Techniques in Wrist and Hand Arthroscopy

261 Pages·2007·44.77 MB·English

by  David J. Slutsky MD FRCS

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TECHNIQUESINWRISTANDHANDARTHROSCOPY ISBN:978-0-443-06697-9
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Techniquesinwristandhandarthroscopy/[editedby]DavidJ.Slutsky,
DanielJ.Nagle.—1sted.
p. ;cm.
Includesbibliographicalreferences.
ISBN978-0-443-06697-9
1. Hand—Endoscopicsurgery. 2. Wrist—Endoscopicsurgery.
3. Arthroscopy. I.Slutsky,DavidJ. II.Nagle,DanielJ.
[DNLM:1. WristJoint—surgery. 2. Arthroscopy—methods. 3. Hand
Joints—surgery.WE830T25652007]I. Title.
RD559.T4382007
617.5’750597—dc22
2007026202
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‘‘To Brett and Jesse, whose love and laughter make life worth living’’
David J. Slutsky
‘‘To my mother and father’’
Daniel J. Nagle
Preface
Arthroscopyofthewristandhandhasevolvedfrombeinga It was a real joy working with many of the pioneers and
diagnosticmodalitytobeingavaluableandeffectivethera- innovators in wrist and hand arthroscopy. We are indebted
peutic tool. Arthroscopy has revolutionized the diagnosis to our contributors without whom this book would not
and treatment of scapholunate and lunotriquetral ligament exist. We appreciate the time, effort and personal sacrifice
disorders as well as triangular fibrocartilage tears. Wrist they have put forth to educate their peers. We are also
arthroscopy is a useful adjunct in the reduction of intra- indebted to Kim Murphy, senior publishing director of
articular fractures of the distal radius as well as percutane- Global Medicine at Elsevier, for allowing us to move for-
ous screw fixation of scaphoid fractures. The staging of ward with this project as well as the associate editors who
degenerative conditions is facilitated through the use of contributed their time and energy to this project including
arthroscopy. Innovative surgeons have developed arthro- Karen Carter, who moved mountains to complete this
scopic techniques for partial carpal resections, release of book, Elyse O’Grady, and Matthew Ray. Special thanks to
wrist contractures, synovectomies, and ganglionectomies. Jenny Koleth and Michael Troy for their postproduction
This book features a compendium of procedures from work as well as multimedia producer Bruce Robison and
someofthetrueleadersinthisfield.Itisintendedtoserve his team and Dave Sewel of Motion Video for their help
as a user’s manual for both the entry level wrist arthrosco- with the video editing.
pist and the experienced surgeon. The methodology and Wehopethatyouwillfindthisbookusefulasyoutackle
the practical aspects of each procedure are stressed along new arthroscopic techniques.
with myriad pearls and tips, oftentimes from the origina-
tors of the technique. The accompanying DVDs illustrate David J. Slutsky, MD, FRCS[C]
thetechniquesandprovideaglimpseintothesurgicalanat- Daniel J. Nagle, MD, FACS, FAAOS
omy in real time.
vii
Foreword
Wrist arthroscopy is more than a tool, diagnostic instru- If arthroscopy is more than a technique, the book you
ment,ortreatmentdevice.Wristarthroscopy isanattitude have in your hands is also more than a how-to-do publica-
that uses technology to better serve the Hyppocratic oath tion.Onthesepagesthereismuchmorethanjustamanual
‘‘primum non nocere’’ (never do harm). Arthroscopy was of arthroscopy. Coming from one of the most knowledge-
not developed to establish a skill competition among sur- able groups of experts in the field, it is not surprising to
geonstoseewhowasabletodomorethroughthesmallest find one of the finest and most complete descriptions of
incision, but to save patients requiring surgery from the all that it takes to successfully master this technique,
burden of dysfunctional, non-aesthetic, and/or symptom- including an endless number of details about the required
atic scars. Arthroscopy is one of the most innovative ways instrumentationandarthroscopicanatomy,aswellasmany
ofgettingwhereweneedtobeinordertosolveaproblem, pearlsmakingdiagnosticexaminationandtreatmentaseffi-
without inflicting more damage to the joint as a toll to get cientasitcanbewiththeminimumpossiblecomplications.
there. Indeed, the introduction of wrist arthroscopy is one Furthermore, in order to increase the didactic value of this
of the best things that happened to us, wrist enthusiasts, publication, each chapter offers the opportunity of observ-
in the last two decades. ing real cases being dealt with by the authors through
Since its introduction by Yung-Cheng Chen in 1979,1 videos of an outstanding quality. But this is not all; this
wrist arthroscopy has gained widespread acceptance. From book contains both an implicit tribute to those who, in
mostly a diagnostic tool in the 80’s, it has evolved in our the past, with less than optimal equipment, dared to look
days into a proven means of safe, reliable treatment of a inside of such a tight joint and see what was there that
growing number of conditions. As a diagnostic tool, it is could be solved without further opening the capsule, and
particularly useful for patients with a painful intracapsular aninvitationtotheyounggenerationstotakethechallenge
problem whose evaluation with the available imaging tech- to make this tool even more reliable for the benefit of our
niquesisuncertain.Inthisregard,arthroscopyhasbecome patients.
the gold standard in the identification and severity assess- Indeed, that old Italian saying according to which great
ment of a good number of wrist pathologies within the surgeons make long incisions (‘‘grande chirurgo, magna
articular space, including ligament derangements, triangu- incisione’’) is to be definitively considered obsolete.
lar fibrocartilage tears, or cartilage defects. In the domain
of therapeutic capabilities, the list of indications is steadily
Reference
increasing.Arthroscopyisausefuladjunctinawidevariety
ofsituations,includingthereductionofintraarticular wrist 1. ChenYC.Arthroscopyofthewristandfingerjoints.Orthop
fractures,percutaneousfixationofunstablecarpaljoints,or ClinNorthAm1979;10:723–33.
resectionof damaged osteoarthriticjointsurfaces. Arthros-
copy,inexperthands,mayalsoperformremarkablywellin
thereleaseofjointcontractures,inthe excisionof prolifer- Marc Garcia-Elias MD, PhD
ating inflamed synovial tissue, or even in the resection of Hand surgeon
occult ganglia. There is no doubt that if the current num- Kaplan Institute
ber of indications of wrist arthroscopy looks already quite Barcelona, Spain
large, with the new developments about to be released, Secretary-General
including robotic control of flexible, miniaturized arthro- Federation of European Societies for
scopes, the future capabilities of arthroscopy are immense. Surgery of the Hand (FESSH)
ix
Contributors
Brian D. Adams, MD Robert E. Carroll, MD
Professor Professor Emeritus of Hand Surgery
Department of Orthopaedics Department of Orthopaedic Surgery
University of Iowa School of Medicine Columbia University College of Physicians and Surgeons
Iowa City, Iowa New York, New York
N. Ashwood, MD, FRCS(Orth) Randall W. Culp, MD
University of Adelaide AssociateProfessorofOrthopedic,Hand,andMicrosurgery
Royal Adelaide Hospital ThomasJeffersonUniversity
Modbury Public Hospital Philadelphia,Pennsylvania
North Adelaide, Australia ThePhiladelphiaHandCenter,P.C.
KingofPrussia,Pennsylvania
G.I. Bain, MD, FRACS
University of Adelaide Francisco del Pin˜al, MD
Royal Adelaide Hospital Instituto de Cirugia Plastica y de la Mano
Modbury Public Hospital Hospital Mutua Montanesa and Clinica Mompia
North Adelaide, Australia Santander, Spain
Ferdinando Battistella, MD Seth D. Dodds, MD
Chief Surgeon Assistant Professor, Hand and Upper Extremity Surgery
Center for Reconstructive Arthroscopic Shoulder Surgery Department of Orthopaedics and Rehabilitation
Istituto Ortopedico Galeazzi Yale University School of Medicine
Milan, Italy New Haven, Connecticut
Richard A. Berger, MD, PhD William B. Geissler, MD
Professor of Orthopedics Professor and Chief, Division of Hand and Upper
Department of Orthopedic Surgery and Anatomy Extremity Surgery
Mayo Clinic Chief,SectionofArthroscopicSurgeryandSportsMedicine
Rochester, Minnesota Director,HandandUpperExtremityFellowship
DepartmentofOrthopaedicSurgeryandRehabilitation
Randy R. Bindra, MD UniversityofMississippiMedicalCenter
Professor of Orthopaedics Jackson,Mississippi
Director of the Center for Hand and
Pau Golano, MD
Upper Extremity Surgery
Departamento Anatomı´a
University of Arkansas for Health Sciences
Universidad de Barcelona
Department of Orthopaedic Surgery
Barcelona, Spain
Little Rock, Arkansas
Steven H. Goldberg, MD
Ce´sar J. Bruno
Hand Surgery Ltd.
Clinical Assistant Professor of Orthopedic Surgery
Waukesha, Wisconsin
University of Virginia
Charlottsville, Virginia Jeffrey A. Greenberg, MD
Co-Director Hand, Microvascular and Indiana Hand Center
Upper Extremity Division Clinical Assistant Professor
Carilion Bone and Joint Center Indiana University School of Medicine
Roanoke, Virginia Indianapolis, Indiana
xi
xii Contributors
Gregory J. Hanker, MD A. Lee Osterman, MD
Assistant Clinical Professor Professor Hand Surgery
Plastic and Reconstructive Surgery Philadelphia Hand Center
University of Southern California Thomas Jefferson University
Southern California Orthopaedic Institute Philadelphia, Pennsylvania
Van Nuys, California
Andrew K. Palmer, MD
Brian J. Harley, MD, FRCS[C]
Professor of Orthopaedic Surgery
Associate Professor of Orthopedic Surgery
SUNY Health Science Center
SUNY Health Science Center
Syracuse, New York
Syracuse, New York
Kevin D. Plancher, MD
Michael R. Hausman, MD
Associate Clinical Professor
Professor, Orthopaedics
Albert Einstein College of Medicine
Assistant Professor, Surgery
New York, New York
The Leni and Peter W. May Department of Orthopaedics
Orthopaedic Foundation for Active Lifestyles
Mount Sinai School of Medicine
Greenwich, Connecticut
New York, New York
Ericka A. Lawler, MD Kongkhet Riansuwan, MD
Visiting Assistant Professor Postdoctoral Research Fellow
Department of Orthopaedic Surgery Department of Orthopedic Surgery
University of Iowa New York Presbyterian Hospital
College of Medicine Columbia University Medical Center
Iowa City, Iowa New York, New York
Jason W. Levine, MD Melvin P. Rosenwasser, MD
Fellow Robert E. Carroll Professor of Surgery
Mississippi Sports Medicine and Orthopaedic Center Hand in the Department of Orthopaedic Surgery
Jackson, Mississippi New York Presbyterian Hospital
Columbia University Medical Center
David M. Lichtman, MD New York, New York
Assistant Professor
Department of Orthopaedic Surgery
Felix H. Savoie III, MD
University of North Texas Health Science Center at Fort
Co-Director, Shoulder/Elbow Service
Worth
Mississippi Sports Medicine and Orthopaedic
John Peter Smith Hospital
Center
Fort Worth, Texas
Jackson, Mississippi
Greg Merrell, MD
Joseph F. Slade III, MD
Department of Orthopaedics and Rehabilitation
Associate Professor
Yale University School of Medicine
Yale Orthopaedics
New Haven, Connecticut
Director
Yale Hand and Upper Extremity Center
Michael J. Moskal, MD
New Haven, Connecticut
Shoulder and Elbow Center
Clinical Instructor, Department of Orthopaedic Surgery
and Sports Medicine David J. Slutsky, MD, FRCS[C]
University of Washington Clinical Assistant Professor
Seattle, Washington UCLA
Clinical Instructor, Department of Orthopaedic Surgery David Geffen School of Medicine
University of Louisville Chief of Reconstructive Hand Surgery
Louisville, Kentucky Harbor-UCLA
Torrance, California
Daniel J. Nagle, MD, FACS, FAAOS
Professor of Clinical Orthopedics Ettore Taverna, MD
Northwestern Feinberg School of Medicine Instituto Galleazi
Chicago, Illinois Milan, Italy
Contributors xiii
Matthew M. Tomaino, MD Eric S. Wroten, MD
Professor and Chief Philadelphia Hand Center
Division of Hand and Upper Extremity King of Prussia, Pennsylvania
University of Rochester Medical Center
Rochester, New York Jeffrey Yao, MD
Assistant Professor of Orthopaedic Surgery
Thomas E. Trumble, MD Stanford University School of Medicine
Professor and Chief, Division of Hand and Microvascular Stanford University Medical Center
Surgery Stanford, California
Department of Orthopaedic Surgery
University of Washington Medical Center
Seattle, Washington
Jennifer Weintraub, MD
Division of Plastic and Reconstructive Surgery
Stanford University Medical Center
Stanford, California
(cid:2)
1
C H A P T E R
David J. Slutsky
Wrist Arthroscopy Portals
Introduction
stagingthedegreeofinstabilityinordertoprovideanalgo-
rithmfortreatment.Midcarpalarthroscopyisalsousefulfor
the assessment and treatment of chondral lesions of the
Since its inception, wrist arthroscopy has continued to
proximal hamate.3 The triquetro-hamate joint can also be
evolve. The initial emphasis on viewing the wrist from the
accessedthroughanotherspecial-usemidcarpalportal.4
dorsal aspect arose from the relative lack of neurovascular
Theclinicalutilityofvolarportalshasbeenrecentlyelu-
structures as well as the familiarity of most surgeons with
cidated.5–7 As kinematic and biomechanical studies have
dorsalapproachestotheradiocarpaljoint.Anatomicalstud-
shed light on the role of the dorsal capsular structures and
iesprovidedabetterunderstandingofboththeinterosseous
palmar subregions of the interosseous ligaments in main-
ligaments as well as carpal kinematics, which led to the
taining carpal stability, it has become prudent to view the
developmentofmidcarpalarthroscopy.Innovativesurgeons
wrist from a palmar perspective. Volar portals for wrist
continuedtopushtheenvelopethroughthedevelopmentof
arthroscopy have certain advantages over the standard
techniquesfortreatingintracarpalpathology,whichinturn
dorsal portals for visualizing dorsal capsular structures as
culminated in a plethora of new accessory portals. This
wellasthepalmaraspectsofthecarpalligaments.Thevolar
chapter explores the standard arthroscopic portals, as well
assomeofthemorerecentandspecial-useportals.1 radial(VR)portalisrelativelyeasytouseandisanidealpor-
talforevaluationofthedorsalradiocarpalligament(DRCL)
and the palmar subregion of the scapholunate interosseous
Indications ligament(SLIL).Itfacilitatestheidentificationofandrepair
of DRCL tears.8,9 The VR portal also facilitates arthro-
scopic reduction of intra-articular fractures of the distal
The indications for the use of the standard dorsal portals radius fractures by providing a clear view of the dorsal rim
are intertwined with the indications for wrist arthroscopy fragments.10
and are largely dependent on the indication for surgery, Thevolarradialmidcarpal(VRM)portalmaybeconsid-
in that this will vary considerably between arthroscopic ered an occasional accessory portal for visualizing the pal-
fracture reduction compared to performing a diagnostic mar aspects of the capitate and hamate in cases of
procedure for chronic wrist pain. These include variable avascular necrosis or osteochondral fractures.6 This portal
combinations of the 3-/,4 portal, the 4-/,5 portal, and the facilitates visualization of the palmar aspect of the capito-
6 radial (6R) and 6 ulnar (6U) portals. Typically, the 3-/,4 hamate interosseous ligament (CHIL), which is important
and 4,/-5 portals are used interchangeably for visualizing in minimizing translational motion11 and has an essential
the radiocarpal joint and for instrumentation. The 4-/,5 role in providing stability to the transverse carpal arch.12
portal and the 6R portal are used to access the ulnocarpal Thevolarulnar(VU)portalprovidesunparalleledviews
joint.The6Uportalistypicallyusedforoutflow.However, ofthedorsalradioulnarligamentandthedorsalulnarwrist
with careful attention to surface landmarks any portal can capsule,whichcontainstheextensorcarpiulnarissubsheath
be used for viewing or instrumentation. (ECUS). Establishing the VU portal is more technically
Midcarpalarthroscopyisessentialinmakingthediagno- demandingbuthaspotentialuseinthearthroscopicdiagno-
sisofscapholunateandlunotriquetralinstability.Thegrad- sis and treatment of patients with ulnar sided wrist pain
ing scale reported by Geissler et al.2 provides a means of and suspected injuries to the ulnar sling mechanism. It is
2
CHAPTER 1 | WristArthroscopyPortals 3
especiallyusefulforvisualizinganddebridingpalmartearsof The midcarpal joint is assessed through two portals,
the lunotriquetral ligament.13 It also aids in the repair or whichallowstriangulationofthearthroscopeandtheinstru-
debridementofdorsallylocatedTFCtearsbecausetheprox- mentation. The midcarpal radial portal (MCR) is located
imityofthe4/-,5and6Rportalsmakestriangulationofthe 1cm distal to the 3-/,4 portal and is bounded radially by
instrumentsdifficult.Thevolaraspectofthedistalradioul- the ECRB and ulnarly by the EDC. The ulnar midcarpal
nar joint can be visualized through the VU portal to assess portal (MCU) is similarly located 1 to 1.5 cm distal to the
the foveal attachment of the triangular fibrocartilage in 4-/,5portalandisboundedbytheEDCandtheEDM.
casesofsuspectedperipheraldetachmentoftheTFC.7 The relative safety of the portals has been studied by
Two dorsal DRUJ portals have been described. The way of cadaver dissection. Although some artifact is ines-
dorsal DRUJ portals may be used to assess the status of capableduetothedisplacementofneurovascularstructures
thearticularcartilageoftheulnarheadandsigmoidnotch. postmortem, this research provides useful guidelines. In
This information may be useful in cases of DRUJ instabil- the clinical situation, distortion of the topographical anat-
ity,orwhenthereisthesuspicionofearlyosteoarthritis(in omy due to fracture/dislocation or swelling as well as the
whichcase arthroscopy maydifferentiate betweentheneed use of intraoperative traction may increase the potential
for DRUJ stabilization or ulnar head excision and arthro- for harm. Hence, a standardized method for establishing
plasty. With inflammatory disorders such as rheumatoid each portal is useful.
arthritis DRUJ, an arthroscopic synovectomy may obviate
the need for a capsular incision. The dorsal DRUJ portals
are infrequently used as an adjunct to arthroscopic wafer Dorsal Cortals
resections of the ulnar head.
Dorsal Radiocarpal Portals
Abrams and co-workers performed anatomical dissections
Contraindications on23unembalmedfreshcadaverextremitiesandmeasured
the distances between the standard dorsal portals and the
contiguous neurovascular structures.14 The 1-/,2 portal
Contraindications to the use of dorsal or volar portals wasfoundtobethemostperilous.Theradialsensorynerve
include any cause of marked swelling that distorts the exits from under the brachioradialis approximately 5cm
topographic anatomy, large capsular tears that might proximal to the radial styloid and bifurcates into a major
leadtoextravasationofirrigationfluid,neurovascularcom- volar and a major dorsal branch at a mean distance of 4.2
promise, bleeding disorders, and infection. Unfamiliarity cm proximal to the radial styloid15 (Figure 1.2). Branches
with the regional anatomy is a relative contraindication. of the superficial radial nerve (SRN) that were radial to
the portal were within a mean of 3mm (range 1 to
6mm),whereasbranchesthatwereulnartotheportalwere
Relevant Anatomy at a mean of 5mm (range 2 to 12mm).
Theradialarterywasfoundatanaverageof3mmradial
to the portal (range 1 to 5mm). Either partial or complete
overlap of the lateral antebrachial cutaneous nerve
The standard portals for wrist arthroscopy are mostly (LABCN) with the SRN occurs up to 75% of the time.16
dorsal (Figure 1.1a through c). This is in part due to the In an anatomical study by Steinberg et al., the LACBN
relative lack of neurovascular structures on the dorsum of was present within the anatomical snuffbox in 9 of 20
the wrist as well as the initial emphasis on assessing the (45%) specimens. Based on these findings, they recom-
volar wrist ligaments. The dorsal portals, which allow mended a more palmar, proximal portal in the snuffbox
access to the radiocarpal joint, are so named in relation to that was no more than 4.5mm dorsal to the first extensor
the tendons of the dorsal extensor compartments. For compartment and within 4.5mm of the radial styloid.15
example, the 1-/,2 portal lies between the first extensor BranchesoftheSRNthatwereradialtothe3-/,4portal
compartmenttendons—whichincludetheextensorpollicus were located at a mean distance of 16mm (range 5 to
brevis (EPB) and the abductor pollicus longus (APL)—and 22mm). In one specimen, an ulnar branch of the SRN
the second extensor compartment, which contains the was found 6mm ulnar to the portal. The distance to the
extensor carpi radialis brevis and longus (ECRB/L). radial artery was a mean of 26.3mm (range 20 to
The 3-/,4 portal is named for the interval between the 30mm). Sensory nerves were remote to the 4-/,5 portal,
third dorsal extensor compartment—which contains the except in one case (where an aberrant SRN branch was
extensor pollicus longus tendon (EPL)—and the fourth found 4mm radial to the portal).
extensor compartment, which contains the extensor digi- The dorsal cutaneous branch of the ulnar nerve
torum communis (EDC) tendons. In a similar vein, the (DCBUN)arisesfromtheulnarnerveanaverageof6.4cm
4-/,5 portal is located between the EDC and the extensor (SD¼2.3cm)proximaltotheulnarheadandbecomessub-
digitiminimi(EDM).The6Rportalislocatedontheradial cutaneous5cmproximaltothepisiform.Itcrossestheulnar
side of the extensor carpi ulnaris (ECU) tendon, compared snuffboxandgivesoffthreetoninebranchesthatsupplythe
tothe6Uportal(whichislocatedontheulnarside). dorsoulnaraspectofthecarpus,smallfinger,andulnarring