Wrist Arthroscopy Techniques E-Book

Christophe Mathoulin

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 315

Veröffentlichungsjahr: 2019

Beschreibung

In the past 5 years, wrist arthroscopy has become the third most common arthroscopic procedure, behind knee and shoulder. The method has evolved significantly over the past decade, providing a better understanding of disease mechanisms and applications. Authored by a renowned expert in the field of hand and wrist surgery, this second edition of Wrist Arthroscopy Techniques is a step-by-step, anatomically illustrated manual encompassing the latest concepts in the field, now greatly enhanced by 200 short videos, accompanying each illustration in the book.

Starting with an introduction about instrumentation and techniques, readers will gain insight into how an arthroscope enables precise visualization and analysis of the internal structural make-up of the wrist.

Each chapter provides a how-to, detailed procedural guide—from the point of incision to closure, accompanied by artfully drawn illustrations. The author shares clinical pearls and provides comprehensive explanations on treating specific conditions, including ligament tears and instability, complex fractures, dorsal and volar wrist ganglia, advanced arthritis, and fibrocartilage tears. Indications, risks, special precautions, and postoperative care are covered.

Special Features:

• 200 brilliant videos provide complete coverage of all procedures
• Meticulous explanation of anatomical structures
• Multiple surgical approaches included, where applicable
• Coverage of new minimally invasive arthroscopy
• Use of pyrocarbon implants, and bone and tendon grafts for reconstruction
• Analyses of postoperative range-of-motion, stability, and overall outcome

Whether you are a seasoned surgeon or an advanced fellow, Wrist Arthroscopy Techniques is certain to be consulted frequently. An invaluable and comprehensive resource tool covering the state-of-the-art arthroscopic techniques, it is a must-have for a

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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.

Wrist Arthroscopy Techniques

2nd Edition

Christophe Mathoulin, MD, FMH

Vice-PresidentInstitut de la Main;Founder and Honorary ChairmanEuropean (International) Wrist Arthroscopy Society (EWAS - IWAS);FounderInternational Wrist CenterClinique BizetParis, France

635 illustrations

ThiemeStuttgart • New York • Delhi • Rio de Janeiro

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) | LCCRD559 (print) | NLM WE 830 | DDC 617.5/75059–dc23

LC record available at https://lccn.loc.gov/2019012210

© 2019 by Georg Thieme Verlag KG

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Contents

Videos

Foreword

Terry L. Whipple

Preface

Acknowledgments

Contributors

1.Materials and Set-Up

2.Surgical Approaches

3.Arthroscopic Anatomy of the Wrist

4.Arthroscopic Treatment of Dorsal Wrist Ganglia

5.Arthroscopic Dorsal Wrist Ganglion Excision with Colored Dye-Aided Stalk Resection

6.Arthroscopic Excision of Volar Wrist Ganglia

7.Arthroscopic Radial Styloidectomy

8.Anatomy of the TFCC: Current Concepts

9.Arthroscopic Repair of Peripheral Tears of the TFCC

10.“Double Loop” Suture Repair in Large Dorsal Tears of the TFCC

11.Arthroscopy-Assisted Foveal Reinsertion of the TFCC with an Anchor

12.Arthroscopic-Assisted Foveal Reinsertion of the TFCC

13.Arthroscopic Reconstruction of the TFCC Using a Free Tendon Graft

14.Arthroscopic Distal Ulnar Resection

15.Arthroscopic Hamatum Head Resection for HALT Syndrome

16.Anatomy of the Scapholunate Complex

17.Dorsal Capsuloligamentous Repair of the Scapholunate Ligament Tear

18.Arthroscopic-Assisted Box Reconstruction of Scapholunate Ligament with Tendon Graft

19.Arthroscopic-Assisted Reconstruction of LT-Ligament

20.Arthroscopic-Assisted Fixation of Trans-Scaphoid Perilunate Dislocation

21.Volar Capsuloligamentous Suture as Treatment of Volar Midcarpal Instability

22.Arthroscopic-Assisted Fixation of Intra-Articular Distal Radius Fractures

23.Arthroscopic-Guided Osteotomy for Distal Radius Malunion

24.Arthroscopic-Assisted Scaphoid Fracture Fixation

25.Arthroscopic Bone Grafting for Scaphoid Nonunion

26.Arthroscopic Replacement of the Proximal Pole of the Scaphoid with a Pyrocarbon Implant

27.Arthroscopic Arthrolysis of the Wrist

28.Arthroscopic Scaphotrapeziotrapezoidal Interposition Arthroplasty

29.Arthroscopic Resection Arthroplasty of Thumb Carpometacarpal Joint

30.Arthroscopic Thumb Carpometacarpal Interposition Arthroplasty

31.Arthroscopic Interposition Arthroplasty in Stage II Scapholunate Advanced Collapse Wrists

32.Arthroscopic Resection Arthroplasty of the Radial Column for Scapholunate Advanced Collapse Wrist

33.Arthroscopic Partial Wrist Fusion

34.Arthroscopic Assessment of Kienbock’s Disease

35.Arthroscopic Bone Grafting for Lunate Ganglion

Index

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

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

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, FAOAEWAS Emeritus Member and Honorary PresidentChief of OrthopaedicsHillelson-Whipple Clinic;Associate Professor of Orthopaedic SurgeryVirginia Commonwealth University School of Medicine;DirectorOrthopaedic Research of VirginiaVirginia, USA

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 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. Jan-Ragnar 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

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

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

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

Edward Wu, MD

Senior Orthopaedic Resident

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

Jeffrey Yao, MD

Associate Professor

Robert A. Chase Hand and Upper Limb Center

Department of Orthopaedic Surgery

Stanford University Medical Center

California, USA

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 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.

Fig. 1.1 Arthroscope with camera angulated at 30°, sizes 1.9 mm, and 2.4 mm in diameter.

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 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.

Video 1.1 Video presenting the different instruments useful for the realization of arthroscopy of the wrist.

Fig. 1.2 Set-up with vertical traction in “fishing rod” allowing the entire forearm to be free in the surgical field.

Video 1.2 Video showing the use of the universal table that facilitates the installation of the wrist.

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. 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.

Fig. 1.3 Set-up using a traction tower.

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 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

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

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) 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.

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.

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).

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).

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 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).

Fig. 2.2 Diagram showing the classic radiocarpal portals named according to their position relative to the dorsal extensor compartments.

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.

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.

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.

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 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.

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 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.

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.

2.5 Distal Radioulnar Portals

There are three distal radioulnar portals: the distal radio-ulnar (DRU) portal, the direct foveal portal, and the proximal “distal radioulnar” portal.

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.

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).

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.

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 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 2.10 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.

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).

Video 2.11 Video showing the scope in distal radioulnar position (DRU) and the needle in the direct foveal portal. Intra-articular view showing the needle entry through the direct foveal portal and positioned at the fovea.

Video 2.12 Video showing the palmar trapezometacarpal portal.

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.

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 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.

Fig. 2.7 Operative view showing needle position to localize the dorsal trapezometacarpal portal using transillumintaion.

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)