Neurovascular relationships of the approaches for arthroscopic total trapeziectomy with ligamentous stabilization

Partial arthroscopic trapeziectomy with ligament reconstruction to treat primary thumb basal joint osteoarthritis

Since the outcome of partial trapeziectomy is not always satisfactory, we proposed using arthroscopy to perform partial trapeziectomy and to perform ligament reconstruction with the abductor pollicis longus tendon. A tendon strip was left intact at its insertion at the base of the first metacarpal and then slipped into the trapeziectomy space. It was fixed into a blind tunnel at the base of the second metacarpal with a bioabsorbable interference screw. Forty-nine patients were surgically treated between 2006 and 2009. With an average follow-up of 3.6 years, 83.5% of patients were satisfied with the procedure; 96% of thumbs were stable and 74% were pain free. The average recovery time was 4.5 months. There were four cases of radial nerve branch irritation and one case of flexor carpi radialis tendinitis; there were no cases of complex regional pain syndrome. This minimally-invasive technique is a less-aggressive treatment approach for thumb carpometacarpal joint arthritis, which simplify postoperative recovery.

Evaluation of the safe zone for percutaneous Kirschner-wire placement in the distal radius: Cadaveric study

Distal radius fractures are a common injury that is often reduced with percutaneous K-wires. The sensory nerves in this area are at risk of injuring from pin placement. Cadaveric studies of the nerve distribution patterns have elucidated certain safe zones for pin placement that limits the risk of sensory nerve injury. These studies have advocated a limited open technique that involves a shallow incision followed by blunt dissection to the bone before a k-wire is drilled into the radius. A previously identified safe zone in the anatomical snuffbox was evaluated in 40 cadaver wrists for k-wire placement via a percutaneous technique that involves putting the pin directly through the skin without an incision or blunt dissection. After k-wire placement each wrist was dissected and sensory nerve distribution relative to the pin placement was evaluated. The variability of the distribution of the sensory nerves, namely the lateral antebracheal cutaneous nerve and the superficial branch of the radial nerve, is such that no truly safe zone exists for pin placement with the percutaneous technique in this area.

[Arthroscopic partial trapezectomy. A radio-anatomical study about 14 cases]

OBJECTIVES

The aim of the study was to assess the accessibility of the trapezium surface to arthroscopic resection related to the degenerative stage, to define the surgical approach and to determine the efficacy of the X-rays for evaluating the amount of resected bone.

METHODS

Fourteen trapezectomies were performed on seven cadaveric specimens using an arthroscopic procedure. Pre- and post-procedure X-rays were used to assess the initial trapeziometacarpal osteoarthritis and the resection performed. Each subject was randomized for using two posterior portals or two posterior portals and one anterior portal. At the end of the procedure, a dissection was performed for evaluating the quality of resection and the anatomical relationship of each surgical approach.

RESULTS

The stages of preprocedure osteoarthritis were comparable between the two sides of the same cadaveric specimen. On post-procedure X-rays, the resection appeared complete in only six out of 14 wrists. During dissection, no injury to neurovascular structures was observed, and the resection was visible macroscopically in 11/14 wrists. Three resections were incomplete, i.e., less than 20 % of total trapezial surface: two of them were seen in the most osteoarthritic cases of the study.

CONCLUSIONS

The arthroscopic approach presents an opportunity to access the entire trapezial surface, even if a high stage of osteoarthritis appears to be a risk for incomplete resection. The addition of a systematic anterior approach to the traditional dorsal approach does not increase the accessibility. Although radiography is not the most appropriate tool to assess the resected surface, it does help to locate the defects of resection and can guide the surgical procedure in situations where there is a risk of incomplete resection.