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Corella F, Ocampos M, Laredo R, Tabuenca J, Larrainzar-Garijo R. Arthroscopic Volar Capsuloligamentous Reattachment and Reinforcement to Bone. J Wrist Surg 2024; 13:98-119. [PMID: 38505205 PMCID: PMC10948247 DOI: 10.1055/s-0043-1775820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/05/2023] [Indexed: 03/21/2024]
Abstract
Background: Injuries of the volar ligaments of the wrist are not uncommon, but their arthroscopic treatment presents a significant challenge. The objective of this paper is to introduce a technique for reattaching (in acute injuries) or reinforcing (in chronic injuries) various volar wrist ligaments to the bone, using standard wrist arthroscopic dorsal and volar portals. Methods: There are three common steps for all the arthroscopic volar capsuloligamentous reattachments or reinforcements Step 1 - Volar Portal Establishment: volar radial, volar ulnar and volar central portals are used depending on which structure needs to be reattached or reinforced. Step 2 - Anchor Placement: the anchor is positioned at the site where the ligament has been detached. Step 3 - Capsuloligamentous Suture and Knotting: a knot pusher is introduced inside the joint from the dorsal portal and advanced inside the volar portal where the threads of the anchor are located. The knot pusher is loaded with the threads and retrieved to the dorsal portal. A 16G Abbocath, loaded with a loop is used to pierce the volar ligaments. The loop of the Abbocath is captured from the dorsal portal and loaded with the threads. Both threads are taken to the volar portal and knotted after releasing the traction. This way the knot is placed out of the wrist and the ligaments are reattached or reinforced to the bone. Result: This technique has been used to reinforce and reattach the scapholunate and lunotriquetral ligaments and to reattach the radiocarpal ligaments and the Poirier space. Since this procedure has been performed in various conditions and in conjunction with other ligament treatments (such as perilunate injuries, carpal bone fractures, distal radius fractures, and reinforcement or reattachment of the dorsal portions of intrinsic ligaments), specific results are not presented. Conclusions: The described technique enables the reattachment and reinforcement of most volar ligaments to the bone using standard wrist arthroscopic portals. It can be performed in conjunction with the treatment of the dorsal portion of intrinsic ligaments or other wrist injuries.
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Affiliation(s)
- Fernando Corella
- Orthopedic and Trauma Department, Hospital Universitario Infanta Leonor, Madrid, Spain
- Hand surgery unit, IOTAM group. Hospital Universitario Quironsalud Madrid, Madrid, Spain
- Surgery Department, School of Medicine, Universidad Complutense de Madrid, Spain
| | - Montserrat Ocampos
- Orthopedic and Trauma Department, Hospital Universitario Infanta Leonor, Madrid, Spain
- Hand surgery unit, IOTAM group. Hospital Universitario Quironsalud Madrid, Madrid, Spain
| | - Rafeal Laredo
- Hand surgery unit, IOTAM group. Quironsalud University Hospital, Madrid, Spain
- Orthopedic and Trauma Department, Quironsalud Toledo, Spain
| | - José Tabuenca
- Orthopedic and Trauma Department, IOTAM group. Hospital Universitario Quironsalud Madrid, Madrid, Spain
| | - Ricardo Larrainzar-Garijo
- Orthopedic and Trauma Department, Hospital Universitario Infanta Leonor, Madrid, Spain
- Surgery Department, School of Medicine, Universidad Complutense de Madrid, Spain
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Dittman LE, Munaretto N, Hinchcliff K, Dutton L, Kakar S. Volar Wrist Arthroscopy Portals Using the NanoScope Are Safer than Traditional Arthroscopy. Hand (N Y) 2024:15589447231221168. [PMID: 38235751 DOI: 10.1177/15589447231221168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND The NanoScope, given its smaller size, may be further from critical structures when establishing volar wrist arthroscopy portals compared to the traditional 2.7-mm arthroscope. METHODS Ten fresh-frozen latex-injected cadaver specimens were utilized. The volar radial (VR) and volar ulnar (VU) portals were created using an inside-out approach. The volar radial midcarpal (VR-MC) and volar ulnar midcarpal (VU-MC) portals were created using an inside-out approach. The arm was then dissected under 3.5-mm loupe magnification. Digital calipers were used to measure the distance between the portals and the surrounding anatomic structures by two fellowship-trained hand surgeons. RESULTS The median nerve was on average 1.6, 7.2, 1.8, and 5.6 mm away from the trochar for the VR, VU, VR-MC, and VU-MC, respectively. The median nerve fascia was pierced by the VR portal in one specimen. The radial artery, ulnar artery, and ulnar nerve were not pierced in any specimen. Compared to historical controls, for the VR-MC portal, the NanoScope was further from all critical structures, aside from the radial artery, and did not pierce any neurovascular structures. For the VU-MC portal, the NanoScope was further from the ulnar artery and median nerve and did not pierce any neurovascular structures. CONCLUSION In developing volar portals, after placing the cannula through the volar capsule from an inside-out approach, we recommend making a volar incision and dissecting the local anatomic structures to guard against injury. Compared to historical controls, the NanoScope was typically further from neurovascular structures.
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Rust AR, Jain SA. The Relationship Between the Wrist Flexion Creases and the Volar Radiocarpal Joint: A Cadaveric Study. Hand (N Y) 2023:15589447231217760. [PMID: 38142433 DOI: 10.1177/15589447231217760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Abstract
BACKGROUND Surgical approaches to the volar radiocarpal joint have historically entailed wide exposure, possibly contributing to poor wound healing and wrist denervation. To avoid wound complications and wrist denervation, minimally invasive and percutaneous approaches to the volar radiocarpal joint have been proposed. To help guide these minimally invasive or percutaneous approaches to the joint, we sought to characterize the relationship between the volar wrist flexion creases and the volar radiocarpal joint. We propose that the wrist flexion creases will be a reliable method for localizing the joint. METHODS Ten cadaveric upper-extremity specimens consisting of fingertip to mid forearm were obtained. Measurements from the proximal and distal wrist flexion creases were taken via fluoroscopy and gross dissection. RESULTS The wrist flexion creases were located distal to the volar radiocarpal joint in all specimens. The volar radiocarpal joint was located 7 and 16 mm proximal to the proximal and distal wrist flexion creases, respectively. The radiographic anatomy correlated well with the underlying deep anatomy. CONCLUSIONS The wrist flexion creases can serve as a reliable superficial landmark for the identification of the volar radiocarpal joint. These landmarks aid clinicians in performing or interpreting a physical examination or in performing minimally invasive or percutaneous approaches to the volar radiocarpal joint.
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Affiliation(s)
- Andrew R Rust
- The Ohio State University College of Medicine, Columbus, USA
| | - Sonu A Jain
- The Ohio State University Wexner Medical Center, Columbus, USA
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Antonoglou G, Vrettakos A, Varvarousis D, Kanavaros P, Troupis T, Paraskevas GK, Chrysanthou C, Apostolidi E, Poutoglidis A. The Risk of Injury in Wrist Arthroscopy Portals: A Cadaveric Study. Cureus 2023; 15:e49702. [PMID: 38161872 PMCID: PMC10757396 DOI: 10.7759/cureus.49702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
During wrist arthroscopy, the wrist joint can be visualized from almost every perspective through a combination of standard dorsal and volar arthroscopic portals. This cadaveric study aims to compare all wrist portals described in terms of their safety in order to rank them according to the distance from the nearest structure at risk for arthroscopic wrist procedures. Twenty-nine cadaveric formalin-embellished upper limbs were examined. Needles were inserted at dorsal and volar portal sites to perform the measurements. During the subsequent dissection, distances were measured as the shortest possible distance from the nearest structure at risk for each portal. Safe zones were determined for all portals, and the safety classification of arthroscopic wrist portals was proposed, ranking them from the safest to the most perilous. Applying the proposed safety classification to arthroscopic practice, wrist arthroscopy can be performed with a lower risk of iatrogenic complications arising from the implementation of the wrist portals.
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Affiliation(s)
| | | | | | | | - Theodore Troupis
- Anatomy, National and Kapodistrian University of Athens, Athens, GRC
| | | | | | - Elpida Apostolidi
- Anatomy and Surgical Anatomy, Aristotle University of Thessaloniki, Thessaloniki, GRC
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Liu CQ, Liang XZ, Tian Y, Zhou B, Xing HC, Wang PM, Wang MX, Chen YR. A study of clinical anatomy of the safe zone for the volar approach for wrist arthroscopy. Orthop Traumatol Surg Res 2023; 109:103607. [PMID: 36958623 DOI: 10.1016/j.otsr.2023.103607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/22/2023] [Accepted: 03/07/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVE The current study was to perform an anatomical observation of the volar approach for wrist arthroscopy and to establish the safe zone for this approach. METHODS Eight preserved specimens and 2 fresh specimens were used to simulate the medial-to-lateral operation and to mark the volar approach. Based on anatomical measurements of the volar approach, the closest distances from the 1/2, 6R, 6U, VR, VR' and VU approaches to the adjacent important structures were established. RESULTS The closest distance from the 1/2 approach to the superficial branch of the radial nerve was 2.4±1.5mm. The closest distances from the 6U and 6R approaches to the dorsal carpal branch of the ulnar nerve were 16.2±1.3mm and 9.0±2.4mm, respectively. The closest distances from the VR and VR' approaches to the palmar cutaneous branch of the median nerve were 6.7±1.1mm and 2.8±0.9mm, respectively; the closest distances to the radial artery were 6.3±4.0mm and 10.0±3.4mm, respectively. Moreover, both of the two approaches passed through the base of the flexor carpi radialis tendon. The closest distance from the VU approach to the ulnar artery and flexor digitorum profundus tendon were 3.3±1.4mm and 0.3±2.5mm, respectively. CONCLUSIONS In conclusion, a safe zone could be located for the establishment of the volar approach for wrist arthroscopy. LEVEL OF EVIDENCE III; retrospective study with no control group.
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Affiliation(s)
- Chuan Qiang Liu
- The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, 250014 Shandong, China.
| | - Xue Zhen Liang
- The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, 250014 Shandong, China; The First Clinical Medical School, Shandong University of Traditional Chinese Medicine, 250355 Shandong, China.
| | - Yuan Tian
- The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, 250014 Shandong, China.
| | - Bin Zhou
- The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, 250014 Shandong, China.
| | - Hai Chang Xing
- The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, 250014 Shandong, China.
| | - Ping Mei Wang
- The First Clinical Medical School, Shandong University of Traditional Chinese Medicine, 250355 Shandong, China.
| | - Ming Xi Wang
- The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, 250014 Shandong, China.
| | - Yan Rong Chen
- The Affiliated Hospital of Shandong University of Traditional Chinese Medicine, 250014 Shandong, China.
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Munaretto N, Hinchcliff K, Dutton L, Kakar S. Is Wrist Arthroscopy Safer with the Nanoscope? J Wrist Surg 2022; 11:450-455. [PMID: 36339076 PMCID: PMC9633142 DOI: 10.1055/s-0042-1750179] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/28/2022] [Indexed: 10/17/2022]
Abstract
Background Nanoscope, given its smaller size, may be safer when establishing dorsal wrist arthroscopy portals compared with the traditional 2.7 mm arthroscope. Case Description Ten fresh frozen cadaver specimens were utilized. Dorsal radiocarpal portals were established with the Nanoscope and calipers were used to measure the distance between the portals and the surrounding anatomical structures. The only structure that was pierced during portal placement was the dorsal sensory branch of the ulnar nerve (DSUN) in one specimen when establishing the 6U portal. Our study did not note any tendon injuries. Literature Review Traditional wrist arthroscopy may be performed with a 2.7 mm arthroscope. With its larger outer sheath cannula, this may place adjacent anatomical structures at risk of injury. Clinical Relevance During wrist arthroscopy, the Nanoscope may be safer when creating portals to underlying structures. Level of Evidence This is a Level IV study.
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Affiliation(s)
| | | | - Lauren Dutton
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sanjeev Kakar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Chen B, Wang L, Liang K, Wang B, Jiang S, Shi H. Treatment of dorsal wrist ganglion cyst by establishing midcarpal volar portal using the “Kiss-in” method. Front Surg 2022; 9:944396. [PMID: 36117835 PMCID: PMC9473313 DOI: 10.3389/fsurg.2022.944396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction This paper introduces the treatment and clinical outcome of the dorsal wrist ganglion cyst utilizing the Kiss-in method to establish a midcarpal volar portal. Materials and methods Patients with dorsal ganglia of the wrist (n = 12, 6 females, 6 males) underwent arthroscopic surgery using the Kiss-in method at our hospital between September 2018 and January 2021. All patients underwent preoperative radiological investigations, such as magnetic resonance imaging (MRI; 12 cases) or ultrasonography (12 cases). The mean age of patients was 30.7 years (range: 19–46 years). The time lost from work, the wrist motion and strength, the presence of scarring, residual symptoms, complications, and recurrence were recorded at a mean follow-up of 24 months. Results Eleven patients showed a good prognosis with active motion recovery. One patient showed the recurrence of ganglion, and the second arthroscopic resection was performed 5 months after the first surgery for this patient. After the surgery, the patient fully recovered. Conclusions Establishing the midcarpal volar portal by the Kiss-in method is safe. The dorsal ganglion cyst resection through the established midcarpal volar portal is a promising approach, allowing better visualization and a broader range motion of the arthroscope.
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Affiliation(s)
- Bo Chen
- Department of Orthopedics, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Leining Wang
- Department of Surgery of Hand and Foot, Beilun People's Hospital, Ningbo, China
| | - Kejiong Liang
- Department of Orthopedics, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Bing Wang
- Department of Surgery of Hand and Foot, Beilun People's Hospital, Ningbo, China
| | - Shuai Jiang
- Department of Orthopedics, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Haifei Shi
- Department of Orthopedics, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Correspondence: Haifei Shi
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Volar Midcarpal Portals in Wrist Arthroscopy. J Hand Surg Am 2019; 44:1094.e1-1094.e6. [PMID: 30902356 DOI: 10.1016/j.jhsa.2019.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 12/17/2018] [Accepted: 02/01/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To describe the placement of volar midcarpal portals using the inside-out technique, and the surrounding anatomical structures at risk. METHODS Five fresh-frozen cadavers were used. Volar ulnar midcarpal (VUMC) and volar radial midcarpal (VRMC) portals were placed using an inside-out technique. The distance between these portals to surrounding anatomical structures was measured in millimeters using a caliper. RESULTS The VUMC portal pierced the flexor digitorum profundus tendon to the middle finger in 1 specimen. The portal was an average 3.7 and 8.4 mm away from the ulnar artery and nerve, respectively. The VRMC portal pierced the palmaris longus in 2 specimens. It usually was between the flexor pollicis longus, the palmaris longus, and the median nerve. It was an average of 1.0 and 1.95 mm away from the median nerve and palmar cutaneous branch of the median nerve, respectively and in 1 specimen, was in contact with the median nerve after piercing the mesoneurium. CONCLUSIONS With increasing use of volar midcarpal arthroscopy, the surgeon needs to have an understanding of the structures at risk when placing the VUMC and VRMC portals. CLINICAL RELEVANCE When developing the volar midcarpal portals, the surgeon needs to pay close attention to the anatomical structures at risk and, in particular, the median nerve from the VRMC portal.
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Abstract
Arthroscopy of the wrist continues to evolve and advance as a valuable clinical technique in hand surgery. This article aims to address safety of wrist arthroscopy and provide an overview of the known iatrogenic complications. Ultimately, the likelihood of associated injuries during wrist arthroscopy is dependent on the surgeon's ability and understanding of the equipment. Case volume and duration of experience directly correlate with mitigating iatrogenic injury and optimizing patient outcomes.
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10
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Abstract
After reviewing this article, readers should have a comprehensive understanding of the indications for diagnostic arthroscopy, technical considerations in performing a systematic evaluation of the wrist, and limitations of this technique.
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Affiliation(s)
- Brett F. Michelotti
- Department of Surgery, Division of Plastic Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | - Kevin C. Chung
- Section of Plastic Surgery, Assistant Dean for Faculty Affairs, University of Michigan Medical School
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Matson AP, Dekker TJ, Lampley AJ, Richard MJ, Leversedge FJ, Ruch DS. Diagnosis and Arthroscopic Management of Dorsal Wrist Capsular Impingement. J Hand Surg Am 2017; 42:e167-e174. [PMID: 28259281 DOI: 10.1016/j.jhsa.2016.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 12/28/2016] [Accepted: 12/31/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE Dorsal wrist capsular impingement (DWCI) is characterized by pain attributable to impingement of dorsal capsular tissue during wrist extension. The diagnostic criteria and management algorithm for this condition have not been well established. The aims of our study were (1) to retrospectively review the clinical presentation and arthroscopic findings of patients treated surgically for DWCI and (2) to evaluate the outcomes of arthroscopic debridement for this condition. METHODS A total of 19 patients were treated with arthroscopic debridement for isolated DWCI from 2006 to 2015 by two surgeons (M.J.R. and D.S.R.) at a single institution. A chart review was performed to gather information on clinical presentation, radiological findings, operative details, and outcomes including numeric pain scale rating, range of motion, Mayo wrist score, and Quick Disabilities of the Arm, Shoulder, and Hand score. Patients were contacted at the time of the study for final telephone follow-up. RESULTS Symptoms were present for a median of 12.5 months (range, 3.5-124.4 mo) prior to surgical intervention, and all patients had pain localized to the dorsal and central wrist with passive terminal wrist extension (100%; 19 of 19). We obtained magnetic resonance imaging in 66% of patients (12 of 19). Diagnostic arthroscopy yielded evidence of infolded, redundant dorsal capsular tissue in all cases (19 of 19), and there was no evidence of concomitant wrist pathology. Compared with preoperative values, postoperative improvements were seen in average numeric pain scale rating (6.0-1.9), Quick Disabilities of the Arm, Shoulder, and Hand score (45.8-4.8), and Mayo wrist score (50.0-87.8). These improvements were sustained at 41.6 months after surgery (range, 11.9-73.8 months). One complication of superficial cellulitis occurred. CONCLUSIONS Dorsal wrist capsular impingement is a clinical diagnosis; magnetic resonance imaging may be helpful in evaluating for other pathologies. Diagnostic arthroscopy yields evidence of redundant dorsal capsular tissue, and arthroscopic debridement of this tissue offers a safe and effective treatment to improve pain and functional scores. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Andrew P Matson
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Travis J Dekker
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Alexander J Lampley
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Marc J Richard
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - Fraser J Leversedge
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC
| | - David S Ruch
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC.
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Naroura I, Zemirline A, Taleb C, Lebailly F, Facca S, Hidalgo Díaz JJ, Collon S, Liverneaux P. Inside-out method to develop volar arthroscopic portals of the wrist in cadaver specimens. HAND SURGERY & REHABILITATION 2016; 35:210-214. [PMID: 27740464 DOI: 10.1016/j.hansur.2016.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 02/02/2016] [Accepted: 02/23/2016] [Indexed: 11/29/2022]
Abstract
Three direct volar portals for wrist arthroscopy have been described previously: two radiocarpal and one midcarpal. The aim of this study was to systematically describe four volar arthroscopic portals through minimally invasive incisions using an inside-out approach from known dorsal portals. Four volar arthroscopic wrist portals were studied on six hand specimens using an inside-out technique: a radial radiocarpal approach (RRCA), an ulnar radiocarpal approach (URCA), a radial midcarpal approach (RMCA) and an ulnar midcarpal approach (UMCA). Each volar approach corresponded to a dorsal approach: the 3/4 portal for RRCA, 4/5 portal for URCA, dorsal radial midcarpal approach for RMCA, and dorsal ulnar midcarpal approach for UMCA. The average range of motion of the scope through the RRCA was 65° in radial deviation and 72° in ulnar deviation; through the URCA it was 62° in radial deviation and 64° in ulnar deviation; through the RMCA it was 62° in radial deviation and 60° in ulnar deviation, and through the UMCA it was 59° in radial deviation and 68° in radial deviation. No iatrogenic injuries to important anatomical structures were noted. Based on these results, it is possible to perform these four volar portals through an inside-out technique with incisions mirroring the dorsal portals. They were easy to perform, safe and should be useful in ligament or bony intracarpal repair indications.
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Affiliation(s)
- I Naroura
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10, avenue Baumann, 67400 Illkirch, France
| | - A Zemirline
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10, avenue Baumann, 67400 Illkirch, France
| | - C Taleb
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10, avenue Baumann, 67400 Illkirch, France
| | - F Lebailly
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10, avenue Baumann, 67400 Illkirch, France
| | - S Facca
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10, avenue Baumann, 67400 Illkirch, France
| | - J J Hidalgo Díaz
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10, avenue Baumann, 67400 Illkirch, France
| | - S Collon
- Department of Orthopedic Surgery, Caen University Hospital, Caen, France
| | - P Liverneaux
- Department of Hand Surgery, SOS main, CCOM, University Hospital of Strasbourg, FMTS, University of Strasbourg, Icube CNRS 7357, 10, avenue Baumann, 67400 Illkirch, France.
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Corella F, Ocampos M, Cerro MD, Larrainzar-Garijo R, Vázquez T. Volar Central Portal in Wrist Arthroscopy. J Wrist Surg 2016; 5:80-90. [PMID: 26855842 PMCID: PMC4742263 DOI: 10.1055/s-0035-1570741] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 12/01/2015] [Indexed: 10/22/2022]
Abstract
Background Nowadays, the wrist is not limited to a dorsal visualization; the joint can be thought of as a "box," which can be visualized from almost every perspective. The purpose of this study was to describe a new volar central portal for the wrist, following three principles: a single incision that allows access to both the radiocarpal and midcarpal joints, centered on the lunate, with the volar structures at risk protected not only by retractors, but also by tendons. Description of Technique The incision begins in the distal wrist crease and extended 1.5 cm proximally up to the proximal wrist crease, following the axis of the third intermetacarpal space. The flexor superficialis tendons are identified and retracted toward the radial side. Next, the fourth and fifth flexor digitorum profundus tendons are retracted toward the ulnar side, while the third and second tendons are retracted toward the radial side. The volar central midcarpal portal is performed under direct vision just over the anterior horn of the lunate through the Poirier space. The volar central radiocarpal portal is created under the lunate through the interval between the ulnocarpal ligaments and the short radioulnar ligament. Methods An anatomical study was performed on 14 cadaver specimens. Two data were recorded: iatrogenic injuries of the structures at risk and the distances to the structures at risk. Results The median (interquartile range [IQR]) distances from the volar central radiocarpal portal to the median nerve, palmar cutaneous branch of the median nerve, and ulnar neurovascular bundle were 10.5 (7.8-15.0), 18.5 (15.8-20.3), and 7.0 (5.0-10.5) mm, respectively. The median (IQR) distances from the volar central midcarpal portal to the median nerve, palmar cutaneous branch of the median nerve, and ulnar neurovascular bundle were 7.0 (4.8-10.3), 16.0 (14.8-19.0), and 4.5 (3.8-9.0) mm, respectively. No iatrogenic injuries were observed. Conclusion The volar central portal is reproducible and safe. The risk of iatrogenic injury is low. The capsule is pierced through one of its thinner portions, and both the radiocarpal and midcarpal joints can be inspected through one single incision.
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Affiliation(s)
- F. Corella
- Hand Surgery Unit, Orthopaedic and Trauma Department, Infanta Leonor University Hospital, Madrid, Spain
- Hand Surgery Unit, Beata Maria Ana Hospital, Madrid, Spain
| | - M. Ocampos
- Hand Surgery Unit, Orthopaedic and Trauma Department, Infanta Leonor University Hospital, Madrid, Spain
- Hand Surgery Unit, Beata Maria Ana Hospital, Madrid, Spain
| | - M. Del Cerro
- Hand Surgery Unit, Beata Maria Ana Hospital, Madrid, Spain
| | - R. Larrainzar-Garijo
- Hand Surgery Unit, Orthopaedic and Trauma Department, Infanta Leonor University Hospital, Madrid, Spain
| | - T. Vázquez
- Department of Human Anatomy and Embryology, School of Medicine, Complutense University of Madrid, Madrid, Spain
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Xie RG, Xing SG, Tang JB. New procedures for precisely establishing volar wrist arthroscopic portals. J Hand Surg Eur Vol 2015; 40:1014-5. [PMID: 25487318 DOI: 10.1177/1753193414561592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- R-G Xie
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
| | - S-G Xing
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
| | - J-B Tang
- Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China
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Arthroscopic ligamentoplasty of the dorsal and volar portions of the scapholunate ligament. J Hand Surg Am 2013; 38:2466-77. [PMID: 24275054 DOI: 10.1016/j.jhsa.2013.09.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 07/11/2013] [Accepted: 09/19/2013] [Indexed: 02/02/2023]
Abstract
Classical arthroscopic techniques for scapholunate instability consist of debridement, thermal shrinkage, and percutaneous pinning. Good results are obtained in acute lesions or in chronic partial tears, but they are less predictable when the lesion is complete, because of the poor healing capacity of the scapholunate ligament and because it is not possible to perform an anatomic ligamentous reconstruction with these techniques. Open techniques are thus required for reconstruction, but they damage the soft tissues. We recently published a description and cadaver study of an arthroscopic ligamentoplasty, trying to combine the advantages of arthroscopic techniques (minimally invasive surgery) and open techniques (reconstruction of the ligament). With this approach, it is possible to reconstruct the dorsal scapholunate ligament and the secondary stabilizers while causing minimal damage to the soft tissues and avoiding injury to the posterior interosseous nerve and detachment of the dorsal intercarpal ligament. The current report describes an additional step to this technique with which it is possible to reconstruct the volar portion of the scapholunate ligament. We also describe an early mobilization postoperative protocol that we believe is equally important.
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Corella F, Del Cerro M, Larrainzar-Garijo R, Vázquez T. Arthroscopic ligamentoplasty (bone-tendon-tenodesis). A new surgical technique for scapholunate instability: preliminary cadaver study. J Hand Surg Eur Vol 2011; 36:682-9. [PMID: 21712303 DOI: 10.1177/1753193411412868] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We present an anatomical study and description of a new surgical technique for arthroscopic treatment of scapholunate ligament injuries. Five cadaver specimens were used to perform the technique. After arthroscopic surgery, anatomic dissection was performed to measure the distances to critical wrist structures such as the posterior interosseous nerve and the radial artery, and the size and position of the plasty. This arthroscopic technique offers three advantages: soft tissue damage is reduced (avoiding an extensive approach and injury to the secondary stabilizers and reducing scar tissue); injury to the posterior interosseous nerve is avoided (maintaining wrist proprioception and the role of the dynamic stabilizers); and a biotenodesis is made that ensures proper placement, tension and functionality of the flexor carpi radialis ligament reconstruction.
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Affiliation(s)
- F Corella
- Hand Surgery Unit, Orthopadic and Trauma Department, Hospital Universitario Infanta Leonor, Madrid, Spain.
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Abstract
Anatomical and biomechanical studies have highlighted the importance of the deep attachment of the TFCC for maintaining stability of the distal radioulnar joint (DRUJ). The standard arthroscopic assessment of the TFCC does not allow one to definitively determine whether the deep fibers are indeed intact, and establishing the diagnosis of a foveal detachment remains an exacting challenge. DRUJ arthroscopy is useful to assess the foveal fibers in any patient with DRUJ instability and can aid in the surgical decision making.
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Affiliation(s)
- David J Slutsky
- Los Angeles County Harbor-UCLA Medical Center, 1000 W Carson Street, Torrance, CA 90502, USA.
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Clavert P, Cognet JM, Kempf JF, Simon P, Kahn JL. [Proposal for new anterior portals for wrist arthroscopic as a complementary approach to open anterior wrist surgery]. ACTA ACUST UNITED AC 2007; 93:339-43. [PMID: 17646814 DOI: 10.1016/s0035-1040(07)90274-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE OF THE STUDY Morphological and morphometric studies of the wrist ligaments are scarce. The radiocapitatum and scapholunate ligaments play a pivotal role in wrist stability. Classically, a posterior approach is used for arthroscopic procedures, but an anterior approach should be possible. We conducted a cadaver study to search for new anterior portals for wrist arthroscopy. MATERIAL AND METHODS Twenty-five formol-treated upper limbs were dissected. The classical anterior approach for open wrist surgery was executed. The different elements of the capsule-ligament system of the anterior aspect of the wrist were identified and labeled. The dissection was then extended to the ulna in search of soft points which were identified and evaluated. The different structures generally identified during wrist arthroscopy were noted. RESULTS Two potential portals were identified in all wrists: one between the radiolunate ligament and the radio-scapho-capitatum ligament on the radial aspect and one between the radio-lunate ligament and the ulno-lunate ligament. Arthroscopic exploration enabled observation of the scapho-lunate ligament, the luno-triquetral ligament, the triangular complex of the carpus, and the entire inferior aspect of the radial joint surface, with no risk of vessel or nerve injury because of the exposure allowed by the osteosynthesis approach. DISCUSSION Wrist arthroscopy is now accepted as a reliable technique not only for diagnostic purposes but also for therapeutic interventions for the treatment of fractures of the lower radius. Most of the arthroscopic portals described in the literature are posterior. The anterior portals described here do not involve any vascular or neurological risk since the radial approach is made under visual control by extension of the open anterior approach and on the ulnar side the noble structures are positioned medially to the ulnar flexor tendon of the carpus. This enables good triangulation necessary for the usual arthroscopic procedures. Finally, these portals have no supplementary morbidity which would be the case with percutaneous portals (injury to the medial nerve, the radial vasculonervous bundle, the radial flexor tendon). CONCLUSION These new arthroscopic portals are complementary to the anterior approach for open wrist surgery and enable a natural extension of joint exploration via both the radial and ulnar approaches described in this study.
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Affiliation(s)
- P Clavert
- Institut d'Anatomie Normale, Faculté de Médecine, 4 rue Kirschleger, 67085 Strasbourg Cedex.
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Abstract
Pain on the ulnar side of the wrist remains poorly understood. As attention has shifted toward the myriad causes of ulnar-sided wrist pain, the utility of viewing the wrist from a volar ulnar (VU) perspective has emerged. Lunotriquetral ligament tears have been implicated in the pathogenesis of volar intercalated segmental instabilities. They often originate in the palmar subregion, which is most important for maintaining stability. These tears are difficult to visualize through the 4, 5, or 6R portals. They are well seen through a VU portal, and the direct line of sight facilitates debridement. The VU portal has potential use in the arthroscopic diagnosis and treatment of patients with injuries to the ulnar sling mechanism. It aids in triangular fibrocartilage repairs especially those involving the dorsal aspect between the ulnar styloid and the radial insertion, because the proximity of the 4, 5, and 6R portals makes triangulation of the instruments difficult. Although arthroscopy of the dorsal aspect of the distal radioulnar joint has been well described, it has largely remained a curiosity, with few clinical indications. Recent biomechanical studies have highlighted the importance of the deep attachment of the triangular fibrocartilage complex in maintaining distal radioulnar joint stability. The volar distal radioulnar portal is useful for assessing the foveal attachment. It may be used where there is the suspicion of a peripheral triangular fibrocartilage detachment due to a loss of its normal tension despite the lack of a visible tear during radiocarpal arthroscopy. The judicious use of these portals deserves consideration for inclusion as part of a thorough arthroscopic examination of selected patients with ulnar-sided wrist pain.
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Affiliation(s)
- David J Slutsky
- Department of Orthopedics, Harbor-UCLA Medical Center, Torrance, CA, USA.
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Atzei A, Luchetti R, Sgarbossa A, Carità E, Llusà M. Installation, voies d'abord et exploration normale en arthroscopie du poignet. ACTA ACUST UNITED AC 2006; 25S1:S131-S144. [PMID: 17349388 DOI: 10.1016/j.main.2006.07.029] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Arthroscopy is an accepted technique for evaluation of intra-articular pathology and treatment of a variety of disorders even in the wrist joint. Dedicated miniaturized instrumentation is needed along with a specific traction system. The external distraction alone (dry technique) allows for complete joint exploration and several type of arthroscopic surgery, avoiding annoying leaking in the subcutaneous tissues, though further distension of the articular pouches can be achieved by saline infusion (fluid distension or wet technique). Knowledge of surface anatomic landmarks and careful surgical technique are required for proper portal placement and in order to avoid injury to the numerous noble structures crossing nearby. Description of radio- and medio-carpal portals is provided along with the different bony, condral, synovial and ligamentous structures that can be visualised or treated through each portal. Surgeon can choose the most suitable portal for scope or instruments, according to specific needs for diagnostic or therapeutic purposes.
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Affiliation(s)
- A Atzei
- U.O. Chirurgia della Mano, Policlinico "G. B. Rossi", Piazzale L.A. Scuro, 10, 37100 Vérone, Italie
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Abstract
Volar portals for wrist arthroscopy have certain advantages over the standard dorsal portals for visualizing dorsal capsular structures as well as the palmar aspects of the carpal ligaments. The volar radial portal is relatively easy to use and is an ideal portal for evaluation of the dorsal radiocarpal ligament and the palmar aspect of the scapholunate interosseous ligament. The volar midcarpal portal may be considered as an occasional accessory portal for visualizing the palmar aspects of the capitate and hamate in cases of avascular necrosis or osteochondral fractures. The volar ulnar portal is especially useful for the viewing and debridement of palmar tears of the lunotriquetral ligament.
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Haisman JM, Bush M, Wolfe S. Wrist Arthroscopy: Standard Portals and Arthroscopic Anatomy. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.jassh.2005.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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