporary K-wire has been removed.
Video 22.2 Video showing the first step of intra-articular reduction of three fragments distal radius fracture.
Video 22.3 Video showing the intra-articular final reduction of three fragments distal radius fracture.
central fragment. The extensor pollicis longus tendon requires special attention, as it is often ruptured in this type of fracture. If complete reduction is achieved with this method, bone substitute is packed into the tract left by the bone tamp to stabilize the reduced articular fragment (▶ Fig. 22.6 and ▶ Fig. 22.7, ▶ Video 22.4 and ▶ Video 22.5). The fracture is comminuted, with no possibility of arthroscopic-assisted intra-articular reduction. There are two options in this case: add an incision on the dorsal side to attempt to improve the reduction or leave it as is.
Detection of associated lesions Associated lesions often determine the prognosis. The first priority is to evaluate the scapholunate ligament, as it is torn in 30% of cases and a tear can lead to secondary
osteoarthritis. The goal is to induce peripheral wound healing by abrading the posterior capsule and then performing either dorsal capsule-to-ligament suture repair or scapholunate and scaphocapitate pinning, with the Kwires left in place for 6 to 8 weeks. The lunotriquetral ligament and triangular fibrocartilage complex (TFCC) must also be evaluated. If the lunotriquetral ligament is torn, lunotriquetral pinning is carried out and left in place for 6 to 8 weeks. If the TFCC is injured, the exact nature of the injury must be determined: ● Central perforation: often degenerative in nature and not related to trauma, and thus does not require treatment. ● Peripheral detachment: repaired based on the surgeon’s preferences but requires 6 weeks of immobilization to achieve good healing.
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Fig. 22.6 Drawing of a large impacted central fragment (diepunch fracture) being reduced with a probe. This type of fragment is easier to reduce with arthroscopic assistance.
Video 22.4 Video showing the first step of intra-articular reduction of multiple fragments distal radius fracture.
●
Foveal detachment: leads to distal radioulnar joint (DRUJ) instability; if DRUJ instability is found after fracture fixation, the foveal portion of the TFCC must be reattached during the same procedure.
The radiocarpal and midcarpal joints are also examined to verify the integrity of the articular surfaces of the wrist bones. It is also important to make sure that none of the carpal bones are damaged, especially the scaphoid.
22.2.4 Third Surgical Phase: Final Fixation The fracture fixation is finalized. If the surgeon decided to use a locking plate, all of the epiphyseal screws will be placed as close as possible to the articular surface. If
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Fig. 22.7 Drawing of locking plate fixation after the central fragment has been reduced.
Video 22.5 Video showing the intra-articular final reduction of multiple fragments distal radius fracture.
possible, these screws should be inserted under arthroscopic guidance to avoid losing the reduction when arm traction is released and to make sure the screw tips do not protrude into the joint. The entire surgical procedure (provisional fixation, arthroscopic evaluation, and final fixation) must not exceed 90 minutes; otherwise, there is a risk of postoperative edema.
22.2.5 Postoperative Care Postoperative care varies depending on the arthroscopic findings: ● If the fracture was anatomically reduced and no ligaments were torn, recovery is similar to that for extra-articular distal radius fractures. If a locking plate
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●
was used, rehabilitation can be initiated immediately after surgery and a splint can be worn for 15 days to provide pain relief. If the fracture was pinned, a splint is worn for 6 weeks and rehabilitation started afterward. If the reduction was incomplete, the radial articular surface was comminuted, reduction of the articular surface required several small-diameter K-wires, or a scapholunate tear required scapholunate and scaphocapitate pinning, a removable brace is worn for 6 weeks. Rehabilitation is initiated once the K-wires have been removed.
Postoperative recovery depends on the fixation method selected and the presence of additional lesions detected during arthroscopic examination.
22.3 Conclusion Arthroscopy is a very useful tool for the diagnosis and treatment of intra-articular distal radius fractures. It allows the surgeon to verify the reduction and then to fine-tune it as needed. It also allows associated injuries to be diagnosed and treated; these typically go undetected and may cause the development of wrist osteoarthritis. It is a difficult technique that can become very timeconsuming.
Reference [1] Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 1986; 68(5):647–659
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23 Arthroscopic-Guided Osteotomy for Distal Radius Malunion Francisco del Piñal
23.1 Introduction “Arthroscopy is the ‘missing link’ to achieving a perfect result in distal radius fractures (DRF).” (Piñal in Green 2018) Intra-articular malunion of the radius causes considerable interference with a patient’s life: limited and painful range of motion is the norm (▶ Fig. 23.1). Most malunion cases occur because of inappropriate management of the original fracture, and more rarely due to secondary subsidence. The former is usually due to not using the arthroscope as the checking tool, at the time of fracture management, but the fluoroscope. Indeed, restoring joint anatomy is the main goal when dealing with a DRF. Imaging with a mini-fluoroscopy is the more common technique for assessing fracture reduction in the operating room (OR). Several papers, however, have demonstrated limitations and poor reliability of this imaging modality for this particular, and similar, applications in our field.1–3 Excellent results have been reported by “outside-in” technique in the treatment of intra-articular malunion.4,5 However, difficulties were noted with visualization once a reduction was achieved and the procedure relied heavily on fluoroscopy rather than direct visualization, which, as stated, is not a very reliable instrument. We devised a technique with arthroscopy that, under good light and magnification, allowed us to precisely trace the cartilage line of the old fracture with the osteotome. In this way, the possibility of wrong-site fracture during the
osteotomy does not exist, thus converting a malunion into an acute fracture.6,7
23.2 Indications and Contraindications Diagnosis of a malunion is often evident from the plain X-rays (▶ Fig. 23.2). Nevertheless, a CT scan with cuts in pure orthogonal planes is invaluable in the decisionmaking process and for surgeon’s orientation at the time of the arthroscopy (▶ Fig. 23.3). Traditionally, a 2 mm or greater step-off of the distal radius articular surface was considered an indication for osteotomy. Each patient should be considered on an individual basis. In a young active patient, even a 1-mm stepoff in the lunate or scaphoid facet should be considered for repair. Alternatively, a low-demand patient with a similar step-off may benefit from a resection arthroplasty, i.e., from leveling the joint—the latter having a much more benign postoperative course. An additional consideration is the status of the cartilage, which again requires experience to take the appropriate decision. In general, the longer time between the fracture and the visit, and the more the patient has attempted to move the joint, the less cartilage will remain. As a rule, no exact contraindications for the procedure can be given. Factors such as—more than 6 months after the fracture; very committed patients in
Fig. 23.1 This 59-year-old patient sustained bilateral distal radius fractures, which were surgically treated elsewhere. Given the continued pain and loss of range of motion on the left wrist, the patient sought a second opinion at 8 weeks post-surgery. (Copyright © Dr Piñal, 2018)
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Fig. 23.2 (a, b) PA and lateral radiographs demonstrated a distal radius malunion with articular incongruity, the apparent loss of radial height, and persistent dorsal angulation with secondary carpal adaptations. A CT scan was ordered to better delineate the malunion. (Copyright © Dr Piñal, 2018)
Fig. 23.3 (a–c) The CT scan confirmed the degree of articular disruption and distal radius malunion. Given these findings, corrective extra- and intra-articular osteotomies were advised. (Copyright © Dr Piñal, 2018)
rehabilitation; and, presence of hardware in the joint—all cast a shadow over the possibility of restoration of the joint. By the same token, in order to prevent further damage, when a patient is seen in the office with a step-off, the physical therapy is to be called off immediately. Furthermore, a splint should be applied while the CT studies are done and surgery scheduled to minimize motion.
23.3 Operative Technique All patients with an intra-articular malunion in the author’s practice are managed similarly. First of all, an arthroscopic exploration is performed. Owing to the large portals needed to introduce the osteotomes, it is paramount that the surgeon adheres to the dry technique,8,9
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Arthroscopic-Guided Osteotomy for Distal Radius Malunion as otherwise constant loss of vision will occur due to lack of watertightness. The only special instruments we use are the osteotomes and periosteal elevators borrowed from the shoulder and knee trays. These are 4-mm wide and with different angulations to access to the always tight wrist (▶ Fig. 23.4). Under tourniquet, the hand is set in traction from an overhead bow. Traction of 12 to 15 kg is evenly applied to all fingers. Establishing the portals is more difficult than in a standard arthroscopy as the space is collapsed by scar tissue. Once the scar tissue is removed, the cartilage is carefully assessed and a decision is made as to whether the osteotomy is feasible. Basically, if the cartilage is mostly preserved, I will go ahead with the osteotomy. Contrarily, if the cartilage is worn, I prefer to carry out some form of salvage operation: ideally an arthroscopic arthroplasty or a transplant of vascularized cartilage.10–12 If the damage is diffuse, the option would be to consider an arthroscopic radioscapholunate fusion.13,14 Typically, once the surgeon has opted for an arthroscopic guided osteotomy, the hand is set on the table and a standard volar-radial approach is carried out exposing the radius. This is needed, above all, not only to remove
the volar callus, but also because there is often hardware to be removed. Furthermore, a volar plate will be used for fixation and has to be preset at this point. Removing the extra-articular callus will weaken the fragment connection. However, no attempt to release the fragments is made at this stage, as they may break at the wrong spot intra-articularly. The hand is now set in traction, and depending on the type of malunion and the location of the step-off, the so-called straight or tear-line osteotomies are carried out. From a technical standpoint, straight cuts with the straight osteotome are the easiest but only possible when the fracture line is straight and in line with one of the portals (▶ Fig. 23.5). For those malunions not amenable to this simple osteotomy (such as any coronal fracture line), multiple perforations are made with the osteotome creating a sort of “tear line” in the cartilage and subchondral bone for easy breakage when prying with the osteotome (▶ Fig. 23.6). Given the space limitations and the fact that quite commonly the malunions are irregular, one has to be prepared to use any portal, any osteotome, and combinations of linear and tear-line osteotomies in order to manage a given malunion.
Fig. 23.4 (a, b) Instruments used during the procedure. From above to below: shoulder periosteal elevator (of 15 and 30° angle) (Arthrex® AR-1342–30° and AR-1342–15°, Arthrex, Naples, FL) and straight and curved osteotomes (Arthrex® AR-1770 and AR1771). (In Ref. 15. Copyright © Dr Piñal, 2018)
Fig. 23.5 Straight line osteotomy. (In Ref. 15. Copyright © Dr Piñal, 2018)
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Fig. 23.6 Tear line osteotomy. (In Ref. 15. Copyright © Dr Piñal, 2018)
Fig. 23.7 Taking into account the preoperative images, the author came up with this sketch. During arthroscopy, scar tissue within the radiocarpal joint is debrided thereby delineating the magnitude of the articular incongruity. (Copyright © Dr Piñal, 2018)
Once the fragment is mobilized, the redundant callus and fibrous tissue are removed from inside and outside the joint, until easily reducible. Hitherto, the case is managed as for an acute fracture.15 The highlights of the surgical management of the case introduced in ▶ Fig. 23.1, ▶ Fig. 23.2, ▶ Fig. 23.3 are presented in ▶ Fig. 23.7, ▶ Fig. 23.8, ▶ Fig. 23.9, ▶ Fig. 23.10, ▶ Fig. 23.11, ▶ Fig. 23.12, ▶ Fig. 23.13, ▶ Fig. 23.14 and the arthroscopy in ▶ Video 23.1.
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23.4 Conclusion
Fig. 23.8 The next step of the procedure comprised removal of the volar plate and of the volar callus from the radial shaft. Note that the radial styloid fragment was relatively well aligned to the shaft of the radius, whereas the volar ulnar fragment was malreduced. Any attempt to mobilize the fragments is delayed until the intra-articular osteotomies are performed as doing so may cause further fragmentation. (Copyright © Dr Piñal, 2018)
The arthroscopic guided osteotomy allows delineation of the original fracture line with minimal additional cartilage injury. The operation enables the surgeon to obtain an anatomic reduction while minimizing the possibility of wrong-site fracture. In the author’s experience with intra-articular osteotomies, excellent results can be consistently achieved if one adheres to the described surgical steps. The reader should be warned that the operation ranks among the most difficult arthroscopic procedures a surgeon can be faced with in the wrist. Furthermore, substantial education in the classic management of distal radius fractures is required. Otherwise, we risk throwing the patient into a catastrophic situation (▶ Fig. 23.15, ▶ Fig. 23.16). The operation with classic arthroscopic technique (wet arthroscopy) is impracticable, thus familiarity with the dry arthroscopic technique is paramount.
Fig. 23.9 With the scope placed within the 6R portal, a curved osteotome was introduced through 3–4 portal to perform the intra-articular osteotomies. Finally, the osteotome was “rocked” until the radial fragment was eventually freed. (Copyright © Dr Piñal, 2018)
Fig. 23.10 The volar distal radius plate was applied and fixed to the distal ulnar fragment (circle) only. (Copyright © Dr Piñal, 2018)
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Fig. 23.11 By using the plate as a reduction tool, the malpositioned lunate facet fragment is anatomically reduced as described by Lanz’s technique for pure extra-articular malunions. (Copyright © Dr Piñal, 2018)
Fig. 23.12 After securing the lunate facet, attention is diverted to reducing the scaphoid fossa fragment. Note it is slightly over-reduced, using the anatomic lunate facet as a guide the fragment is depressed with a periosteal elevator (1) and the radial fragment compressed with the thumb (2). The assistant secures the scaphoid facet with a K-wire (3) followed by screw fixation into the plate (4). (Copyright © Dr Piñal, 2018)
Fig. 23.13 Final arthroscopic view of the corrected intra-articular malunion. (Copyright © Dr Piñal, 2018)
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Fig. 23.14 (a–c) Postoperative CT scan confirming correction of the distal radius articular surface with alignment of the carpus. (Copyright © Dr Piñal, 2018)
Video 23.1 Video showing a clinical case of arthroscopic intraarticular osteotomy for malunion of distal radius fracture.
Fig. 23.15 At 6 months post-surgery, note the improvement in range of motion compared to the preoperative examination. (Copyright © Dr Piñal, 2018)
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Fig. 23.16 (a) This patient was operated on arthroscopically for correcting an articular malunion by the same surgeon who had treated the original fracture 2 years earlier. The result of this first malunion correction (b) was a larger step-off than before and a disastrous functional result (c). The case was retaken by the author and after a second intra-articular osteotomy a good functional outcome was achieved (d). (Copyright © Dr Piñal, 2018)
References [1] Edwards CC, II, Haraszti CJ, McGillivary GR, Gutow AP. Intra-articular distal radius fractures: arthroscopic assessment of radiographically assisted reduction. J Hand Surg Am. 2001; 26(6):1036–1041 [2] Lutsky K, Boyer MI, Steffen JA, Goldfarb CA. Arthroscopic assessment of intra-articular distal radius fractures after open reduction and internal fixation from a volar approach. J Hand Surg Am. 2008; 33(4): 476–484 [3] Capo JT, Kinchelow T, Orillaza NS, Rossy W. Accuracy of fluoroscopy in closed reduction and percutaneous fixation of simulated Bennett’s fracture. J Hand Surg Am. 2009; 34(4):637–641 [4] Ring D, Prommersberger KJ, González del Pino J, Capomassi M, Slullitel M, Jupiter JB. Corrective osteotomy for intra-articular malunion of the distal part of the radius. J Bone Joint Surg Am. 2005; 87(7):1503– 1509 [5] Prommersberger KJ, Ring D, González del Pino J, Capomassi M, Slullitel M, Jupiter JB. Corrective osteotomy for intra-articular malunion of the distal part of the radius. Surgical technique. J Bone Joint Surg Am. 2006; 88 Suppl 1 Pt 2:202–211 [6] del Piñal F, García-Bernal FJ, Delgado J, Sanmartín M, Regalado J, Cerezal L. Correction of malunited intra-articular distal radius fractures with an inside-out osteotomy technique. J Hand Surg Am. 2006; 31 (6):1029–1034
[7] del Piñal F, Cagigal L, García-Bernal FJ, Studer A, Regalado J, Thams C. Arthroscopically guided osteotomy for management of intra-articular distal radius malunions. J Hand Surg Am. 2010; 35(3):392–397 [8] del Piñal F, García-Bernal FJ, Pisani D, Regalado J, Ayala H, Studer A. Dry arthroscopy of the wrist: surgical technique. J Hand Surg Am. 2007; 32(1):119–123 [9] del Piñal F. Dry arthroscopy and its applications. Hand Clin. 2011; 27 (3):335–345 [10] del Piñal F, Klausmeyer M, Thams C, Moraleda E, Galindo C. Arthroscopic resection arthroplasty for malunited intra-articular distal radius fractures. J Hand Surg Am. 2012; 37(12):2447–2455 [11] del Piñal F, Garcia-Bernal JF, Delgado J, et al. Reconstruction of the distal radius facet by a free vascularized osteochondral autograft: anatomic study and report of a case. J Hand Surg Am. 2005; 30A: 1200–1210 [12] del Piñal F, Klausmeyer M, Moraleda E, et al. Vascularized graft from the metatarsal base for reconstructing major osteochondral distal radius defects. J Hand Surg Am. 2013; 38(10):1883–1895 [13] Ho PC. Arthroscopic partial wrist fusion. Tech Hand Up Extrem Surg. 2008; 12(4):242–265 [14] del Piñal F, Tandioy-Delgado F. (Dry) arthroscopic partial wrist arthrodesis: tips and tricks. Handchir Mikrochir Plast Chir. 2014; 46(5): 300–306 [15] del Piñal F. Atlas of distal radius fractures. Thieme, New York. 2018
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24 Arthroscopic-Assisted Scaphoid Fracture Fixation 24.1 Introduction Scaphoid fractures represent 2% of all fractures, 11% of hand fractures, and 60% of wrist fractures. Luckily, these fractures are becoming easier to diagnose due to a better understanding of the clinical signs, physician training, and modern imaging methods such as X-rays, but especially MRI and CT scan. These fractures have typically been treated by cast immobilization, but internal fixation is increasingly used. In the mid-1980s, Herbert and Fischer1 transformed the indications for fracture fixation by developing a scaphoid-specific screw. More recently, the use of cannulated screws has led to the development of percutaneous techniques, which simplify postoperative recovery and, more importantly, preserve vascularization. Nevertheless, it is not unheard of to have minor rotational problems that can lead to delayed union or nonunion. Wrist arthroscopy allows for the evaluation and reduction of scaphoid fractures, while limiting incisions and therefore preserving the scaphoid’s vascularity.
24.2 Operative Technique 24.2.1 Patient Preparation and Positioning Surgery is generally performed on an outpatient basis under regional anesthesia. The patient is placed supine, with the arm resting on an arm board with an attached tourniquet. A standard traction tower is used during the arthroscopic procedures.
24.2.2 First Phase: K-Wire Insertion into the Scaphoid A small, 2-mm anterior volar incision is made through which a 1-mm K-wire is inserted into the scaphoid under
fluoroscopy control (▶ Fig. 24.1a-c). This step can be the most difficult one of the entire procedure. It is important to know how the scaphoid is shaped and oriented. If a rolledup drape is placed under the wrist to extend it to 60°, the K-wire will be about 45° to horizontal. The K-wire is angled from the distal tubercle toward the middle of the carpus. A useful exercise consists of determining the scaphoid’s position by placing a thumb on the distal tubercle and the index on the proximal pole of the scaphoid on the dorsal side of the wrist (▶ Fig. 24.2). It then becomes obvious that the distal tubercle is in line with the flexor carpi radialis, closer to the midline than to the lateral side of the wrist, and that the proximal pole is located in the middle of the wrist. If the wrist is extended without moving the thumb and index from their positions, the scaphoid will feel nearly horizontal. These maneuvers can provide the surgeon with a spatial reference when inserting the K-wire.
24.2.3 Second Phase: Arthroscopic Checking Traction is placed along the wrist’s main axis and the Kwire position is checked in the radiocarpal and midcarpal joints. The radiocarpal inspection is carried out through the 6R and/or 3–4 portals. When properly positioned, the K-wire tip will be visible as it emerges from the scaphoid. The K-wire will be located above the posterior margin of the radius when the wrist is pulled along its axis. The quality of the reduction is evaluated through the midcarpal joint, typically using the MCU portal. One may be surprised to find that, although the reduction appears complete on X-rays, there is a rotation misalignment with a small step-off in the fracture area (▶ Fig. 24.3, ▶ Video 24.1). If the reduction is not satisfactory, the K-wire is removed from the proximal pole but left flush with the distal part of the scaphoid (▶ Fig. 24.4). The assistant pulls on the thumb along its main axis (▶ Fig. 24.5, ▶ Video 24.2).
Fig. 24.1 Drawing (a), intraoperative view (b), and X-ray (c) of the retrograde percutaneous insertion of a K-wire into the scaphoid bone.
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Fig. 24.2 Drawing of bone landmarks on the scaphoid being palpated to determine the scaphoid’s position. After performing small wrist flexion movements, the thumb is placed on the distal tubercle and the index on the proximal pole (red arrows).
Fig. 24.3 Drawing of the midcarpal evaluation of a non-reduced scaphoid fracture.
Video 24.1 Video showing the arthroscopic view of the midcarpal evaluation of a non-reduced scaphoid fracture.
External maneuvers and a hook probe are used to reduce the proximal pole back into the correct position. The Kwire is reinserted up to the proximal pole and the reduction is checked again (▶ Fig. 24.6, ▶ Video 24.3).
Fig. 24.4 Drawing of the K-wire being removed from the proximal pole with the wrist still in traction.
24.2.4 Third Phase: Screw Insertion The hand is released from the traction tower and placed flat on the table (▶ Fig. 24.7a, b). Because of their self-tapping design, modern cannulated screws make internal fixation of the scaphoid easier. Obviously, the screw length must be measured precisely. Fluoroscopy is used continuously throughout this surgical phase.
24.2.5 Final Arthroscopic Checking Traction is placed on the hand again for the final arthroscopic verification steps. First, the quality of the reduction is checked through the midcarpal portal. A few turns can
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Fig. 24.5 Drawing of the arthroscopic reduction method used with a displaced scaphoid fracture: the assistant pulls on the thumb and a probe is then used to reduce the proximal pole onto the distal tubercle under midcarpal and radiocarpal arthroscopic control.
Fig. 24.6 Drawing of the scaphoid after it has been reduced and temporarily secured with the K-wire reinserted into the proximal pole.
Video 24.2 Video showing the reduction method used with a displaced scaphoid fracture: the assistant pulls on the thumb and a probe is then used to reduce the proximal pole onto the distal tubercle under midcarpal and radiocarpal arthroscopic control.
Video 24.3 Video showing the scaphoid after it has been reduced and temporarily secured with the K-wire reinserted into the proximal pole.
be added to the screw as needed to achieve the desired compression (▶ Fig. 24.8 and ▶ Fig. 24.9, ▶ Video 24.4). The intra-osseous positioning of the screw is verified through the portal. This will be easier to do if the K-wire is left in place to serve as reference. In some cases, despite X-rays not revealing any problems, a few of the screw threads jut out through the cartilage. The screw must be removed and another midcarpal check performed to make sure the compression is still correct. If a problem is found, a smaller screw should be inserted (▶ Fig. 24.10, ▶ Video 24.5).
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The small incisions are left open for healing by secondintention. There are no wound healing sequelae.
24.2.6 Postoperative Care If the construct is stable and there are no associated injuries, the range of motion exercises can be initiated right away. A small removable anterior splint can be used to reduce pain, especially during the first few postoperative days. X-rays are performed regularly until union is complete.
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Fig. 24.7 Drawing (a) and intraoperative view (b) of a cannulated screw being inserted into the reduced scaphoid, which is being held by the K-wire.
Fig. 24.8 Intraoperative view of the final screw fixation under arthroscopic control.
Fig. 24.9 Drawing showing the midcarpal evaluation of a completely reduced scaphoid fracture. The red arrows show the compression effect.
Video 24.4 Video showing the midcarpal evaluation of a completely reduced scaphoid fracture.
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Video 24.5 Video showing the radiocarpal inspection performed to ensure that the distal end of the screw does not jut out into the joint space.
Fig. 24.10 Drawing of the radiocarpal inspection performed to ensure that the distal end of the screw does not jut out into the joint space. The red arrows point the area where a part of the screw could jut out of the scaphoid.
highly demanding patients, who understand the advantages and disadvantages of this method. By using arthroscopy, the surgeon can avoid some of the usual pitfalls associated with internal fixation by ensuring that the screw is perfectly positioned and the fracture completely reduced.
Reference 24.3 Conclusion Even for fractures that are not displaced, internal fixation of scaphoid fractures is a commonly used technique in
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[1] Herbert TJ, Fischer WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br. 1984; 66(1):114–123
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25 Arthroscopic Bone Grafting for Scaphoid Nonunion 25.1 Introduction Scaphoid fractures are often initially missed and then diagnosed only once nonunion manifests. Because the natural history of these fractures results in radiocarpal arthritis and ultimately midcarpal arthritis, they must be surgically treated. However, there is still a controversy about what the best treatment strategy is. The various techniques range from less invasive ones, such as percutaneous fixation, to more invasive ones, such as autologous bone grafting from the iliac crest or vascularized bone grafts. Surgical treatment of nonunions can be performed in a minimally invasive manner with arthroscopy. This simplifies postoperative recovery, reduces complications, and preserves the wrist’s capsule-ligament complex—and, thus, the scaphoid’s precarious vascularization.
25.2 Operative Technique 25.2.1 Patient Preparation and Positioning The procedure is performed under regional anesthesia using a tourniquet. The patient’s arm is secured to an arm board. Finger traps are used to apply 5 to 7 kg (11–15.5 lbs.) of traction along the arm’s axis.
25.2.2 Radiocarpal and Midcarpal Exploration The scope is introduced into the 6R portal and the shaver into the 3–4 portal. The integrity of the scapholunate
Fig. 25.1 Drawing of the nonunion site being palpated with a probe.
ligament can be verified using this approach. The quality of cartilage at the proximal pole of the scaphoid and radial styloid process is also verified. If needed, radial styloidectomy can be performed arthroscopically at this point, in the procedure (Chapter 7). Arthroscopic treatment of the nonunion is performed via the midcarpal joint. The scope is introduced into the midcarpal ulnar (MCU) portal and instruments into the midcarpal radial (MCR) portal. The first phase of the arthroscopic procedure consists of complete synovectomy with a shaver.
25.2.3 Nonunion Site Preparation The nonunion site will be visible or will appear as a bone fissure filled with fibrous tissue (▶ Fig. 25.1, ▶ Video 25.1). This fissure can be located with a hook probe. The nonunion site is abraded with a curved curette, shaver, and/or burr in succession (▶ Fig. 25.2, ▶ Video 25.2). The goal is to expose bleeding cancellous bone on both sides, visible by arthroscopy (▶ Fig. 25.3).
25.2.4 Bone Graft Harvesting The bone graft is harvested from the ipsilateral wrist (▶ Video 25.3). An incision is made on the lateral side of the wrist between the first and second extensor compartments. The sensory branches of the radial nerve are identified and protected. The periosteum under the extensor tendons in the first and second compartments are roughened with a bone rasp to free up the graft collection area. A three-sided osteotomy is performed while leaving a “bone cap” attached to the radius (▶ Fig. 25.4). The bone graft is harvested with a curette; the graft’s volume must be larger than the defect being filled (▶ Fig. 25.5). After the graft has been collected, the cap is placed back onto the harvest site. The periosteum will spontaneously move
Video 25.1 Video showing an arthroscopic view of the nonunion from the midcarpal joint.
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Video 25.2 Video showing an arthroscopic view of curettage of the nonunion site with the curette in radial midcarpal portal (MCR) and the scope in ulnar midcarpal portal (MCU).
Fig. 25.2 Drawing of nonunion site being debrided with a burr inserted through the radial midcarpal portal (MCR) with the scope in ulnar midcarpal portal (MCU).
Video 25.3 Video showing the technique for harvesting bone cancellous bone graft from distal lateral aspect of the radius.
Fig. 25.3 Arthroscopic view of the abraded nonunion site after debridement.
Fig. 25.4 Drawing of the bone graft harvesting site. Once the extensor tendons in the first and second compartments have been reflected below the periosteum, a cortical bone cap, still attached on its proximal side, is lifted, allowing access to the cancellous bone in the distal radius.
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Fig. 25.5 Drawing of the graft being collected with a curette.
Fig. 25.6 Drawing of the two extensor compartments being repositioned once the cortical bone cap is replaced after graft collection.
step can be performed with traction on the hand, or by setting the hand flat on the arm board if necessary. Reduction and K-wire positioning are verified by arthroscopy and fluoroscopy (▶ Fig. 25.7).
25.2.6 Graft Implantation and Fixation
Fig. 25.7 Drawing of the scope in the midcarpal joint being used to verify the reduction after pinning.
back into place (▶ Fig. 25.6). The skin is closed with interrupted sutures.
25.2.5 Temporary Fixation of the Nonunion The abraded nonunion site is reduced and temporarily held in place with one or more K-wires (1.0 mm). This
The next step is performed in a dry environment. If the initial part of the procedure was performed in a wet environment, all the fluid must be aspirated. The bone graft is inserted into a trocar and then the end of the trocar is placed at the nonunion site. The graft is pushed into the trocar with a blunt guide wire (▶ Fig. 25.8a, b, ▶ Video 25.4) until the nonunion site is filled. The bone graft is tamped down with a spatula (▶ Fig. 25.9, ▶ Video 25.5). At this point in the procedure, biological glue can be used to stabilize the grafts. Nevertheless, once the scaphoid is fixed and the traction released, the capitate’s native anatomical position will provide sufficient graft stabilization. Once the bone graft is in place, scaphoid fixation can be performed. If the nonunion is located in the scaphoid’s body, the fragments are secured with a compression screw, preferably a self-tapping cannulated one, which is inserted through a small distal percutaneous incision. If the nonunion is at the proximal pole, stabilization can be improved by transcutaneous scapholunate pinning through a lateral incision. Two or three K-wires (1.0 or 1.2 mm) are inserted so that their trajectories fix both the nonunion site and the scapholunate gap. The K-wires are buried under the skin (▶ Fig. 25.10a–c, ▶ Video 25.6).
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Fig. 25.8 (a) Drawing of the graft being placed through a trocar inserted into the MCR portal, with the distal tip placed at the nonunion site. (b) Arthroscopic view of the graft seated in the nonunion site, with the trocar in the MCR portal and the scope in the MCU portal.
Video 25.4 Video showing an intraoperative view of the trocar placement and the graft being pushed down with a blunt guidewire.
Fig. 25.9 Drawing showing the graft being tamped down with a spatula introduced through radial midcarpal portal (MCR).
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Video 25.5 Video showing the graft being tamped down with a spatula introduced through radial midcarpal portal (MCR).
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Fig. 25.10 (a) X-ray of nonunion at the proximal pole of the scaphoid. (b) Postoperative X-ray of the fixation construct consisting of triple scapholunate pinning that spans the scaphoid body, grafted nonunion site, proximal pole, and lunate. (c) X-ray showing bone union 60 days after the K-wires were removed.
25.2.7 Closure and Postoperative Care The wrist is immobilized until union is achieved. Rehabilitation is initiated once the splint and/or K-wires have been removed.
25.3 Conclusion Video 25.6 Video showing a clinical case.
Scaphoid nonunion is a common problem because the initial fracture can go undetected and the bone is poorly vascularized. It can eventually progress to scaphoid nonunion advanced collapse and must be treated surgically before osteoarthritis sets in. Arthroscopic bone grafting is a simple, reliable technique that preserves vascularization, especially in cases of proximal pole nonunion.
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26 Arthroscopic Replacement of the Proximal Pole of the Scaphoid with a Pyrocarbon Implant 26.1 Introduction Avascular necrosis of the proximal pole of the scaphoid is challenging to treat. Vascularized bone grafts do not always provide the expected results. In some cases, the necrotic proximal pole is fragmented and attempts to repair it are unrealistic. A mobile pyrocarbon implant was first implanted in 2000 through a standard open approach.1 Inserting this implant arthroscopically is a logical next step because all the extrinsic ligaments remain intact, thereby preserving carpal bone stability. However, this technique is reserved for cases where reconstruction is impossible.
ligament must be cut if it is still intact. A small No. 11 scalpel is used (▶ Fig. 26.3a, b). Stevens’s tenotomy scissors are then used to cut through the entire scapholunate ligament (▶ Fig. 26.4, ▶ Video 26.2). The proximal pole or its various fragments are then removed using hemostats (▶ Fig. 26.5a–c, ▶ Video 26.3). If the dorsal and volar portions of the scapholunate ligament are difficult to cut, this can be accomplished with a shaver inserted in the 3–4 portal; the scope is placed into the radiocarpal ulnar portal for the dorsal portion and the MCU portal for the volar portion.
26.2 Operative Technique 26.2.1 Patient Preparation and Positioning The procedure is performed under regional anesthesia with the arm secured to an arm board and upward traction of 5 to 7 kg (11–15.5 lbs.) applied to the hand, wrist, and forearm.
26.2.2 Arthroscopic Portals and Exploration Three portals are generally used during this procedure (▶ Fig. 26.1): ● Standard 3–4 portal, extended to about 1 cm to allow the implant to pass through it ● 6R or 4–5 portals for the scope ● Midcarpal ulnar (MCU) portal for midcarpal verification ● Sometimes, we can use the 1–2 radiocarpal portal to perform a styloidectomy (▶ Video 26.1)
Fig. 26.1 Drawing of the three portals typically used during arthroscopic replacement of the proximal pole of the scaphoid with a pyrocarbon implant.
The procedure starts with the 3–4 and 6R or 4–5 portals. The scope is inserted into the medial portal. A shaver is used to debride the joint (synovitis, bone, and/or cartilage debris). The proximal pole is located and the degree of necrosis measured (one or multiple fragments, etc.). The arthroscope and sheath are then introduced through the MCU portal to assess the proximal pole’s position relative to the remainder of the scaphoid and the lunate (▶ Fig. 26.2a, b).
26.2.3 Proximal Pole Excision All of the proximal pole’s fragments will be taken out through the 3–4 portal with the scope in the radiocarpal ulnar portal. But first, the scapholunate inter-osseous
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Video 26.1 Video showing the arthroscopic styloidectomy as first step of the procedure.
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Fig. 26.2 Drawing (a) and midcarpal arthroscopic view (b) of the scaphoid on the left, lunate on the right, and necrotic proximal pole of the scaphoid in the middle.
Fig. 26.3 Drawing (a) and intraoperative view (b) of a scalpel blade being used to start cutting the scapholunate inter-osseous ligament.
Video 26.2 Video showing scalpel blade and fine-tips scissors being used to make the final cut in the scapholunate interosseous ligament.
Fig. 26.4 Drawing of fine-tips scissors being used to make the final cut in the scapholunate inter-osseous ligament.
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Fig. 26.5 Drawing (a), intraoperative (b), and arthroscopic view (c) of the excision of necrotic fragments from the proximal pole of the scaphoid.
Video 26.3 Video showing the excision of necrotic fragments from the proximal pole of the scaphoid.
If the scaphoid’s proximal end has a convex shape, a burr is inserted through the 3–4 portal and used to reshape this end until it becomes concave and can match the implant’s shape (▶ Fig. 26.6, ▶ Video 26.4).
Fig. 26.6 Drawing and intraoperative view during burring of the remaining proximal end of the scaphoid.
26.2.4 Selection of Implant Size The first option for selecting the proper implant size is to reconstruct the proximal pole on the back table and then compare it with the trial implants (▶ Fig. 26.7). The selected implant is then pushed into the 3–4 portal with the fingers under radiocarpal and midcarpal arthroscopic control (▶ Fig. 26.8). If the implant is the correct size, the midcarpal view will show that the space between the scaphoid and lunate is completely filled. A hemostat is used to remove the trial implant under radiocarpal and/or midcarpal arthroscopic control. The implant’s ovoid shape can make it difficult to grasp. One trick is to place a small plastic tube (such as surgical drain tubing) on the tips of the hemostat.
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Video 26.4 Video showing the burring of the remaining proximal end of the scaphoid.
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Fig. 26.7 Intraoperative view of the various fragments from the necrotic proximal pole being reconstructed on the back table to compare the fragments to the size of the trial implants.
Fig. 26.8 Drawing of the trial implant being put into place.
Fig. 26.9 Drawing (a) and intraoperative view (b) of the final implant being inserted through an extended 3–4 radiocarpal incision.
26.2.5 Placement of the Final Implant The final implant is inserted in the same manner (▶ Fig. 26.9a, b, ▶ Video 26.5) under dual radiocarpal and midcarpal control (▶ Fig. 26.10). The skin at the extended 3–4 portal incision is closed with simple interrupted sutures. These sutures can be removed when the first dressing is changed one week later.
26.2.6 Postoperative Care The mobile implant allows for the immediate recovery of joint range of motion. Nevertheless, a removable anterior
Video 26.5 Video showing the insertion of the implant.
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Arthroscopic Replacement of the Proximal Pole of the Scaphoid with a Pyrocarbon Implant splint is used to reduce pain, while allowing patients to regain their range of motion. If needed, rehabilitation can be initiated after the third week.
26.3 Conclusion Arthroscopic replacement of a necrotic proximal pole is a simple, reliable technique that does not burn any bridges. Long-term results with this implant are promising.2 This method avoids the use of more extensive palliative methods. However, it should be used only in cases where reconstruction is impossible.
References [1] Pequignot JP, Lussiez B, Allieu Y. [A adaptive proximal scaphoid implant]. [in French]. Chir Main. 2000; 19(5):276–285 [2] Gras M, Wahegaonkar AL, Mathoulin C. Treatment of avascular necrosis of the proximal pole of the scaphoid by arthroscopic resection and prosthetic semireplacement arthroplasty using the pyrocarbon adaptive proximal scaphoid implant (APSI): long-term functional outcomes. J Wrist Surg. 2012; 1(2):159–164
Fig. 26.10 Midcarpal arthroscopic view of the seated implant, which is perfectly positioned between the scaphoid and the lunate.
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27 Arthroscopic Arthrolysis of the Wrist 27.1 Introduction Intra-articular wrist fractures (radius and scaphoid) and, occasionally, the repair of intrinsic ligaments (even arthroscopic ones) can lead to wrist stiffness due to intraarticular fibrosis, which is more severe in the radiocarpal than the midcarpal joint. Open surgical arthrolysis itself produces postoperative fibrosis, which limits its effectiveness. Arthroscopy avoids this pitfall by cleaning out the joint without affecting the joint capsule and enabling immediate recovery of the patient’s range of motion.
27.2 Operative Technique 27.2.1 Patient Preparation and Positioning
view of the joint is hampered by significant fibrosis. A needle is introduced through the 4–5 portal and an attempt is made to find its distal tip at the end of the scope (▶ Fig. 27.1). A shaver is inserted through the 4–5 portal and the position of the distal end is located without moving the scope. The view gradually improves as the intraarticular fibrosis is removed (▶ Fig. 27.2, ▶ Video 27.1). This entire medial area is debrided to fully release the TFCC. In some cases, a secondary 6R portal may be needed.
27.2.3 Resection of the Fibrous Radiocarpal Wall Once the medial part of the joint has been completely cleaned out, the scope is inserted into the 6R portal. In
The procedure is performed under regional anesthesia. The range of flexion and extension is measured under regional anesthesia to verify the true nature of the stiffness. The arm is then secured to an arm board and upward traction of 5 to 7 kg (11–15.5 lbs.) is applied to the hand and forearm.
27.2.2 Debridement of the Medial Radiocarpal Joint The 3–4 radiocarpal portal is used first. The sheath and scope are placed at a slightly medial angle toward the triangular fibrocartilage complex (TFCC). In most cases, the
Fig. 27.1 Drawing of the difficulties encountered when trying to locate the needle in the radiocarpal joint because of extensive fibrosis.
Video 27.1 Video showing the arthroscopic view of fibrosis when the scope enters into the wrist.
Fig. 27.2 Drawing of fibrosis gradually being resected with a shaver.
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Arthroscopic Arthrolysis of the Wrist many cases, there will be a fibrous wall between the scapholunate ligament and the ridge separating the scaphoid and lunate facets of the radius. This wall can be very thick (▶ Fig. 27.3a, b, ▶ Video 27.2). The wall is cut away completely with Stevens tenotomy scissors from dorsal to volar (▶ Fig. 27.4a, b, ▶ Video 27.3, ▶ Video 27.4).
27.2.4 Debridement of the Radiocarpal Dorsal Recess After cleaning the rest of joint, the final step of radiocarpal debridement consists of separating the adhesions between the dorsal capsule and the first row of carpal bones (▶ Fig. 27.5, ▶ Video 27.5). The scope remains in the 6R portal. The dorsal part of the joint capsule can be inspected through triangulation and the scope’s angulation. The shaver is introduced into the 3–4 portal to release all of the adhesions between the proximal row
and the capsule, starting at the lunate and moving toward the scaphoid, making sure that the entire dorsal recess of the joint is freed. It is important not to cut the dorsal capsulo-scapholunate septum (DCSS), which is located between the capsule and the dorsal portion of the scapholunate ligament. The DCSS is very important for stabilizing the scapholunate joint.
27.2.5 Inspection of the Radiocarpal Joint The scope is placed in the 6R and then the 3–4 portal. The joint is inspected from the styloid recess of the TFCC to the radial styloid process to make sure that no adhesions remain. If the arthrolysis procedure is hemorrhagic, a suitable radiofrequency probe is used to achieve hemostasis in any areas of the capsule that are bleeding.
27.2.6 Debridment of the Midcarpal Joint
Video 27.2 Video showing the fibrous wall between the scapholunate inter-osseous ligament and the ridge between the lunate and scaphoid facets on the radius.
Wrist stiffness is much more rarely attributable to the midcarpal joint, and any fibrosis in this joint is rarely significant. The scope is introduced through the midcarpal ulnar portal. The shaver is introduced through the radial midcarpal (MCR) portal and the joint is completely cleaned out. The position of the scope and shaver are then reversed to finish the debridement. The dorsal part of the joint capsule is completely released at the carpometacarpal joint. If needed, the instruments can remain in the same portals but shifted into the scaphotrapezio-trapezoidal (STT) joint to remove any adhesions between the scaphoid and the capitate. In this particular
Fig. 27.3 Drawing (a) and arthroscopic view (b) of the fibrous wall between the scapholunate inter-osseous ligament and the ridge between the lunate and scaphoid facets on the radius.
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Fig. 27.4 (a) Drawing of fine tip scissors being used to initially cut into the fibrous wall. (b) Drawing showing the last part of the fibrous wall being cut with scissors.
Video 27.3 Video showing fine-tips scissors being used to initially cut into the fibrous wall.
Video 27.4 Video showing the last part of the fibrous wall being cut with scissors.
Video 27.5 Video showing the joint that is free of fibrosis.
Fig. 27.5 Drawing of a shaver being used to resect the fibrosis located in the dorsal recess of the joint capsule.
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Arthroscopic Arthrolysis of the Wrist instance, the 1–2 STT portal can be used to finish the arthrolysis.
27.2.7 Postoperative Care The hand traction is released, and then the range of motion in flexion and extension is measured to determine the improvement. A simple dressing is placed on the wrist and rehabilitation is started immediately.
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27.3 Conclusion The presence of intra-articular fibrosis, especially in the radiocarpal joint, is not unexpected during recovery from intracarpal trauma involving bones and ligaments. Arthroscopic arthrolysis is a challenging procedure from a technical standpoint, but patients are extremely satisfied with the procedure because it is usually completely painless.
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28 Arthroscopic Scaphotrapeziotrapezoidal Interposition Arthroplasty 28.1 Introduction Isolated osteoarthritis of the scaphotrapeziotrapezoidal (STT) joint is rare, but very painful. As a general rule, conservative treatment is used. If this fails, the STT fusion is traditionally the next treatment option, but the repercussions on joint mobility are problematic. Isolated resection of the distal tubercle of the scaphoid is another option1; however, secondary collapse can lead to pain recurrence. Interposition arthroplasty avoids this pitfall. Arthroscopic surgery gives the surgeon a better view of the STT joint, which makes it easier to resect the distal tubercle, and postoperative recovery is faster.
Video 28.1 Video showing the scope moving from the MCR portal into the STT joint while passing between the scaphoid and the lateral side of the capitate.
28.2 Operative Technique 28.2.1 Patient Preparation and Positioning The procedure is performed under regional anesthesia. The patient’s arm is secured to the table. Upward traction can be placed on either the long fingers or the thumb alone. If traction is placed on the thumb, only 2–3 kg (4.5–6.5 lbs.) of counterweight is needed.
28.2.2 Midcarpal Joint Debridement This procedure requires only a midcarpal joint approach. The midcarpal ulnar (MCU) portal is the most straightforward way to enter the joint. A shaver is introduced through the midcarpal radial (MCR) portal to debride the joint. The scope and shaver positions are then reversed to finish the midcarpal joint debridement.
28.2.3 Scaphotrapeziotrapezoid Joint Exploration The STT joint can be easily examined with the scope in the MCR portal. From the midcarpal joint, the medial and distal faces of the scaphoid are followed while passing between the scaphoid and the capitate (▶ Video 28.1). When the scope reaches the STT joint, the view may be hindered by widespread synovitis. The joint must first be cleaned out through the 1–2 or STT portal. A needle is inserted between the first and second compartments, about 1.5 cm below the trapeziometacarpal joint. Because this joint is straight, the natural angulation of the carpal bones does not need to be taken into account as it does when determining the positions of other portals. The scope is held stationary and used to find the needle tip inside the joint (▶ Fig. 28.1).
Fig. 28.1 Intraoperative view of the needle in the 1–2 portal being located with the scope’s transillumination feature.
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Arthroscopic Scaphotrapeziotrapezoidal Interposition Arthroplasty A small horizontal incision is made. Mosquito forceps are used to pass through the capsule, and the shaver is inserted into the joint. Synovectomy is performed until the entire joint is completely debrided; any small cartilage fragments are also removed (▶ Video 28.2).
28.2.4 Distal Resection of the Scaphoid
implant size. Although trial implants can be used, the implant’s excellent primary stability makes it difficult to subsequently remove arthroscopically. A simpler method consists of using a graduated probe, inserted into the STT joint through the 1–2 portal. The probe’s tip hooks onto the anterior part of the scaphoid. The scope is then used to count the number of marking and determine the implant size (▶ Fig. 28.4).
A burr is introduced into the 1–2 portal. The tubercle on the distal pole is resected under visual control, starting at its dorsal section and gradually going toward its volar section (▶ Fig. 28.2, ▶ Video 28.3). The resection must be uniform. It is also important to ensure that no bone lip remains, especially on the medial portion against the capitate (▶ Fig. 28.3). When the resection is properly carried out, the scope (2–3 mm), which is still in the MCR portal, can easily be moved into the STT joint. Nevertheless, it is easier to directly inspect the quality of the resection through the 1–2 portal (▶ Video 28.4).
28.2.5 Implant Selection The different types of implants are available. We prefer using a thin, pyrocarbon implant with a dual concave shape. Various methods can be used to select the proper
Fig. 28.2 Drawing of the initial burring of the scaphoid’s distal facet.
Video 28.2 Video showing the scaphotrapeziotrapezoidal (STT) joint.
Video 28.3 Video showing the initial burring of the scaphoid’s distal facet.
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Fig. 28.3 Drawing of the scaphoid’s distal facet being resected with a shaver.
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28.2.6 Implant Placement First, the 1–2 portal incision must be extended to about 1 cm to insert the implant. The capsule also has to be opened further while making sure not to damage the superficial branch of the radial nerve. The capsule can be opened safely by introducing mosquito forceps into the joint and spreading them. The implant is either inserted directly with the fingers (▶ Fig. 28.5) or the forceps where the tips have been “dressed” so as not to damage the pyrocarbon. A piece of surgical drain tubing can be placed on the forceps tips for this purpose. The implant must be positioned such that one of the implant’s concave sides fits into the natural concavity of the trapezium and trapezoid. The implant will spontaneously settle into the correct position, and its primary stability is excellent (▶ Fig. 28.6, ▶ Video 28.5).
28.2.7 Closure and Postoperative Care After releasing the hand traction, the capsule is closed with one cross-stitch of resorbable suture. The 1–2 portal incision can be closed with 1 or 2 skin sutures, which are removed at the first dressing change (▶ Fig. 28.7). The joint is immobilized with a thumb abduction splint for 1 month (▶ Fig. 28.8a, b). Rehabilitation is typically
Video 28.4 Video showing the open space in the STT joint after the scaphoid’s distal facet has been resected.
Fig. 28.4 Drawing of the implant size being measured with a graduated probe.
Fig. 28.5 Drawing of the implant being directly inserted into the scaphotrapeziotrapezoidal (STT) joint through a slightly wider 1–2 portal incision.
Fig. 28.6 Arthroscopic view of the implant in the proper position, with the scaphoid at the bottom, trapezoid at the top, and capitate on the right.
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Video 28.5 Video showing the final placement of implant.
Fig. 28.7 Drawing of the implant in position and the wider portal skin incision closed.
Fig. 28.8 X-rays of a clinical case of the isolated STT osteoarthritis, before (a) and after (b) interposition arthroplasty with a pyrocarbon implant.
performed by the patient. The patient must be informed that a fully functional, pain-free wrist requires 3 months of recovery time.
height. It does not burn any bridges: a secondary procedure can still be performed later if the arthritis progresses to the trapeziometacarpal joint.
28.3 Conclusion
Reference
Treatment of isolated STT osteoarthritis by arthroscopy is straightforward for patients and provides stable, longterm results. Interposition arthroplasty preserves carpal
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[1] Normand J, Desmoineaux P, Boisrenoult P, Beaufils P. [The arthroscopic distal pole resection of the scaphoid: clinical results in STT osteoarthritis]. Chir Main. 2012; 31(1):13–17
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29 Arthroscopic Resection Arthroplasty of Thumb Carpometacarpal Joint Tyson Cobb, Jessica Cobb
29.1 Introduction Arthroscopic resection arthroplasty (ARA) of thumb CMC joint is a simple procedure for patients that can be accomplished through two or three portals allowing for minimal soft tissue dissection and, therefore, an early recovery and less postoperative scarring, pain, and stiffness. Our research has shown that mean postoperative return to full duty times are about half of that of ligament reconstruction tendon interposition procedures. Tendon harvest, resection of trapezium, interposition, pins and sutures are not typically necessary.1,2 Stages III (isolated CMC arthritis) and IV (pantrapezial arthritis) can be treated with the ARA. When the CMC and scaphotrapeziotrapezoid (STT) joints are arthritic and symptomatic, both are resected through separate portals.
29.2 Operative Technique 29.2.1 Patient Preparation and Positioning The patient is placed supine on the operating room table with the shoulder abducted. The brachium is taped tightly to an arm table. The tape should be as close to the flexor crease of the elbow as possible (▶ Fig. 29.1a). Thumb traction (3–6 kg) is applied with a traction tower and Chinese finger trap after standard prep and draping (▶ Fig. 29.1b). The procedure can be performed using general, regional, or wide-awake local (WALANT) anesthesia, with or without a tourniquet.3 If WALANT anesthesia is used, the injection is given 30 minutes prior to start of surgery to allow sufficient time for vasoconstriction. If general
anesthesia is used, local anesthetic is injected after the patient is induced to provide hemostasis and pain relief postoperatively. Approximately, 8 to 10 mL of 0.25% bupivacaine (or 1% lidocaine) with epinephrine is infiltrated under the skin and in the subcutaneous tissue at each portal site. The needle is passed across the joint and out the back side of the joint, where an additional 8–10 mL is placed (▶ Fig. 29.2).
29.2.2 Portal Placement and Exploration of the Thumb CMC Joint Dorsal and volar portals are localized on both sides of the first dorsal compartment with 18-gauge hypodermic needles under fluoroscopy. The needles are placed centrally and parallel to the joint (▶ Fig. 29.3a, b). These two portals should be at least 2 cm apart to allow better visualization of the radial side of the joint. An incision is made just through the skin with a No. 15 blade. Care should be taken not to injure superficial nerves. The radial artery, superficial branches of the radial nerve, and extensor tendons are all near. These structures are protected through proper blunt dissection. Blunt dissection with a hemostat allows entry into the joint (▶ Fig. 29.4). A blunt hemostat is used to dissect down to, and through, the capsule. Avoid aggressive spreading in the subcutaneous tissue, where subcutaneous nerves can be irritated. A second dorsal portal (the dorsal ulnar portal) can be used as necessary for better viewing the radial side of the joint by placing a trocar into the volar portal, across the CMC or the STT joint and out the dorsum of the hand. The cannula is retrograded over the trocar into the joint (▶ Fig. 29.5a, b). The dorsal ulnar portal improves the visualization of the radial side of the joint. Fig. 29.1 (a) Arm is taped to the hand table. (b) The thumb is hung in finger trap traction.
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Fig. 29.2 Approximately 40 cc of 0.25% Marcaine with epinephrine is injected prior to beginning case.
Fig. 29.4 Incision is made with a No.15 blade just through the skin and a hemostat is used to dissect down to and puncture the capsule and enter the joint.
Fig. 29.3 (a) Portal sites are localized with 18-gauge hypodermic needles and care is taken to make sure the portals are placed far enough apart to allow for visualization of the radial side of the joint. Shown here is a patient undergoing ARA of the CMC and the STT (stage IV). (b) Fluoroscopic guidance is used to confirm that hypodermic needles are centrally located and parallel in joint.
Fig. 29.5 “Inside-out” technique for establishing the ulnar dorsal portal for the CMC and/or STT. (a) Second dorsal portal (which is often used to better visualize the radial side of the joint) is established by placing a blunt probe through the volar portal and across the CMC or the STT, exiting the dorsum of the hand. (b) Cannula is placed retrograde over the probe and inserted into the joint. Probe is removed, and scope is placed in the newly established ulnar dorsal portal.
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29.2.3 Debridement and Denervation of the Thumb CMC Joint A 30° 2.7-mm arthroscope is placed in the dorsal portal and a 3.5 full-radius shaver with suction in the volar portal. The shaver is used to perform synovectomy and clean the joint of any debris for better visualization (▶ Fig. 29.6). A hemostat or grasper is used to remove loose bodies as necessary (▶ Fig. 29.7). A 1.9-mm or 2.3mm scope is used for stage I or II cases, where joint salvage procedures are planned, or for smaller tighter joints. Arthroscopy of the STT joint is performed when symptomatic using volar and dorsal portals centered over the STT joint (approximately 1 cm proximal to the volar and dorsal portals as described for the CMC ARA). As instruments are taken in and out of the joint, the portals will occasionally seem to become obstructed and not allow access. When this occurs, simply reverse the portal placement steps. If the instrument will not enter the joint, try the hemostat. If the hemostat will not enter, try the needle. If the needle does not enter, you are in the wrong plane and may need to use fluoroscopy. Radio frequency ablation with a 3.5-mm Serfas ablater (Stryker Santa Clara, CA) is used to perform intra-articular joint denervation. Using a high setting, the ablator is used to transect the articular sensory branches of the superficial
Fig. 29.6 Scope is stabilized with index finger to prevent pistoning in and out of joint. A 3.5 shaver is used to perform synovectomy and debridement to allow clear visualization of the joint.
radial sensory branch, median motor branch, ulnar motor branch, palmar cutaneous branch, and lateral antebrachial cutaneous nerves.2,3 These nerves are resected by removing the capsule proximally and distally with the Serfas ablater (Stryker Santa Clara, CA). High saline inflow and outflow prevents overheating (▶ Video 29.1).
29.2.4 Arthroscopic Resection Arthroplasty: CMC Joint A 4.0-mm barrel bur (Stryker, Santa Clara, CA) is placed into the volar portal and used to resect 2 to 3 mm of bone from the distal aspect of the trapezium and proximal aspect of the first metacarpal. The bur is perched on the side of the trapezium as resection is started so a ridge of bone is not left behind. The bur is then advanced across the joint in a trough of resected bone using a dorsal-volar windshield wiper motion. After bone has been resected up to scope, the portals are switched and segment of bone near the dorsal portal is resected. Fluoroscopy is used to assess the amount of resection (▶ Fig. 29.8). Care is taken to resect the opposite joint (▶ Video 29.2).
29.2.5 Arthroscopic Resection Arthroplasty: STT Joint For patients with symptomatic STT joints, repeat aforementioned steps for STT resection. The STT resection arthroplasty is also performed with the 4.0-mm barrel bur. Approximately 2 to 3 mm of bone is resected from the distal aspect of the scaphoid and from the proximal aspect of the trapezium and trapezoid (▶ Fig. 29.9).
Fig. 29.7 Loose body being removed with hemostat.
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29.2.6 Tourniquet Removal, Hemostasis, and Pain Control If a tourniquet is used, it is deflated to confirm hemostasis. An additional 20–30 mL of 0.25% bupivacaine with epinephrine (if not contraindicated) is injected directly into the resected joint to provide further hemostasis and aid in postoperative pain control. The assistant holds their fingertips tightly over the portals to prevent fluid from leaking out while the surgeon is injecting the remaining bupivacaine into the resected joint space. The total amount of 0.25% bupivacaine used throughout the entire case is typically approximately 40–60 mL. No interposition, pins, or sutures are used. In the rare case of postresection instability, a tight rope or palmaris tendon stabilization technique can be used to stabilize the joint.
with opposition to the tip of the index finger and progress to tips of the middle, ring, and small fingers before being able to achieve opposition to the base of the small finger. Patients should attempt to perform these exercises actively. However, patients should be instructed to use assistance from contralateral hand until they can achieve these motions actively. This preoperative visit with therapy allows the patient to get over the initial anxiety that often occurs with the removal of postoperative dressing and allows the surgeon to perform a more complete assessment at 7–10 days postoperatively, after the patient has begun to work on their range of motion. Postoperative blocks and continued therapy visits can be helpful to facilitate the early range of motion in patients who are having difficulty. It is important to communicate to the therapist that moderate swelling and bruising is normal,
29.2.7 Closure and Postoperative Care Portals are closed with steri-strips. A well-padded thumb spica splint with an elastic bandage (ACE) is applied. When necessary, a second compressive ACE is applied for a short period during the immediate postoperative recovery period for hemostasis. Patients are instructed to keep their extremities elevated and apply ice. They begin with gentle range of motion of the digits the day after surgery. Patients are warned that their fingers may remain numb for 18–36 hours after surgery due to the long-acting effects of the bupivacaine with epinephrine. Patients are scheduled to see a hand therapist on postoperative day 5–7 for fabrication of a hand-based arthroplast orthosis and instruction for a home program of therapy to be started before their first postoperative follow-up with the surgeon. The home therapy program should emphasize on the gentle range of motion of the thumb and CMC joint in three planes: 1) Extension: lay hand flat on a table, palm up, and push tip of thumb to table; 2) Palmar abduction: hand flat on table, palm up, with thumb metacarpal pointed at ceiling; 3) Opposition: thumb tip pulled to base of small finger. Initially, patients may need to start
Video 29.1 Video showing the intraoperative view of the ARA procedure for the thumb CMC joint arthritis.
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Fig. 29.8 Postoperative X-ray showing resected CMC and STT joints.
Video 29.2 Video showing the internal view of the ARA procedure for thumb CMC joint arthritis.
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Arthroscopic Resection Arthroplasty of Thumb Carpometacarpal Joint rehabilitation protocols typically used for open CMC procedures; thus, it is important to stress the importance of early motion, as it is the author’s belief that early range of motion provides for better overall outcome. There is a wide range in time required for pain resolution following this procedure. Some patients will be doing very well within a few weeks of surgery, whereas others may require many months. The surgeon should resist the urge for early revision surgery in those that are slow to respond and rather reassure the patient that pain will resolve with time.
29.3 Conclusion The ARA as treatment for 1st CMC arthritis is a reliable, effective, and safe procedure for patients. Failure rate with this procedure is less than 5% if joints are completely resected. We have 14 years of follow-up on our earliest patients and recurrence has not occurred. Fig. 29.9 Arthroscopic view of resected STT joint is showing resection of proximal surface of the trapezium (right) and trapezoid (left). The remaining cartilage of the trapeziotrapezoid joint is shown separating the trapezium and the trapezoid.
especially as patients will have variable levels of commitment to ice and elevation. In addition, many therapists may be more familiar with more restrictive therapy and
References [1] Cobb T, Sterbank P, Lemke J. Arthroscopic resection arthroplasty for treatment of combined carpometacarpal and scaphotrapeziotrapezoid (pantrapezial) arthritis. J Hand Surg Am. 2011; 36(3):413–419 [2] Cobb TK, Walden AL, Cao Y. Long-term outcome of arthroscopic resection arthroplasty with or without interposition for thumb basal joint arthritis. J Hand Surg Am. 2015; 40(9):1844–1851 [3] Wilhelm A. Denervation of the wrist. Tech Hand Up Extrem Surg. 2001; 5(1):14–30
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30 Arthroscopic Thumb Carpometacarpal Interposition Arthroplasty 30.1 Introduction Osteoarthritis in the thumb carpometacarpal (CMC) joint is a common condition, especially in women over 60 years of age. Various treatment approaches are currently being used, including fusion, prosthesis, and trapeziectomy, with or without ligament reconstruction. The outcomes are generally good with these methods, but problems persist. In the early stages of moderate osteoarthritis and normal alignment, arthroscopic interposition arthroplasty makes sense. It is straightforward for the patient and does not burn any bridges if another procedure is needed later on.
30.2 Operative Technique 30.2.1 Patient Preparation and Positioning
of performing a synovectomy with the shaver (▶ Video 30.1). The shaver and scope positions can be reversed to finish the synovectomy. In some cases, the joint will contain foreign bodies that are free-floating or partially attached to the capsule. These must be completely removed (▶ Video 30.2).
30.2.4 Osteophyte Resection No matter which type of implant is being used, every single trapezium osteophyte must be resected. The medial osteophyte is removed first with the scope in 1D and the burr in 1P (▶ Fig. 30.3a–c, ▶ Fig. 30.4, ▶ Video 30.3). The burr and scope positions are reversed if a lateral osteophyte needs to be resected (▶ Fig. 30.5, ▶ Video 30.4). A pyrocarbon implant may require resection of the volar and dorsal osteophytes at the base of the first metacarpal as well.
The procedure is performed under regional anesthesia. The patient’s arm is secured to the arm board. Traction is placed on the thumb using a finger trap. Only 2 to 3 kg (4.5–6.5 lbs.) of counterweight is needed.
30.2.2 Exploration of the Thumb Carpometacarpal Joint A needle is used to locate the 1 palmar (1P) portal, which is in front of the first compartment (abductor pollicis longus and extensor pollicis brevis). This portal is located at the palmar-dorsal skin junction of the hand, or even slightly in front on the volar side (▶ Fig. 30.1). The terminal branches of the radial nerve are not a concern at this level. This portal can be enlarged as needed to accommodate the implant. The joint is identified with hemostats and then the sheath and arthroscope are inserted. Direct entry is possible because this joint is not concave as the wrist joint is. A standard 2.4-mm scope is used, although some prefer to use a smaller 1.9-mm scope. Based on our experience, this smaller, more fragile scope is not necessary. The second portal (1 dorsal, 1D) is located using a needle and the scope’s transillumination feature; this portal is positioned behind the first compartment (▶ Fig. 30.2a, b). The shaver is inserted through this portal.
30.2.3 Debridement of the Thumb Carpometacarpal Joint The thumb CMC joint is usually filled with inflamed synovial tissue. As a consequence, the first step consists
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Fig. 30.1 Intraoperative view of a needle being used to locate the 1 palmar (1P) portal in front of the first compartment.
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Fig. 30.2 (a, b) Intraoperative views of the 1 dorsal (1D) portal being located using the scope’s transillumination feature.
Video 30.1 Video showing the cleaning of the joint to ameliorate the visibility.
Video 30.2 Video showing removal of foreign body.
Fig. 30.3 Drawing (a), intraoperative view (b), and arthroscopic view (c) of the initial stages of the medial osteophyte being resected with a burr.
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Fig. 30.4 Drawing of progressive resection of the medial osteophyte with a burr.
Fig. 30.5 Drawing of the distal end of the trapezium being completely resected after the scope and burr positions have been reversed.
Video 30.3 Video showing the progressive resection distal trapezium with a burr. Video 30.4 Video showing the final resection of trapezium.
30.2.5 Placement of Implant For both arthroscopic and open surgery, enough space must be created in the joint to accommodate the implant. The four osteophytes are resected first, as described in the previous step. A graduated probe is used to determine the size of the implant needed. The 1P portal will need to be enlarged to 1 cm. The joint capsule is opened with hemostats, using the same technique. The chosen implant is then either pushed or pulled into the joint, and the scope is used to verify its positioning (▶ Fig. 30.6, ▶ Fig. 30.7, ▶ Fig. 30.8a–f, ▶ Video 30.5).
30.2.6 Closure and Postoperative Care Fig. 30.6 Drawing of one of the methods used to insert the implant through a slightly enlarged 1P portal incision.
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The capsule is closed with one cross-stitch of resorbable suture and the 1P skin incision is also closed with suture.
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Video 30.5 Video showing the final placement of the implant.
Fig. 30.7 Drawing of the seated implant.
Fig. 30.8 Example of clinical case: anteroposterior (A/P) (a) and lateral (b) X-rays of isolated osteoarthritis in the thumb CMC joint with alignment maintained; A/P (c) and lateral (d) X-rays after interposition of a pyrocarbon spacer; photos of the thumb 7 days after surgery (e, f); the enlarged 1P incision was closed with a few sutures.
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Arthroscopic Thumb Carpometacarpal Interposition Arthroplasty A thumb abduction splint is used for about 1 month before starting rehabilitation.
30.3 Conclusion As long as the indications are followed, interposition arthroplasty for thumb CMC arthritis is a straightforward
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technique for patients; it provides satisfactory results without burning any bridges in case another type of surgery is later needed.
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31 Arthroscopic Interposition Arthroplasty in Stage II Scapholunate Advanced Collapse Wrists 31.1 Introduction Arthritis secondary to scapholunate (SL) ligament rupture has been divided into four stages. In a stage II scapholunate advanced collapse (SLAC) wrist, only the scaphoid fossa of the radius is arthritic (▶ Fig. 31.1). The goldstandard treatment consists of proximal row carpectomy; however, this is a fairly aggressive, definitive treatment. To avoid or delay this inevitability, an arthroscopic technique can be used that combines styloidectomy, SL gap stabilization, and interposition arthroplasty between the first and second row of carpal bones.
31.2 Operative Technique 31.2.1 Patient Preparation and Positioning The procedure is performed under regional anesthesia. The patient’s arm is secured to the arm board. An atraumatic hand holder is used to apply 5 to 7 kg (11–15.5 lbs.) traction along the arm’s axis.
stripper is utilized to harvest the graft (▶ Video 31.1). A grasping suture is applied to the two ends of the tendon graft using 4’0 Ethilon 4.0 or similar non-braided suture material. The suture is passed several times (Krackow suture), about 1.5 cm on both ends of the tendon graft in order to create a strong grasping suture construct, and the ends of the suture are left long for retrieval while passing the tendon graft through the trans-osseous tunnels (▶ Video 31.1).
31.2.3 Debridement and Exploration of Radiocarpal Joint The radiocarpal joint is typically affected by significant synovitis, often with accompanying bone and cartilage fragments. The sheath and arthroscope are inserted through the 3–4 portal. The shaver is inserted in the 6R portal to start debriding the medial side of the radiocarpal joint. The synovectomy is completed after the
31.2.2 Harvesting the Tendon Graft The tendon graft must be strong and long enough to stabilize the distal radioulnar joint (DRUJ), and thin enough to pass through the bone tunnels. Usually, a palmaris longus (PL) tendon graft suffices. However, in case the PL is absent, a hemi flexor carpi radialis or a plantaris tendon graft may be harvested. The PL tendon graft is harvested through a small incision at the distal flexion crease of the wrist joint at the base of the carpal tunnel. A tendon
Video 31.1 Video showing the technique of harvesting the PL.
Fig. 31.1 X-ray of a patient with stage II SLAC wrist secondary to SL dissociation; there is a visible gap between the scaphoid and the lunate, and osteoarthritis between the scaphoid and scaphoid fossa of the radius; however, the midcarpal joint is intact.
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Arthroscopic Interposition Arthroplasty in Stage II Scapholunate Advanced Collapse Wrists positions of the scope and shaver are reversed. All cartilage fragments must be removed (▶ Video 31.2).
styloidectomy procedure (▶ Fig. 31.3, ▶ Video 31.4) (refer to Chapter 7). The styloid is resected at an angle while preserving the volar and dorsal attachments of the
31.2.4 Styloidectomy The scope can be placed either in the 3–4 or 6R portal; both portals can be used if needed. The joint assessment often reveals that the cartilage on the scaphoid fossa of the radius – and on the proximal pole of the scaphoid – is completely gone (▶ Fig. 31.2). All the other cartilage surfaces will be intact. After locating the 1–2 portal with a needle, the shaver is inserted to complete the synovectomy around the radial styloid process (▶ Video 31.3). A burr is used to perform the styloidectomy as in a typical arthroscopic
Video 31.3 Video showing the 1–2 portal.
Video 31.2 Video showing the exploration and cleaning of radiocarpal joint.
Fig. 31.3 Drawing of the PL graft attached to the anchor sutures.
Fig. 31.2 Arthroscopic view of the radiocarpal joint showing the lack of cartilage on the proximal aspect of the proximal pole of the scaphoid and the scaphoid fossa of the radius.
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Video 31.4 Video showing the radial styloidectomy.
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Fig. 31.4 (a) Intraoperative and (b) arthroscopic views of the suture anchor being inserted into the tip of the radial styloid process through the 1–2 portal.
Video 31.5 Video showing the insertion of anchor into the radial styloid.
extrinsic ligaments (dorsal radiocarpal and radioscaphocapitate). After the styloidectomy, a suture anchor is introduced by the 1–2 portal and inserted into the tip of the styloid process under arthroscopic control (▶ Fig. 31.4, ▶ Video 31.5). The anchor’s sutures are externalized by the 1–2 portal and will be used to secure the tip of the Vshaped interposition implant.
31.2.5 Stabilization of SL Joint Space Repairing the SL ligament at this point is unrealistic; nevertheless, dorsal capsule-to-ligament suture repair (see Chapter 17) can be used to stabilize the SL joint to avoid further degradation. This is performed using the same technique as the SL ligament repair in less advanced SLAC cases. It is rare to find the dorsal SL ligament stump still attached to the scaphoid. The following technical tricks can be used instead: (1) We catch a large part of the dorsal capsule, proximally and dorsally, to constrict the capsule and reduce the SL space. Proximally, the two needles pass through two different points on the capsule approximately 1 cm apart. It is sometimes necessary to extend the 3–4 radiocarpal portal to protect the extensor
Video 31.6 Video showing the dorsal capsuloligamentous repair using a constriction of dorsal capsule.
tendons. Distally, the radio-midcarpal portal is also extended. Two different openings, 1 cm apart, will be needed to pass the mosquito forceps (Chapter 17). The distal knot stays outside the dorsal capsule (▶ Video 31.6). With the final knot, constriction of the dorsal capsule avoids the need for K-wires. (2) An anchor is inserted into the dorsal distal part of the proximal pole (Chapter 17). The suture in the anchor is used as the first suture for dorsal capsuloligamentous repair. Another suture is added, like in the classic technique, and used to catch a large part of the dorsal capsule to achieve reduction, as described in Chapter 17. The final phase of the dorsal capsule-to-ligament repair will be carried out at the end of the procedure.
31.2.6 Preparation for Interposition Arthroplasty A PL graft is typically used for this step, but other tendon grafts can be used also. The two ends of the graft are loaded with absorbable suture, typically 3/0 Vicryl®. The sutures associated with the anchor in the radial styloid process will be attached to the tip of the V (▶ Fig. 31.5).
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31.2.7 Passage of the Implant’s Dorsal Portion
▶ Video 31.7). The second end of the graft follows this same path.
The first suture at the dorsal end of the graft is passed intra-articularly using mosquito forceps from the 1–2 portal to the 3–4 portal (▶ Fig. 31.6). The graft’s marking suture is passed extra-articularly from the 3–4 portal to the 6R portal, volar to the extensor tendons (▶ Fig. 31.7). Lastly, the suture is loaded in the mosquito forceps, which is introduced inside the joint through the 6R portal and then externalized by the 1–2 portal (▶ Fig. 31.8,
31.2.8 Passage of the Implant’s Volar Portion After making the 1–2 portal incision slightly wider (1– 2 cm), the radial pedicle and the flexor carpi radialis are reflected forward. Long mosquito forceps are loaded with one of sutures at the end of the graft, and then passed through the 1–2 portal toward the volar aspect, while
Fig. 31.5 Drawing of the sutures associated with the anchor in the radial styloid process will be attached to the tip of graft.
Fig. 31.6 Drawing of the first step of dorsal passage of implant from the 1–2 portal to the 3–4 portal.
Fig. 31.7 Drawing of second step of dorsal passage of implant from the 3–4 portal to the 6R portal extra-articularly.
Fig. 31.8 Drawing of last step of dorsal passage of implant from the 6R portal to the 1–2 portal.
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Arthroscopic Interposition Arthroplasty in Stage II Scapholunate Advanced Collapse Wrists staying outside the capsule (▶ Fig. 31.9). With the scope in 6R, the forceps enter the joint between the radioscaphocapitate ligament and the long radiolunate ligament, or even better, on the ulnar side of the long radiolunate ligament. This suture is retrieved through the 1–2 portal using mosquito forceps and externalized by the 1–2 portal (▶ Fig. 31.10, ▶ Video 31.8). Traction is applied to this suture until the graft is positioned correctly inside the joint (▶ Video 31.9).
31.2.9 Stabilization of Tendon Graft The two ends of the graft are tied together and secured to the styloid process using the sutures from anchor (▶ Fig. 31.11, ▶ Video 31.10). Fig. 31.10 Drawing of last step of dorsal passage of implant from volar ulnar portal to the 1–2 portal.
Video 31.7 Video showing the dorsal passage of tendon graft.
Video 31.8 Video showing the volar passage of tendon graft.
Fig. 31.9 Drawing of the first step of volar passage of implant from the 1–2 portal to volar radial portal.
Video 31.9 Video showing the tendon graft in position into the joint.
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31.2.10 Closure and Postoperative Care After releasing traction on the hand, suture stabilization of the SL ligament is performed with the wrist extended. The incisions are typically left to heal by first intention. If the 1–2 portal is extended to insert the implant, one or two sutures may be needed to close it. A volar splint is worn in the resting position (between 45° and 60° extension) for 45 days (▶ Video 31.11).
Fig. 31.11 Drawing of last step of dorsal passage of implant from the 6R portal to the 1–2 portal.
31.3 Conclusion Although arthroscopic interposition arthroplasty is a tricky technique, it is a straightforward solution for patients with stage II SLAC wrists. It does not burn any bridges with other palliative techniques and recreates the radiocarpal joint space in a way that provides the patient with pain-free function (▶ Fig. 31.12a, b).
Video 31.10 Video showing the two ends of the graft tied together and secured to the styloid process using the sutures from anchors.
Video 31.11 Video showing the final sutures fixation.
Fig. 31.12 X-rays before surgery (a) and at 5 years postoperative (b) of a patient with a stage II SLAC wrist.
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32 Arthroscopic Resection Arthroplasty of the Radial Column for Scapholunate Advanced Collapse Wrist Tyson Cobb, Jessica Cobb
32.1 Introduction The chapter describes the surgical technique to successfully complete a minimally invasive arthroscopic treatment for symptomatic advanced scapholunate advanced collapse (SLAC) wrists. This minimally invasive procedure can be performed through small portals and allows for minimal soft tissue dissection and, therefore, early recovery and less postoperative scarring, pain, and stiffness. Sutures, interposition, pins, and postoperative casts are not necessary. Compared to four-corner fusion and proximal row carpectomy, this procedure allows for more rapid recovery. Our research with 10 years of follow-up on this procedure has shown high patient satisfaction with no recurrences and an acceptable failure rate.
need.1 The patient is placed supine on the operating table with a tourniquet placed on the brachium. Tape is used to secure the brachium to hand table (▶ Fig. 32.1). Fingertrap traction of 5 kg to index and/or long fingers is used with a traction tower (▶ Fig. 32.2). Standard radiocarpal and midcarpal arthroscopy can be performed using standard 3–4, 4–5, 6R, 6U, 1–2, volar flexor carpi radialis (FCR) portals, and midcarpal portals as indicated; however, the 1–2 and 3–4 or 4–5 portals are often all that is required. Portals are localized with 18-gauge needles (▶ Fig. 32.3); 10 mL of 0.25% bupivacaine with epinephrine is injected at each portal site. Skin incisions are made with a No. 15 scalpel just through the dermis. Blunt dissection is performed with a hemostat to enter joint (▶ Fig. 32.4).
32.2 Surgical Technique 32.2.1 Patient Preparation and Positioning General, regional, or wide-awake anesthesia can be used based on surgeon and patient preference and medical
Fig. 32.1 Arm is taped to the hand table.
Fig. 32.2 Arm is hung in traction.
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Fig. 32.3 The 1–2 portal is established with 18-gauge needle.
Fig. 32.4 Incision is made with No. 15 blade and joint is entered with hemostat.
Fig. 32.5 Index finger helps stabilize scope. Fig. 32.6 Serfas (Stryker, San Jose, CA) ablater is used for denervation.
32.2.2 Arthroscopy Arthroscopy is performed with a 2.7-mm, 30° arthroscope. A synovectomy and resection of debris and the torn scapholunate ligament with a 3.5-mm aggressive shaver is performed (Stryker Endoscopy, San Jose, CA) (▶ Fig. 32.5). A radiofrequency ablator (Serfas 3.5-mm, Stryker) is employed to denervate the arthritic portion of the joint to be resected volarly, radially, and dorsally (▶ Fig. 32.6).2,3 This is performed by resecting the sensory nerve endings as they enter the joint on the capsule. The capsule is vaporized from its attachment to the radius. High fluid flow protects the joint from overheating (▶ Fig. 32.7). We believe that pain relief is in part due to disrupting the sensory nerve pathway.3–10 Sensory contributions are included from the anterior interosseous nerve, lateral antebrachial cutaneous nerve, posterior interosseous nerve, palmar cutaneous branch of the median nerve, deep branch of the ulnar nerve, and superficial branch of the radial nerve. A 4mm 12-flute barrel burr (Stryker Endoscopy, San Jose,
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Fig. 32.7 Cannula and trocar placed in the joint following the normal volar tilt of distal radius; the 4–5 portal may be difficult to enter in some patients with SLAC wrists because lunate may not be distally distracted.
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Arthroscopic Resection Arthroplasty of the Radial Column for Scapholunate Advanced Collapse Wrist CA) is inserted into the 1–2 portal for bone resection, using the 3–4 or 4–5 portal for initial viewing. The scope is moved as needed between the 4–5, 3–4, and 1–2 portals to enhance visualization from various perspectives (▶ Fig. 32.8). Volar FCR portal is used infrequently as needed for better visualization of dorsal aspect of the joint (▶ Fig. 32.9).
32.2.3 Resection Resection begins with the burr perched on the radial edge of the styloid to ensure that a ridge of bone is not left behind. Synovium and capsule tissue are removed to define the margin of bone clearly prior to starting bony resection. Bone resection is facilitated by making the 1–2 portal slightly below the joint line, which results in the instrument slightly angled upward as it enters the joint. The styloid is resected to a depth of 4 mm. A trough of bone is resected by oscillating the burr volarly and dorsally using a windshield-wiper motion, advancing from the radial to the ulnar side until the entire abnormal portion of the radius is removed (▶ Video 32.1). Precautions are taken to protect capsular ligaments by carefully burring away cortical bone until the volar wall becomes pliable, up to but not through the soft tissue envelope
Fig. 32.8 Resection may be better visualized from ulnar side of joint.
(▶ Fig. 32.10a, b). The entire radial column up to healthyappearing cartilage on the lunate fossa of the radius is resected (▶ Fig. 32.11). The transition to the lunate fossa is an abrupt change to normal cartilage starting at the ridge separating the scaphoid and lunate fossae. The proximal 2/3rd of the arthritic scaphoid is commonly resected (▶ Fig. 32.12). Fluoroscopy is implemented to ensure an adequate amount of bone resection (▶ Fig. 32.13a, b). Most failures occur because of inadequate
Fig. 32.9 Volar portal can be established with inside out technique as necessary to better visualize the dorsal side of the joint.
Video 32.1 Internal view of ARARC.
Fig. 32.10 (a, b) Showing how to protect the volar ligament with the hood on the shaver.
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Fig. 32.11 Small ronguers may be helpful when removing bone.
Fig. 32.12 Typical appearance of arthritic scaphoid.
Fig. 32.13 (a, b) Postoperative X-ray 1, 2, 3.
resection; thus, aggressive bone removal is recommended. Failure to remove the impinging portion of the scaphoid will also result in persistent postoperative pain. Midcarpal resection is not necessary.
32.2.4 Completion Traction is released at the end of the procedure to ensure resolution of impingement of the proximal pole of the scaphoid on the radius. Portals are plugged by assistant’s fingers to prevent leakage and additional 0.25% bupivacaine with epinephrine or 1% lidocaine with epinephrine is injected into the resected joint (if not contraindicated). We typically use a total of 60 mL of 0.25% bupivacaine with epinephrine. Portals are closed with adhesive strip skin closures and the patient is placed in a well-padded volar splint with compressive Ace bandage.
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32.2.5 Postoperative Care Patients are instructed to ice and elevate the extremity. The wrist is splinted for 7–10 days. Thereafter, the patients are placed in a removable splint and encouraged to begin range of motion exercises. Use is allowed as tolerated after 1 week. Formal therapy is utilized as needed for patients requiring more supervision. Early motion encourages stem cells to form fibrocartilage which provides a gliding surface and cushion for the joint.11,12
References [1] Lalonde D. Minimally invasive anesthesia in wide awake hand surgery. Hand Clin. 2014; 30(1):1–6 [2] Van de Pol GJ, Koudstaal MJ, Schuurman AH, Bleys RL. Innervation of the wrist joint and surgical perspectives of denervation. J Hand Surg Am. 2006; 31(1):28–34
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Arthroscopic Resection Arthroplasty of the Radial Column for Scapholunate Advanced Collapse Wrist [3] Wilhelm A. Partial joint denervation: wrist, shoulder, and elbow. Plast Reconstr Surg. 2010; 126(1):345–347 [4] Cobb T, Sterbank P, Lemke J. Arthroscopic resection arthroplasty for treatment of combined carpometacarpal and scaphotrapeziotrapezoid (pantrapezial) arthritis. J Hand Surg Am. 2011; 36(3): 413–419 [5] Cobb TK, Walden AL, Cao Y. Long-term outcome of arthroscopic resection arthroplasty with or without interposition for thumb basal joint arthritis. J Hand Surg Am. 2015; 40(9):1844–1851 [6] Leclaire R, Fortin L, Lambert R, Bergeron YM, Rossignol M. Radiofrequency facet joint denervation in the treatment of low back pain: a placebo-controlled clinical trial to assess efficacy. Spine. 2001; 26 (13):1411–1416, discussion 1417 [7] Loréa PD. First carpometacarpal joint denervation: anatomy and surgical technique. Tech Hand Up Extrem Surg. 2003; 7(1):26–31
[8] Radu CA, Schachner M, Tränkle M, Germann G, Sauerbier M. [Functional results after wrist denervation]. Handchir Mikrochir Plast Chir. 2010; 42(5):279–286 [9] Weinstein LP, Berger RA. Analgesic benefit, functional outcome, and patient satisfaction after partial wrist denervation. J Hand Surg Am. 2002; 27(5):833–839 [10] Wilhelm A. Denervation of the wrist. Tech Hand Up Extrem Surg. 2001; 5(1):14–30 [11] Altman RD, Kates J, Chun LE, Dean DD, Eyre D. Preliminary observations of chondral abrasion in a canine model. Ann Rheum Dis. 1992; 51(9):1056–1062 [12] Vachon A, Bramlage LR, Gabel AA, Weisbrode S. Evaluation of the repair process of cartilage defects of the equine third carpal bone with and without subchondral bone perforation. Am J Vet Res. 1986; 47 (12):2637–2645
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33 Arthroscopic Partial Wrist Fusion 33.1 Introduction Partial wrist fusion is a definitive palliative treatment used in cases of advanced wrist arthritis, which are most often secondary to scapholunate ligament injuries (SLAC wrist) and scaphoid nonunion (SNAC wrist). This procedure is recommended for stage III SLAC and SNAC cases. The exact nature of the fusion will depend on the quality of the remaining cartilage. The advent of cannulated, selftapping screws has greatly simplified these procedures.
33.2 Surgical Technique
rasp and spatula can be used to excise all or part of the scaphoid bone. In cases of SL ligament injury sequelae, the SL ligament is torn and the entire scaphoid fossa of the radius is arthritic. The scaphoid bone is removed as a single piece. In cases of scaphoid nonunion sequelae, only the radial styloid is arthritic; the segment of the scaphoid fossa of the radius across from the pole will be intact. The proximal pole remains attached to the lunate by the SL ligament. In these cases, only the distal part of the scaphoid is removed (▶ Fig. 33.2, ▶ Video 33.1). The incision is reclosed layer by layer (▶ Fig. 33.3a, b). Grafts can be harvested from the resected scaphoid bone.
33.2.1 Patient Preparation and Positioning The procedure is done in two phases: an open procedure to excise the scaphoid and then a fully arthroscopic procedure to carry out the arthrodesis. An open technique is used for the scaphoidectomy because excision is faster than when performed arthroscopically, although the final result is the same. The second part of the procedure (the arthroscopy phase) is performed with the arm secured to an arm board and traction applied along the hand axis with an atraumatic hand holder.
33.2.2 Scaphoidectomy Only a plain distal lateral volar incision over the scaphoid tubercle is needed here (▶ Fig. 33.1). This incision can be either horizontal or longitudinal. The volar scaphotrapezial ligaments are always more difficult to cut if a dorsal approach is used. After cutting these ligaments, a bone Fig. 33.2 Drawing of the scaphoid being excised in one piece; a distal fragment in a stage III SNAC wrist is shown here.
Fig. 33.1 Intraoperative view of a small distal volar incision being made over the distal tubercle of the scaphoid. A needle is used to locate the scaphotrapeziotrapezoid (STT) joint; these ligaments are intact and solidly attached.
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Video 33.1 Video showing the scaphoid excision in one piece by a volar approach.
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Fig. 33.3 Intraoperative view of the distal volar incision before the skin and capsule are closed (a) and after suturing is complete (b).
33.2.3 Exploration of Radiocarpal Joint Traction is placed on the wrist using an atraumatic hand holder and 5 to 7 kg (11–15.5 lbs.) of counterweight. The 3–4 portal is used to explore the radiocarpal joint. The main purpose is to inspect the lunate fossa of the radius and assess the quality of the lunate cartilage. In stage III SNAC wrists, the proximal pole of the scaphoid and the cartilage across from the scaphoid fossa of the radius must also be inspected. At this point, a styloidectomy may be needed (refer to Chapter 7). If so, a burr is introduced through the 1–2 portal to resect the radial styloid process without disturbing the volar and dorsal attachments of the extrinsic ligaments (dorsal radiocarpal and radioscaphocapitate).
33.2.4 Exploration of the Midcarpal Joint The arthroscope and sheath are introduced through the midcarpal ulnar (MCU) portal. The shaver is introduced through the midcarpal radial (MCR) portal to debride the joint, which may show signs of extensive synovitis. The shaver and scope are reversed to debride the remainder of the joint (▶ Fig. 33.4).
Fig. 33.4 Intraoperative view of the medial and ulnar radiocarpal portals needed to carry out the partial wrist fusion.
33.2.5 Preparation for Arthrodesis The scope is returned to the MCU portal. A burr is introduced into the MCR portal to resect the surface of the capitate and lunate until bleeding subchondral bone is visible (▶ Fig. 33.5a, b, ▶ Video 33.2). In cases of stage III SNAC wrists, the remaining distal segment of the proximal pole of the scaphoid must also be
resected. A scapholunate-capitate fusion will eventually be performed. A four-corner fusion will be performed in cases of stage III SLAC wrists (▶ Fig. 33.6). The scope and burr positions are reversed to resect the head of the hamate and distal aspects of the triquetrum until bleeding bone is exposed.
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Fig. 33.5 Drawing (a) and intraoperative view (b) of cartilage and bone being resected from the bones being fused in the midcarpal joint so that bleeding subchondral bone is exposed.
Video 33.2 Video showing the midcarpal cartilage and bone resection to prepare the arthrodesis.
Fig. 33.6 Drawing of the final arthroscopic verification of scapholunate-capitate fusion in a stage III SNAC wrist.
Fig. 33.7 Drawing (a) and intraoperative view (b) of bone graft material (harvested from the excised scaphoid) being placed in the fusion area.
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33.2.6 Hamate Resection If an isolated lunocapitate or scapholunate-capitate fusion will be performed, especially without a graft, the hamate can impinge with part of the lunate and cause residual pain particularly in patients with a Viegas Type II lunate (see Chapter 3). In this case, it is useful to resect the proximal head of the hamate with a burr in the MCU portal and the scope in the MCR portal.
33.2.7 Addition of Bone Graft Material The arthrodesis procedure can be carried out with or without a bone graft. However, adding a graft preserves carpal
Fig. 33.8 Drawing of the bone grafts in place for a four-corner fusion.
height, especially when performing scapholunate-capitate fusion. The scope is placed in the MCU portal. A shaver is used to finish debriding the joint. Any fluid in the joint must be completely aspirated. From this point on, the procedure is performed in a dry environment. Graft material is placed between the first and second row of carpal bones using the burr’s barrel or a trocar. The graft material is pushed into the joint (▶ Fig. 33.7a, b, ▶ Fig. 33.8).
33.2.8 Fixation of the Arthrodesis Fixation is carried out with 2–3 mm diameter, dual thread cannulated, self-tapping screws that compress the bones together. Kirschner wires are inserted under arthroscopic or fluoroscopic control, depending on the type of fixation chosen. Hamate-triquetral and capitolunate fixation is typically used, but this depends on surgeon’s preference: hamate-lunate and triquetrocapitate fixation, four-corner fusion, fixation between the capitate, scaphoid, and lunate in SNAC 3 wrists, etc. (▶ Fig. 33.9a–c, ▶ Video 33.3). After releasing wrist traction, the cannulated screws are placed under fluoroscopic control through small skin openings. Compression is provided by the screws.
Video 33.3 Video showing the fixation of scapholunatecapitate fusion with screws.
Fig. 33.9 Drawing (a) and A/P (b) and lateral (c) intraoperative X-rays of the fixation of a scapholunate-capitate fusion with cannulated screws in a stage III SNAC wrist.
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Fig. 33.10 X-rays (a, b) of a scapholunate-capitate fusion case with the 3 years of follow-up; photograph (c) of dorsal side of the wrist for the same patient showing the absence of scars; photographs showing flexion (d) and extension (e) range of motion in the same patient. Although these movements are modest, they are sufficient and pain-free.
33.3 Conclusion 33.2.9 Closure and Postoperative Care None of the small dorsal incisions need to be closed. An anterior splint is worn until the bones have fused, typically 6–8 weeks later. Rehabilitation is initiated after bone union.
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Partial wrist fusion is a definitive palliative treatment that is commonly used in advanced wrist osteoarthritis cases. The goal is to avoid total wrist fusion and maintain sufficient range of motion (▶ Fig. 33.10a–e). By performing this arthrodesis procedure arthroscopically, the devascularization associated with standard open techniques is avoided, which improves fusion. It also simplifies postoperative recovery. Various types of partial fusions are amenable to arthroscopy.
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34 Arthroscopic Assessment of Kienbock’s Disease Greg Bain, Simon MacLean
34.1 Introduction We regard arthroscopy as the gold standard for assessment of the articular surfaces in patients with Kienbock’s disease. Imaging is also imperative in the work-up of these patients, although the extent of articular cartilage damage is often underestimated on plain radiographs. High-resolution or contrast-enhanced MRI and CT scanning provide excellent details on lunate vascularity, necrosis, and the presence of fracture, but poorly delineate articular surface integrity, which is best assessed with direct arthroscopic visualization and probing. In some cases of osseous ischaemia and necrosis, an intact chondral envelope is still present. In these cases, lunate preservation surgery may be indicated. In all cases of Kienbock’s disease where we have performed arthroscopy, synovitis is present, and an arthroscopic synovectomy can then be easily performed. We introduced the Bain and Begg Classification to hone surgical decision-making based on the integrity of articular surfaces evaluated during arthroscopy (▶ Fig. 34.1).1,2 Functional surfaces are defined as those with a normal arthroscopic appearance, often smooth and glistening. Non-functional articulations are those with degeneration; fibrillation, fissuring, chondral detachment, or subchondral fracture. This is important, as it brings into assessment of Kienbock’s disease, the articular surface. Armed with this information, the surgeon can make an informed
decision on treatment, which includes the osseous findings identified on X-ray and CT scan. The aim of surgical treatment is to bypass or excise nonfunctional surfaces to reduce pain and maintain functional wrist motion between intact articular surfaces. Our recently published Lichtman-Bain algorithm is a framework for the treating surgeon based on osseous, vascular, and chondral components of the disease (▶ Fig. 34.2). Surgical treatment can then proceed based on both patient and surgical factors.3–7 The algorithm emphasizes five key components for decision-making including, patient age, the state of the lunate, the state of the wrist, what the surgeon can offer, and what the patient wants.
34.2 Technique 34.2.1 Set-Up We suspend the arm on a traction tower. A 2.7-mm 30° arthroscope is used. Portal sites are injected with 15– 20 mL of 1% lidocaine, 1:200,00 adrenaline mixture, 20– 30 minutes before the procedure. A tourniquet is applied, but not inflated. Portals used include 3–4 portal, 6R portal, radial midcarpal portal, and ulnar midcarpal portal. Dry arthroscopy is then performed, allowing for better visualization and resolution of the articular surfaces. Tissue perfusion is best assessed dry, as fluid insufflation compresses the capillaries within the synovium.
Fig. 34.1 The Bain and Begg articular-based classification of Kienbock’s disease. (Copyright © Dr Greg Bain, 2018)
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A. Patient’s age? A1. < 15 years – Non-operative A2. 16 -20 years – Attempt non-operative. Consider unloading procedure. A3. > 70 years – Attempt non-operative. Consider synovectomy and /or follow algorithm below. B. Stage of the lunate? B1. Lunate intact (Cortex and cartilage intact – Lichtman 0, I, II, Schmitt A, Bain 0) Protect / unload the lunate: •
Orthosis or cast (trial for 2–3 months)
•
Radial shortening osteotomy, capitate shortening for ulnar positive variance (radial epiphysiodesis*)
•
(Alternatives – Lunate decompression, vascularized bone graft*, radius forage*)
B2. Lunate compromised (Localized lunate disease – Lichtman IIIA, Schmitt B, Bain 1) Lunate reconstruction: •
MFT*, lunate replacement*, PRC (RSL fusion, SC [or STT] fusion)
B3. Lunate not reconstructable (Advanced lunate disease - Lichtman IIIC, Schmitt C, Bain 2b) Lunate salvage (excision): •
Lunate replacement*, capitate lengthening, PRC (SC fusion)
C. State of the wrist? C1 - Carpal instability with intact articulations - Stabilize Typical scaphoid flexion, with RSA > 60° (Lichtman IIIB) •
Stabilize radial column (SC fusion)
C2 - Localized carpal degeneration - Reconstruct C2a. Radiolunate articulation compromised (Lichtman IIIA, Bain 2a) • • • •
Bypass (SC fusion) reconstruct (MFT graft) replace (lunate prosthesis) Fuse (RSL fusion)
C2b. Radioscaphoid articulation compromised • PRC if lunate facet intact • RSL fusion if lunate facet compromised and midcarpal joint intact C3 - KDAC, Advanced carpal collapse and degeneration - Salvage Wrist not reconstructable (Advanced wrist disease – Lichtman IV, Bain 4) •
Salvage (fusion or arthroplasty)
Other options that can be considered have been placed in (parentheses). STT fusion is an alternative to SC fusion. *Alternate procedures, techniques that require specialized skills and therefore affect what the surgeon can offer. The classification determines the recommended treatment based on the patient’s age (A), status of the lunate (B) and the status of the wrist (C). What the surgeon can offer (D) and what the patient wants (E) ultimately determine what is performed. Fig. 34.2 The Lichtman-Bain algorithm for the management of Kienbock’s disease. (Copyright © Dr Greg Bain, 2018)
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34.2.2 Inspection A meticulous inspection of the joint is then performed. Ballottement with the probe allows assessment of the integrity of the chondral surfaces. Correlating this information from arthroscopy with preoperative imaging assists the surgeon in making a better treatment decision. Bain and Begg reported that synovitis was present in all cases and the degree of synovitis correlated with the degree of articular damage.8 Plain radiographs will often underestimate the severity of the articular changes and the findings at arthroscopy will commonly change the recommended treatment. Bain et al. reported that in 82% of cases there was at least one nonfunctional articulation, and 61% had at least two nonfunctional articulations.8 Cases were identified with an intact chondral envelope, although softening and collapse of the subchondral bone plate were noted. This is an important subgroup as attempts at revascularization and unloading of the lunate can then provide a good functional outcome. ● Chondral softening, fibrillation, fissure, or fracture can then be identified. ● A “concealed fracture” may be present if a coronal fracture is present with an intact chondral envelope (▶ Fig. 34.3). ● A “floating surface” may be present if there has been osseous necrosis and collapse, but an intact chondral surface remains. In this instance, the surface “floats” when the wrist is tractioned, creating a potential space between the intact articular surface and collapsed bone. The scapholunate and lunotriquetral ligaments may tear as a result of lunate collapse and tilt. We find perilunate ligament tears are a common finding during arthroscopy in these cases.
34.2.3 Simple Procedures and Decision-Making A synovectomy is performed in every case. In patients with early disease, this may be definitive treatment, and in patients with more advanced disease, this may be a pain-relieving intervention. Loose fragments and flaps are debrided using shavers, baskets, or pituitary rongeurs. The chondral articulating surfaces are then classified using the Bain and Begg classification. The state of the articulations, wrist, and treatment options can then be determined using the Lichtman-Bain Algorithm.
34.3 Conclusion Wrist arthroscopy best defines the status of the articulating surfaces in Kienbock’s disease. Chondral changes do not always mirror the osseous or vascular status of the lunate. After arthroscopic assessment, synovectomy and debridement can then be performed, and in some cases, definitive arthroscopic management performed (▶ Video 34.1)
Video 34.1 Video explaining the difference possibilities regarding on arthroscopic lunate condition inn Kienbock’s disease.
Fig. 34.3 Arthroscopic assessment of nonfunctional articular surfaces. On probing the proximal lunate, a concealed fracture is identified. Irregular surfaces with exposed bone may also be present. (Copyright © Dr Greg Bain, 2018)
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References [1] Bain GI, Begg M. Arthroscopic assessment and classification of Kienbock’s disease. Tech Hand Up Extrem Surg. 2006; 10(1):8–13 [2] Bain GI, Durrant A. An articular-based approach to Kienbock avascular necrosis of the lunate. Tech Hand Up Extrem Surg. 2011; 15(1): 41–47 [3] Lichtman DM, Pientka WF, II, Bain GI. Kienböck Disease: A New Algorithm for the 21st Century. J Wrist Surg. 2017; 6(1):2–10 [4] Bain GI, MacLean SB, Tse W-L, Ho P-C, Lichtman DM. Kienböck Disease and Arthroscopy: Assessment, Classification, and Treatment. J Wrist Surg. 2016; 5(4):255–260
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[5] Lichtman DM, Pientka WFBG. Addendum: Kienböck Disease: A New Algorithm for the 21st Century. J Wrist Surg. 2017 [6] MacLean SBM, Kantar K, Bain GI, Lichtman DM. The Role of Wrist Arthroscopy in Kienbock Disease. Hand Clin. 2017; 33(4):727–734 [7] Lichtman DM. BGI. Kienbock’s Disease: Advances in Diagnosis and Treatment. 1st ed. Spinger; 2016 [8] Bain GI, Durrant A. An articular-based approach to Kienbock avascular necrosis of the lunate. Tech Hand Up Extrem Surg. 2011; 15(1): 41–47
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35 Arthroscopic Bone Grafting for Lunate Ganglion 35.1 Introduction Lunate cysts are relatively common but usually painless. They are generally discovered by chance during an MRI or CT examination (▶ Video 35.1). Pain can develop when the outer wall of the cyst collapses, opening the cyst to the scapholunate (SL) joint space. The standard treatment consists of curettage of the cyst and, typically, bone grafting. Open treatment is very challenging and requires a large volar incision. Arthroscopy makes it possible to perform noninvasive treatment that preserves the vascular and anatomical structures by passing through the proximal, nonvascularized portion of the SL ligament.
35.2 Operative Technique 35.2.1 Patient Preparation and Positioning The procedure is performed under regional anesthesia using a tourniquet. The patient’s arm is secured to the arm board. Finger traps are used to apply 5 to 7 kg (11– 15.5 lbs.) traction along the arm’s axis.
35.2.2 Radiocarpal Exploration The scope is introduced in the 3–4 portal and the shaver in the radiocarpal 1–2 portal. The first phase of the arthroscopic procedure consists of complete synovectomy with a shaver, reversing the shaver and scope positions. With the scope in the 1–2 portal, the SL ligament–specifically, its proximal portion–can be located (▶ Video 35.2).
35.2.3 Locating and Curettage of Cyst With the scope in the 1–2 portal, an intramuscular needle is introduced in the 3–4 portal with its tip aimed at the
Video 35.1 Video showing the presentation of clinical case with visualization of lunate ganglion on CT scan.
proximal portion of the ligament. The needle is inserted through the ligament to locate the intra-osseous cyst for which the outer wall has collapsed (▶ Fig. 35.1a, b, ▶ Video 35.3). The ganglion is usually on the volar side. Once the ganglion has been located, a curette is inserted through the ligament under arthroscopic guidance (▶ Fig. 35.2a–c). The entire ganglion is then resected using the curette and the shaver (▶ Fig. 35.3a, b). This step can be performed either with saline irrigation or as a dry procedure (▶ Video 35.4).
35.2.4 Bone Graft Harvesting The bone graft is harvested from the ipsilateral wrist. An incision is made on the lateral side of the wrist between the 1st and 2nd extensor compartments. The sensory branches of the radial nerve are identified and protected. The periosteum under the extensor tendons in the 1st and 2nd compartments is roughened with a bone rasp to free up the graft collection area. A three-sided osteotomy is performed while leaving a “bone cap” attached to the radius. The bone graft is harvested with a curette; its volume must be larger than the defect being filled. After the graft has been collected, the cap is placed back on the harvest site. The periosteum will spontaneously replace itself. The skin is closed with interrupted sutures (▶ Video 35.5).
35.2.5 Bone Graft Application The next step is performed in a dry environment. If the initial part of the procedure was performed in a wet environment, all the fluid must be aspirated. The bone graft is inserted into a trocar and then the trocar’s tip placed in the cyst cavity (▶ Fig. 35.4a, b). The graft is pushed into the trocar with a blunt guidewire until the cyst cavity is filled (▶ Fig. 35.5a, b). The bone graft is packed down with a blunt guidewire (▶ Fig. 35.6, ▶ Video 35.6).
Video 35.2 Video showing the different portals used for the procedure.
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Video 35.3 Video showing the technique used to locate the ganglion.
Fig. 35.1 Drawing (a) and intraoperative view (b) of the needle-locating technique of lunate ganglion.
Fig. 35.2 Drawing (a) and intraoperative view (b, c) of lunate ganglion curettage.
Fig. 35.3 Drawing (a) and intraoperative view (b) of lunate ganglion emptied.
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Video 35.4 Video showing ganglion curettage.
Video 35.5 Video showing the technique of harvesting cancellous bone graft from the radius.
Fig. 35.4 Drawing (a) and intraoperative view (b) of the filling of the ganglion with the bone graft.
Fig. 35.5 Drawing (a) and intraoperative view (b) of the bone graft completely filling the ganglion.
Video 35.6 Video showing the filling of the ganglion with the bone graft.
Fig. 35.6 Intraoperative view of graft packed in the ganglion with a spatula.
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35.2.6 Closure and Postoperative Care The wrist is immobilized until union is achieved (▶ Video 35.7). Rehabilitation is initiated once the splint is removed around 6th week.
35.3 Conclusion Video 35.7 Video showing the final dressing.
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Arthroscopic treatment of intra-osseous ganglion cysts of the lunate provides precise and minimally invasive control over the resection and grafting steps. Pain relief is obtained with no loss of function or joint stiffness.
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Index Note: Page numbers set bold or italic indicate headings or figures, respectively.
1 1-2 radiocarpal portal 6 – in interposition arthroplasty for scapholunate collapse 160, 161, 163 – in lunate ganglion bone grafting 179 – in lunotriquetral ligament reconstruction 93, 94 – in radial styloidectomy 30, 30– 31 – in resection arthroplasty of radial column for scapholunate collapse 166 – in scaphoid proximal pole replacement implantation 136, 136 – in trans-scaphoid perilunate dislocation fixation 102 – in volar ganglion excision 26, 27–28
3 3-4 radiocarpal portal 4, 5 – in arthrolysis 141 – in box reconstruction of scapholunate interosseous ligament with tendon graft 87 – in distal ulnar resection 65 – in dorsal capsuloligamentous repair of scapholunate interosseous ligament tear 79– 80, 81 – in dorsal ganglion excision with dye-aided stalk resection 24 – in interposition arthroplasty for scapholunate collapse 159 – in intra-articular radius fracture fixation 114 – in lunate ganglion bone grafting 179 – in lunotriquetral ligament reconstruction 94 – in radial styloidectomy 30, 30– 31, 31 – in scaphoid nonunion bone graft 131 – in scaphoid proximal pole replacement implantation 136, 136, 139 – in scapholunate injury 76, 77 – in scapholunate stability testing 74 – in trans-scaphoid perilunate dislocation fixation 102, 103, 105 – in triangular fibrocartilage complex foveal reinsertion, with anchor 50 – in triangular fibrocartilage complex reconstruction with tendon graft 60
– in volar capsuloligamentous suture for midcarpal instability 109 – in volar ganglion excision 26, 27–28
4 4-5 radiocarpal portal 5 – in arthrolysis 141 – in box reconstruction of scapholunate interosseous ligament with tendon graft 87 – in fixation of intra-articular radius fracture 114 – in scaphoid proximal pole replacement implantation 136, 136 – in triangular fibrocartilage complex foveal reinsertion 54 – in triangular fibrocartilage complex reconstruction with tendon graft 60 – in volar ganglion excision 28
6 6R radiocarpal portal 5, 5 – in arthrolysis 141 – in distal ulnar resection 66 – in dorsal capsuloligamentous repair of scapholunate interosseous ligament tear 79–80 – in dorsal wrist ganglion excision with colored dye-aided stalk resection 23 – in fixation of intra-articular radius fracture 114 – in hamatum head resection 69 – in interposition arthroplasty for scapholunate collapse 159 – in lunotriquetral ligament reconstruction 93 – in osteotomy for distal radius malunion 122 – in radial styloidectomy 31 – in scapholunate injury 76, 77 – in scapholunate stability testing 74 – in trans-scaphoid perilunate dislocation fixation 105 – in triangular fibrocartilage complex foveal reinsertion 54, 57 – in triangular fibrocartilage complex reconstruction with tendon graft 60 – in triangular fibrocartilage complex tear repair 40, 42, 44, 45–46 – in volar capsuloligamentous suture for midcarpal instability 109
– in volar ganglion excision 28, 28 6U radiocarpal portal 6 – in box reconstruction of scapholunate interosseous ligament with tendon graft 87 – in triangular fibrocartilage complex foveal reinsertion, with anchor 50, 51–53 – in triangular fibrocartilage complex reconstruction with tendon graft 61
A American position 12 Arcuate ligament 10, 16, 16, 108– 109 Arthrolysis – indications for 141 – open vs. arthroscopic 141 – operative technique 141, 141, 142–143 – patient positioning in 141 – patient preparation in 141 – postoperative care in 144 – radiocarpal dorsal recess debridement in 142, 143 – radiocarpal joint debridement in 141, 141 – radiocarpal joint inspection in 142 – radiocarpal wall resection in 141, 142–143 Arthroplasty – interposition –– in scapholunate collapse ––– closure in 164 ––– operative technique 159, 159, 160–164 ––– patient positioning in 159 ––– patient preparation in 159 ––– postoperative care in 164 ––– radiocarpal joint in 159, 160 ––– styloidectomy in 160, 160, 161 ––– tendon graft harvesting in 159, 159 –– scaphotrapeziotrapezoidal ––– closure in 147, 148 ––– implant placement in 147, 147, 148 ––– implant selection in 146, 147 ––– midcarpal joint debridement in 145 ––– operative technique 145, 145, 146–148 ––– patient positioning for 145 ––– patient preparation in 145 ––– postoperative care in 147, 148 ––– scaphoid resection in 146, 146, 147 ––– scaphotrapeziotrapezoid joint exploration in 145, 145
– resection –– of radial column for scapholunate collapse 165, 165, 166–168 –– of thumb carpometacarpal joint 149, 149, 150–153 Arthroscope 1, 1 Arthroscopy column 1 Avascular necrosis, of proximal pole of scaphoid 136, 136, 137– 140
B Bain and Begg Classification 175, 175 Bipolar diathermy machine 1 Blade 4 Bone graft – in lunate ganglion 179, 179, 180–182 – in partial wrist fusion 172–173, 173 – in scaphoid nonunion 131, 131, 132–135
C Capsuloligamentous suture – dorsal, in scapholunate interosseous ligament repair 80, 80, 81, 83 – volar, in midcarpal instability 109, 109, 110–112 Carpometacarpal joint (CMC), thumb – interposition arthroplasty 154, 154, 155–157 – resection arthroplasty 149, 149, 150–153 Chondropathy, isolated radial 30 CMC, see Carpometacarpal joint (CMC), thumb Colored dye-aided stalk resection, in dorsal wrist ganglion 23, 23, 24–25
D DCSS, see Dorsal capsuloligamentous/capsuloscapholunate septum (DCSS) Deep radioulnar ligament (DRUL) 34 DIC, see Dorsal intercarpal (DIC) ligament Direct foveal portal 7, 8 DISI, see Dorsal intercalated segmental instability (DISI) Distal radioulnar joint (DRUJ) 33, 33, 36, 48 – in fixation of intra-articular radius fracture 116
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Index – in triangular fibrocartilage complex foveal reinsertion, with anchor 49, 49, 50 – portal, in triangular fibrocartilage complex tear 40, 40 Distal radioulnar portal 7, 8 Distal radius fracture (DRF) – fixation of intra-articular 113, 113, 114–116 – in ulnar impaction syndrome 64, 67 – malunion of, osteotomy for 118, 118, 119–125 Dorsal 1 portal 8, 9 – in thumb carpometacarpal interposition arthroplasty 154– 155 Dorsal capsuloligamentous/ capsulo-scapholunate septum (DCSS) 15 – in arthrolysis 142 – in dorsal wrist ganglia surgery 17, 17, 20 – in scapholunate complex anatomy 73, 73–74 – in scapholunate injury 76, 77 – in scapholunate interosseous ligament tear repair 79, 79 Dorsal intercalated segmental instability (DISI) 87–88, 89, 108 Dorsal intercarpal (DIC) ligament – in scapholunate complex anatomy 72, 73 – in scapholunate injury 78 Dorsal radiocarpal (DRC) ligament – in lunotriquetral ligament reconstruction 97, 99 – in radial styloidectomy 30 – in scapholunate complex anatomy 72 – in scapholunate injury 76 Dorsal wrist ganglion – arthroscopic treatment of 17, 17, 18–21 – excision with colored dye-aided stalk resection 23, 23, 24–25 DRC, see Dorsal radiocarpal (DRC) ligament DRF, see Distal radius fracture (DRF) DRUJ, see Distal radioulnar joint (DRUJ) DRUL, see Deep radioulnar ligament (DRUL) Dry arthroscopy 2, 69, 93, 122, 175 Dye-aided stalk resection, in dorsal wrist ganglion 23, 23, 24–25
E ECU, see Extensor carpi ulnaris (ECU) tendon Exploration – principles 12 – radiocarpal 13, 13, 14–16 Extensor carpi ulnaris (ECU) tendon, in lunotriquetral ligament reconstruction 93, 94
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Extensor pollicis longus (EPL) tendon, in fixation of intraarticular radius fracture 114
F Fracture – distal radius –– fixation of intra-articular 113, 113, 114–116 –– in ulnar impaction syndrome 64, 67 –– malunion of, osteotomy for 118, 118, 119–125 – lunate, iatrogenic, in box reconstruction of scapholunate interosseous ligament 89 – scaphoid –– fixation 126, 126, 127–130 –– fixation of 126, 126, 127–130 –– in box reconstruction of scapholunate interosseous ligament 89 –– in trans-scaphoid perilunate dislocation 102–103, 104–105 –– nonunion, bone grafting for 131, 131, 132–135 Functional surfaces 175
G Ganglia – dorsal –– arthroscopic treatment of 17, 17, 18–21 –– excision with colored dye-aided stalk resection 23, 23, 24–25 – lunate, bone grafting in 179, 179, 180–182 – volar, arthroscopic excision of 26, 26, 27–29 Ghost sign 36, 37 Grafting – bone –– in lunate ganglion 179, 179, 180–182 –– in partial wrist fusion 172–173, 173 –– in scaphoid nonunion 131, 131, 132–135 – tendon –– in box reconstruction of scapholunate ligament ––– K-wire fixation of radiolunate joint in 88, 89 ––– midcarpal exploration in 87 ––– operative techniques 87, 88– 91 ––– patient positioning in 87 ––– patient preparation in 87 ––– postoperative care in 90 ––– radiocarpal exploration in 87 –– in interposition arthroplasty for scapholunate collapse 159, 159, 160 –– in lunotriquetral ligament reconstruction 95, 96–98
–– in reconstruction of triangular fibrocartilage complex ––– graft area preparation in 60, 61 ––– harvesting in 59, 60 ––– operative technique 59, 59, 60–63 ––– patient preparation in 59, 59 ––– postoperative care in 62 ––– radial tunnel in 59, 60–61 ––– ulnar tunnel in 61, 61, 62
H HALT syndrome 68–69, 69 Hamate arthritis lunotriquetral instability (HALT syndrome) 68– 69, 69 Hamate resection, in partial wrist fusion 173 Hamatum head resection 69, 70– 71 Harvesting – of bone graft –– in lunate ganglion 179, 181 –– in partial wrist fusion 170 –– in scaphoid nonunion 131, 132–133 – of tendon graft –– for box reconstruction of scapholunate interosseous ligament 88, 89 –– for triangular fibrocartilage complex reconstruction 59, 60 –– in interposition arthroplasty for scapholunate collapse 159, 159 Henry anterior approach 113 Hook sign 36, 36–37 Hook test 44, 48
I Implant – in interposition arthroplasty for scapholunate collapse 162, 162, 163–164 – in scaphoid proximal pole avascular necrosis 136, 136, 137–140 – in scaphotrapeziotrapezoidal interposition arthroplasty 146, 147, 147, 148 – in thumb carpometacarpal interposition arthroplasty 156, 156, 157 Incisions 4 Instruments 1, 1 Interposition arthroplasty – in scapholunate collapse –– closure in 164 –– operative technique 159, 159, 160–164 –– patient positioning in 159 –– patient preparation in 159 –– postoperative care in 164 –– radiocarpal joint in 159, 160 –– styloidectomy in 160, 160, 161
–– tendon graft harvesting in 159, 159 – in thumb carpometacarpal joint 154, 154, 155–157 Irrigation 2 Isolated radial chondropathy 30
K K-wire fixation – in box reconstruction of scapholunate interosseous ligament 88, 89 – in fixation of intra-articular radius fracture 114 – in lunotriquetral ligament reconstruction 94, 94–95 – in scaphoid fracture fixation 126, 126, 127, 127, 135 – in scaphoid nonunion 133 – in scapholunate interosseous ligament tear repair 82, 83 – in trans-scaphoid perilunate dislocation fixation 106, 106 Kienbock’s disease 175, 175–177
L Lichtman-Bain algorithm 175, 176 Ligament of Testut 13, 13 Light sources 1 Long radiolunate ligament (LRL) 12, 13, 13 – in midcarpal instability 108 – in scapholunate injury 76 – in volar wrist ganglion excision 26, 27–28 LRL, see Long radiolunate ligament (LRL) LT, see Lunotriquetral (LT) ligament Lunate fracture, iatrogenic, in box reconstruction of scapholunate interosseous ligament 89 Lunate ganglion, bone grafting in 179, 179, 180–182 Lunate, anatomical variations of 68, 68 Lunotriquetral (LT) ligament 13, 14 – in hamatum head resection 69 – reconstruction –– extensor carpi ulnaris tendon in 93, 94 –– k-wire fixation in 94, 94–95 –– operative technique 93, 93, 94– 101 –– patient positioning for 93 –– patient preparation for 93 –– PEEK screw in 96, 98 –– postoperative care in 100
M Malunion, of distal radius fracture, osteotomy for 118, 118, 119–125 MCR, see Radial midcarpal portal (MCR) MCU, see Midcarpal portal, ulnar
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Index Midcarpal assessment 15 Midcarpal instability 108, 108–109 Midcarpal joint – extrinsic ligaments in 76 – in box reconstruction of scapholunate interosseous ligament 90 – in dorsal capsuloligamentous repair of scapholunate interosseous ligament tear 80, 80, 81 – in dorsal wrist ganglia 17, 18, 19 – in HALT syndrome 69–70 – in partial wrist fusion 171, 171 – in scaphoid nonunion 131, 133 – in scaphotrapeziotrapezoidal interposition arthroplasty 145 – in volar midcarpal instability 108–111 – midcarpal ulnar portal for 6 – radial midcarpal portal for 6 Midcarpal portal – palmar 10, 11 – radial 6, 6, 7 –– in box reconstruction of scapholunate interosseous ligament with tendon graft 87, 90 –– in dorsal capsuloligamentous repair of scapholunate interosseous ligament tear 80, 82 –– in dorsal wrist ganglia surgery 20, 21 –– in hamatum head resection 69, 70 –– in partial wrist fusion 171 –– in scaphoid nonunion bone grafting 131, 132 –– in scapholunate injury 76 –– in scapholunate stability testing 74 –– in scaphotrapeziotrapezoidal interposition arthroplasty 145 –– in trans-scaphoid perilunate dislocation fixation 102, 103– 105 –– in volar capsuloligamentous suture for midcarpal instability 109 – scaphotrapeziotrapezoid 6, 6, 7 – ulnar 6, 6, 7 –– in box reconstruction of scapholunate interosseous ligament with tendon graft 87, 90 –– in dorsal capsuloligamentous repair of scapholunate interosseous ligament tear 80 –– in dorsal wrist ganglia 19, 20– 21 –– in hamatum head resection 69, 70 –– in partial wrist fusion 171, 173 –– in scaphoid fracture fixation 126 –– in scaphoid nonunion bone grafting 131, 132 –– in scapholunate injury 76
–– in scapholunate stability testing 74 –– in scaphotrapeziotrapezoidal interposition arthroplasty 145 –– in trans-scaphoid perilunate dislocation fixation 102, 105 –– in volar capsuloligamentous suture for midcarpal instability 109 Mucoid dysplasia, in dorsal ganglia 17, 20, 20
N Non-functional articulations 175
O Osteotomy – in distal ulnar resection 65 – in malunion of distal radius fracture 118, 118, 119–125
P Palmar 1 portal 8, 8, 9 – in thumb carpometacarpal interposition arthroplasty 154, 154 Palmar approach, in radial styloidectomy 31, 31 Palmar midcarpal portal 10, 11 Palmar portals 9 Palmaris longus tendon graft – in interposition arthroplasty for scapholunate collapse 159, 159, 160 – in reconstruction of triangular fibrocartilage complex –– graft area preparation in 60, 61 –– harvesting in 59, 60 –– operative technique 59, 59, 60– 63 –– patient preparation in 59, 59 –– postoperative care in 62 –– radial tunnel in 59, 60–61 –– ulnar tunnel in 61, 61, 62 Partial wrist fusion – arthrodesis fixation in 173, 173 – arthrodesis preparation in 171, 172 – bone graft in 172–173, 173 – closure in 174 – hamate resection in 173 – midcarpal joint in 171, 171 – patient positioning in 170 – patient preparation in 170 – postoperative care in 174 – radiocarpal joint in 171 – scaphoidectomy in 170, 170, 171 – surgical technique 170, 170, 171–173 PEEK screw, in lunotriquetral ligament reconstruction 96, 98 Perilunate dissociation 93 Plating
– in distal radius fracture malunion 122 – in distal radius fractures 113, 114, 114 Posterior radioulnar ligament (PRUL) 34 – See also Radioulnar ligament (RUL) Proximal “Distal Radioulnar” Portal 8 Push test 79, 79
R Radial chondropathy 30 Radial midcarpal portal (MCR) 6, 6, 7 – in box reconstruction of scapholunate interosseous ligament with tendon graft 87, 90 – in dorsal capsuloligamentous repair of scapholunate interosseous ligament tear 80, 82 – in dorsal wrist ganglia surgery 20, 21 – in hamatum head resection 69, 70 – in partial wrist fusion 171 – in scaphoid nonunion bone grafting 131, 132 – in scapholunate injury 76 – in scapholunate stability testing 74 – in scaphotrapeziotrapezoidal interposition arthroplasty 145 – in trans-scaphoid perilunate dislocation fixation 102, 103– 105 – in volar capsuloligamentous suture for midcarpal instability 109 Radial palmar radiocarpal portal 9, 10 Radial styloid fractures, lateral 113 Radial styloidectomy 30, 30, 31–32 – in box reconstruction of scapholunate interosseous ligament with tendon graft 88 – in interposition arthroplasty for scapholunate collapse 160, 160, 161 Radiocarpal exploration 13, 13, 14–16 Radiocarpal joint 13–14 – extrinsic ligaments in 76 – in arthrolysis 141, 141–142 – in box reconstruction of scapholunate interosseous ligament 87 – in distal ulnar resection 65 – in foveal reinsertion of triangular fibrocartilage complex 50, 57 – in HALT syndrome 69 – in interposition arthroplasty for scapholunate collapse 159, 160 – in partial wrist fusion 171
– in radial styloidectomy 30 Radiocarpal portal 4, 5 – 6R 5, 5 –– in arthrolysis 141 –– in distal radius fracture malunion 122 –– in distal ulnar resection 66 –– in dorsal capsuloligamentous repair of scapholunate interosseous ligament tear 79– 80 –– in dorsal wrist ganglion excision with colored dye-aided stalk resection 23 –– in fixation of intra-articular radius fracture 114 –– in hamatum head resection 69 –– in interposition arthroplasty for scapholunate collapse 159 –– in lunotriquetral ligament reconstruction 93 –– in osteotomy for distal radius malunion 122 –– in radial styloidectomy 31 –– in scapholunate injury 76, 77 –– in scapholunate stability testing 74 –– in trans-scaphoid perilunate dislocation fixation 105 –– in triangular fibrocartilage complex foveal reinsertion 54, 57 –– in triangular fibrocartilage complex reconstruction with tendon graft 60 –– in triangular fibrocartilage complex tear repair 40, 42, 44, 45–46 –– in volar capsuloligamentous suture for midcarpal instability 109 –– in volar ganglion excision 28, 28 – 6U 6 –– in box reconstruction of scapholunate interosseous ligament with tendon graft 87 –– in triangular fibrocartilage complex foveal reinsertion, with anchor 50, 51–53 –– in triangular fibrocartilage complex reconstruction with tendon graft 61 – 1–2 6, 6 –– in interposition arthroplasty for scapholunate collapse 160, 161, 163 –– in lunate ganglion bone grafting 179 –– in lunotriquetral ligament reconstruction 93, 94 –– in radial styloidectomy 30, 30– 31 –– in resection arthroplasty of radial column for scapholunate collapse 166 –– in scaphoid proximal pole replacement implantation 136, 136
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Index –– in trans-scaphoid perilunate dislocation fixation 102 –– in volar ganglion excision 26, 27–28 – 3–4 4, 5 –– in arthrolysis 141 –– in box reconstruction of scapholunate interosseous ligament with tendon graft 87 –– in distal ulnar resection 65 –– in dorsal capsuloligamentous repair of scapholunate interosseous ligament tear 79– 80, 81 –– in dorsal ganglion excision with dye-aided stalk resection 24 –– in fixation of intra-articular radius fracture 114 –– in interposition arthroplasty for scapholunate collapse 159 –– in intra-articular radius fracture fixation 114 –– in lunate ganglion bone grafting 179 –– in lunotriquetral ligament reconstruction 94 –– in radial styloidectomy 30, 30– 31, 31 –– in scaphoid nonunion bone graft 131 –– in scaphoid nonunion bone grafting 131 –– in scaphoid proximal pole replacement implantation 136, 136, 139 –– in scapholunate injury 76, 77 –– in scapholunate stability testing 74 –– in trans-scaphoid perilunate dislocation fixation 102, 103, 105 –– in triangular fibrocartilage complex foveal reinsertion, with anchor 50 –– in triangular fibrocartilage complex reconstruction with tendon graft 60 –– in volar capsuloligamentous suture for midcarpal instability 109 –– in volar ganglion excision 26, 27–28 – 4–5 5 –– in arthrolysis 141 –– in box reconstruction of scapholunate interosseous ligament with tendon graft 87 –– in fixation of intra-articular radius fracture 114 –– in scaphoid proximal pole replacement implantation 136, 136 –– in triangular fibrocartilage complex foveal reinsertion 54 –– in triangular fibrocartilage complex reconstruction with tendon graft 60 –– in volar ganglion excision 28 – dorsal 4
186
– radial palmar 9, 10 – ulnar palmar 9 Radiolunate (RL) joint, K-wire fixation of, in box reconstruction of scapholunate interosseous ligament 88 Radiolunotriquetral ligament 17 Radioscaphocapitate ligament (RSC) 12, 13, 13 – in midcarpal instability 108 – in radial styloidectomy 30 – in scapholunate complex anatomy 73 – in scapholunate injury 76 – in trans-scaphoid perilunate dislocation fixation 103, 104 – in volar ganglion excision 26, 27–28 Radioulnar joint, in distal ulnar resection 65, 66–67 – See also Distal radioulnar joint (DRUJ) Radioulnar ligament (RUL) – in triangular fibrocartilage complex anatomy 33, 34–35 – in triangular fibrocartilage complex foveal reinsertion 54, 54 Radius fractures, fixation of intraarticular distal 113, 113, 114– 116 Resection arthroplasty – of radial column for scapholunate collapse 165, 165, 166–168 – of thumb carpometacarpal joint 149, 149, 150–153 RL, see Radiolunate (RL) joint RSC, see Radioscaphocapitate ligament (RSC) RUL, see Radioulnar ligament (RUL)
S SC, see Scaphocapitate ligament (SC) Scaphocapitate ligament (SC) 12, 13 Scaphoid fracture – fixation 126, 126, 127–130 – in box reconstruction of scapholunate interosseous ligament 89 – in trans-scaphoid perilunate dislocation 102–103, 104–105 – nonunion, bone grafting for 131, 131, 132–135 Scaphoid nonunion advanced collapse (SNAC) 30, 170, 170, 171, 172, 173, 173 Scaphoid, avascular necrosis of proximal pole, implant for 136, 136, 137–140 Scapholunate (SL) joint – in dorsal wrist ganglion 23 – K-wire fixation of, in scapholunate interosseous ligament tear repair 82, 83
– stability –– classification of 74, 74, 75 –– extrinsic ligaments in 76, 76 –– predynamic, testing of 73 –– stage I 74, 75 –– stage II 74 –– stage IIIa 74, 75 –– stage IIIb 74, 75 –– stage IIIc 74 –– stage IV 74, 75 –– stage V 74 Scapholunate advanced collapse (SLAC) 30, 32, 159, 159, 164, 165, 166, 170 Scapholunate complex anatomy – biomechanics in 72 – carpal ligaments in 72 – dorsal capsulo-scapholunate septum in 73, 73–74 – dorsal intercarpal ligament in 72, 73 – dorsal radiocarpal ligament in 72, 73 – extrinsic ligaments in 72, 73 – radioscaphocapitate ligament in 73 – scapholunate interosseous ligament in 72 – scaphotrapezial ligament in 73 Scapholunate dissociation 87 Scapholunate interosseous ligament (SLIL) 13, 13 – box reconstruction of, with tendon graft –– K-wire fixation of radiolunate joint in 88, 89 –– midcarpal exploration in 87 –– operative techniques 87, 88–91 –– patient positioning in 87 –– patient preparation in 87 –– postoperative care in 90 –– radiocarpal exploration in 87 – depression 13 – dorsal capsuloligamentous repair of 81 –– in large detachment without stump on scaphoid 85, 85, 86 –– in large tear with instability 83, 84 –– midcarpal joint exploration in 80 –– operative technique for 79, 79, 80–86 –– patient positioning for 79 –– patient preparation for 79 –– postoperative care in 86 –– radiocarpal exploration in 79, 79 –– suture in 80, 80, 81 – in dorsal wrist ganglion excision with dye-aided stalk resection 23, 24–25 – in scapholunate complex anatomy 72, 72 – in trans-scaphoid perilunate dislocation fixation 103 Scaphotrapezial (ST) ligament – in scapholunate complex anatomy 73
– in scapholunate injury 76 Scaphotrapeziotrapezoid (STT) joint 16, 16 – arthritis of 145 – in hamatum head resection 70 Scaphotrapeziotrapezoid (STT) portal 6, 6, 7 Scaphotrapeziotrapezoidal interposition arthroplasty – closure in 147, 148 – implant placement in 147, 147, 148 – implant selection in 146, 147 – midcarpal joint debridement in 145 – operative technique 145, 145, 146–148 – patient positioning for 145 – patient preparation in 145 – postoperative care in 147, 148 – scaphoid resection in 146, 146, 147 – scaphotrapeziotrapezoid joint exploration in 145, 145 Screw fixation – in lunotriquetral ligament reconstruction 96, 98 – in scaphoid fracture 127, 129– 130 Set-up 2, 3 Short radiolunate ligament (SRL) 12, 13 – in scapholunate injury 76 SL, see Scapholunate (SL) joint SLIL, see Scapholunate interosseous ligament (SLIL) SRL, see Short radiolunate ligament (SRL) SRUL, see Superficial radioulnar ligament (SRUL) ST, see Scaphotrapezial (ST) ligament Stalk resection, colored dye-aided, in dorsal wrist ganglion 23, 23, 24–25 STT, see Scaphotrapeziotrapezoid (STT) joint Styloid recess 14 Superficial radioulnar ligament (SRUL) 34 Surgical approaches, general principles of 4, 4 Synovial cyst, dorsal – arthroscopic treatment of 17, 17, 18–21 – excision with colored dye-aided stalk resection 23, 23, 24–25
T TC, see Triquetrocapitate ligament (TC) Tendon graft – in box reconstruction of scapholunate ligament –– K-wire fixation of radiolunate joint in 88, 89 –– midcarpal exploration in 87
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Index –– operative techniques 87, 88–91 –– patient positioning in 87 –– patient preparation in 87 –– postoperative care in 90 –– radiocarpal exploration in 87 – in interposition arthroplasty for scapholunate collapse 159, 159, 160 – in lunotriquetral ligament reconstruction 95, 96–98 – in reconstruction of triangular fibrocartilage complex –– graft area preparation in 60, 61 –– harvesting in 59, 60 –– operative technique 59, 59, 60– 63 –– patient preparation in 59, 59 –– postoperative care in 62 –– radial tunnel in 59, 60–61 –– ulnar tunnel in 61, 61, 62 TFCC, see Triangular fibrocartilage complex (TFCC) TH, see Triquetrohamate ligament (TH) THC, see Triquetrohamatocapitate (THC) ligament Thumb carpometacarpal joint – interposition arthroplasty 154, 154, 155–157 – resection arthroplasty 149, 149, 150–153 Traction 1, 2 Trampoline effect 14, 39 Trampoline sign 36, 36 Trampoline test 44 Trans-scaphoid perilunate dislocation (TSPD) 102, 102 – closed reduction in 102, 102– 103 – fixation of –– closed reduction in 102 –– exploration in 102, 103–104 –– K-wire fixation in 106, 106 –– operative technique 102, 102, 103–106 –– patient positioning in 102 –– patient preparation in 102 –– postoperative care in 106 –– radiocarpal synovectomy in 102 –– stability assessment in 106, 106
–– volar capsule dissection in 103, 104–105 – screw fixation of scaphoid in 106 Trapeziometacarpal portal 8 Triangular fibrocartilage complex (TFCC) – anatomy 33, 33, 34–35 – as three-dimensional structure 35, 35 – biomechanics of 35, 35 – examination of 36, 36, 37 – exploration 14, 14 – foveal reinsertion of –– exploration in 54, 54 –– operative technique 54, 54, 55– 58 –– patient preparation for 54 –– postoperative care in 55 –– radioulnar ligament in 54, 54 –– with anchor ––– anchor insertion in 49, 50, 52 ––– distal radioulnar joint in 49, 49, 50 ––– exploration in 48, 48, 49 ––– operative technique 48, 48, 49–53 ––– patient preparation for 48 ––– postoperative care in 53 ––– suture in 50, 51–52 – histology of 33 – in arthrolysis 141 – in distal ulnar resection 65, 65, 65, 67 – in fixation of intra-articular radius fracture 115 – in HALT syndrome 68, 69 – in ulnar impaction syndrome 64, 69 – reinsertion, instrument kit for 1 – tears –– classification of 38 –– complete 38 –– distal 38 –– dorsal 44, 44, 45–47 –– examination of 36, 36, 37 –– foveal deinsertion 38 –– massive irreparable 38 –– pull test in 39 –– repair of ––– "double loop" suture in dorsal 44–47
––– distal radioulnar joint portal in 40, 40 ––– double loop suture in dorsal 44 ––– exploration in 38, 39 ––– patient preparation for 38 ––– postoperative care in 46 ––– suture in 40, 40, 41–43 – tendon graft in reconstruction of –– graft area preparation in 60, 61 –– harvesting in 59, 60 –– operative technique 59, 59, 60– 63 –– patient preparation in 59, 59 –– postoperative care in 62 –– radial tunnel in 59, 60–61 –– ulnar tunnel in 61, 61, 62 – vascularization of 33 Triquetrocapitate ligament (TC) 12 Triquetrohamate ligament (TH) 12 Triquetrohamatocapitate (THC) ligament, in midcarpal instability 108 TSPD, see Trans-scaphoid perilunate dislocation (TSPD)
U UC, see Ulnocapitate ligament (UC) UCL, see Ulnar collateral ligament (UCL) UL, see Ulnolunate ligament (UL) Ulnar collateral ligament (UCL) 33, 34–35, 48, 48 Ulnar impaction syndrome 64, 64, 69 Ulnar midcarpal portal (MCU) 6, 6, 7 – in box reconstruction of scapholunate interosseous ligament with tendon graft 87, 90 – in dorsal capsuloligamentous repair of scapholunate interosseous ligament tear 80 – in dorsal wrist ganglia 19, 20–21 – in hamatum head resection 69, 70 – in partial wrist fusion 171, 173 – in scaphoid fracture fixation 126
– in scaphoid nonunion bone grafting 131, 132 – in scapholunate injury 76 – in scapholunate stability testing 74 – in scaphotrapeziotrapezoidal interposition arthroplasty 145 – in trans-scaphoid perilunate dislocation fixation 102, 105 – in volar capsuloligamentous suture for midcarpal instability 109 Ulnar palmar radiocarpal portal 9 Ulnar resection, distal – exploration in 65 – patient positioning in 64 – patient preparation in 64 – postoperative care in 65 – radiocarpal synovectomy in 65 – radioulnar joint in 65, 66–67 – triangular fibrocartilage complex ligament in 65, 65 – with intact triangular fibrocartilage complex 65, 67 Ulnocapitate ligament (UC) 12 – in scapholunate injury 76 Ulnocarpal ligament 14 Ulnolunate ligament (UL) 12 – in scapholunate injury 76 – in triangular fibrocartilage complex anatomy 33, 34 Ulnotriquetral ligament (UT) 12 – in scapholunate injury 76 – in triangular fibrocartilage complex anatomy 33, 34 Ulnotriquetro-capitate ligament 16 UT, see Ulnotriquetral ligament (UT)
V VISI, see Volar intercalated segmental instability (VISI) Volar intercalated segmental instability (VISI) 95, 108 Volar ulnar (VU) approach 109, 110 Volar wrist ganglia, arthroscopic excision of 26, 26, 27–29
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