Techniques in Wrist and Hand Arthroscopy [2nd Edition] 9780323448406

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Techniques in Wrist and Hand Arthroscopy [2nd Edition]
 9780323448406

Table of contents :
Front cover......Page 1
Techniques in WRIST and hand arthroscopy......Page 5
Copyright......Page 6
Dedication......Page 7
Preface......Page 9
Table of Contents......Page 11
Video Contents......Page 13
1 Wrist Arthroscopy Portals......Page 15
Indications......Page 16
Dorsal radiocarpal portals......Page 17
Volar radial portal......Page 18
Volar distal radioulnar portal......Page 19
3,4 and 4,5 relevant clinical and biomechanical studies......Page 20
Required......Page 22
Methodology......Page 23
6r and 6u portals......Page 24
Midcarpal portals......Page 25
Volar portals......Page 26
References......Page 29
Thenar portal......Page 31
Stt-p portal......Page 32
Trapeziometacarpal joint......Page 34
Scaphotrapezial trapezoidal joint......Page 36
References......Page 38
II Ulnocarpal Joint......Page 39
Mechanism and classification......Page 40
Diagnosis and nonoperative treatment......Page 41
Type ib lesions......Page 43
Repair ......Page 45
Relevant anatomy and biomechanics......Page 47
Surgical technique......Page 48
References......Page 49
Triangular fibrocartilage complex anatomy......Page 51
Diagnosis......Page 52
Volar distal radioulnar portal......Page 58
Arthroscopic-assisted suture repair techniques......Page 59
Outcomes......Page 61
References......Page 62
Mechanism and classification......Page 64
Arthroscopic wafer resection......Page 65
Indications......Page 66
Alternative procedures......Page 67
Outcomes......Page 69
Relevant anatomy and etiology......Page 70
Treatment......Page 71
Ulnar styloid nonunions......Page 72
References......Page 75
III Carpal Ligament Injury......Page 77
Relevant anatomy and biomechanics......Page 78
Treatment......Page 79
Surgical technique......Page 80
Arthroscopic classification of ligament instability......Page 81
Indications......Page 82
Thermal shrinkage......Page 83
Outcomes......Page 84
Indications......Page 85
Surgical technique......Page 86
Outcomes......Page 87
Surgical technique......Page 88
Outcomes......Page 90
References......Page 91
Relevant anatomy and biomechanics......Page 93
Diagnosis......Page 94
Surgical technique......Page 95
Outcomes......Page 96
Outcomes......Page 99
References......Page 100
Relevant anatomy and biomechanics......Page 101
Contraindications......Page 102
Surgical technique......Page 103
Results......Page 105
References......Page 107
Relevant anatomy and biomechanics......Page 109
Imaging......Page 110
Treatment......Page 112
Arthroscopic capsular shrinkage......Page 113
Outcomes......Page 114
References......Page 115
IV Wrist and Carpal Fractures......Page 117
Relevant anatomy and biomechanics......Page 118
Diagnosis......Page 119
Nonoperative......Page 120
Dorsal approach......Page 121
Volar approach......Page 124
Arthroscopic bone grafting......Page 127
Complications......Page 129
Coronal fractures of the scaphoid......Page 131
Outcomes......Page 132
References......Page 133
Mechanism of injury......Page 135
Classification......Page 136
Ligamentotaxis......Page 137
Temporary external fixation: Indications......Page 138
Complications......Page 139
Surgical technique......Page 140
Volar plating......Page 142
Reduction techniques......Page 144
Complications......Page 145
Radial styloid fractures......Page 146
Three-part fractures......Page 148
Four-part fractures......Page 149
Outcomes......Page 150
References......Page 151
Relevant biomechanics and natural history......Page 153
Surgical technique......Page 154
Outcomes......Page 155
References......Page 158
Relevant anatomy and biomechanics......Page 159
Diagnosis......Page 164
Surgical treatment......Page 165
Outcomes......Page 168
References......Page 172
V Arthritis and Degenerative Disorders......Page 173
Contraindications......Page 174
Dorsal capsulotomy......Page 175
Distal radioulnar joint......Page 176
Postoperative management......Page 177
References......Page 178
Indications for arthroscopic synovectomy......Page 179
Surgical technique......Page 180
Arthrosis of the proximal pole of the hamate......Page 181
Outcomes......Page 182
Outcomes......Page 183
Septic arthritis......Page 184
References......Page 185
Diagnosis......Page 186
Open treatment......Page 187
Arthroscopic survey......Page 189
Arthroscopic-assisted scaphocapitate fusion with lunate excision......Page 192
Arthroscopic proximal row carpectomy......Page 193
Outcomes......Page 195
References......Page 196
Relevant anatomy and etiology......Page 197
Surgical technique......Page 198
Outcomes......Page 201
References......Page 202
Pathophysiology......Page 203
Diagnosis......Page 204
Equipment......Page 205
Surgical technique......Page 206
Outcomes......Page 208
References......Page 209
Relevant anatomy and pathomechanics......Page 210
Diagnosis......Page 212
Indications......Page 213
Surgical technique......Page 214
References......Page 216
Instrumentation and methodology......Page 218
Surgical technique......Page 219
Arthroscopic-assisted 4-corner fusion and scaphoidectomy......Page 221
Arthroscopic-assisted scaphocapitate fusion with and without lunate excision......Page 222
Arthroscopic-assisted radioscapholunate fusion......Page 224
Outcomes......Page 225
References......Page 226
Diagnosis......Page 227
Surgical technique......Page 228
Outcomes......Page 229
References......Page 232
VI Small Joint Arthroscopy......Page 233
Physical examination and imaging......Page 234
Arthroscopic assisted reduction of mcp joint dislocation......Page 235
Surgical technique......Page 236
Outcomes......Page 238
References......Page 239
Ligament anatomy and biomechanics......Page 240
Treatment......Page 241
Surgical technique......Page 242
Outcomes......Page 243
References......Page 247
Anatomy and pathomechanics......Page 248
Surgical technique......Page 249
Postoperative management......Page 250
Outcomes......Page 251
References......Page 253
Biomechanics and anatomy......Page 254
Trapeziometacarpal joint portals  (video 25-1)......Page 255
Diagnosis......Page 256
Nonoperative......Page 258
Arthroscopic partial or complete trapeziectomy with interposition......Page 259
Arthroscopic partial or complete trapeziectomy without tendon interposition......Page 260
Outcomes......Page 261
References......Page 263
Relevant anatomy and pathomechanics......Page 264
Contraindications......Page 266
Surgical technique......Page 267
Interposition substances......Page 269
Complications......Page 270
Arthroscopic partial trapeziectomy......Page 272
Pyrocarbon implants......Page 273
References......Page 275
B......Page 277
F......Page 278
M......Page 279
S......Page 280
U......Page 281
W......Page 282

Citation preview

32  SECTION I I  |  Ulnocarpal Joint

TFCC DC TFCC

* * UH

4–5

A

3,4

A

DC

SN

TFCC 4–5

B

B

TFCC

4–5

TFCC

C FIGURE 3.12 (A) View of a radial triangular fibrocartilage complex (TFCC) tear (asterisk) from the 4,5 portal, which exposes the ulnar head (UH). (B) Sigmoid notch (SN) has been debrided back to bleeding bone (arrow) and a 2.5-mm drill bit is positioned before drilling. (C) Complete repair. Note how the interosseous suture (asterisk) pulls the edge of the TFCC up against the debrided sigmoid notch. sometimes entrapped in this tear, limiting rotation of the forearm, and that it is well visualized from a volar portal. The clinical findings varied and included the following: • tenderness at the dorsoulnar aspect of the wrist was positive in all wrists • fovea sign was positive in five wrists • tenderness at the dorsal aspect of the DRUJ was present in one wrist

C FIGURE 3.13 (A) Horizontal triangular fibrocartilage complex (TFCC) tear (arrow) seen from the 3,4 portal with separation of the dorsal TFC rim from the dorsal capsule (DC). (B) Placement of an absorbable suture. (C) Completed repair. Pain with forearm rotation was positive in all wrists. The ulnar head ballottement test induced pain in all wrists, whereas dorsal instability of the ulnar head was present in one wrist with this test. The ulnocarpal stress test was positive in five wrists. Axial and sagittal images on MRI revealed the dorsal tear in five wrists. All wrists were treated with an arthroscopic capsular repair. The final functional outcome per the Modified Mayo Wrist Score (MMWS) at an average follow-up of 16.1 months was four excellent and one good.

CHAPTER 3  |  Triangular Fibrocartilage Tears  33

Outcomes Reiter et al. reviewed the results of an inside-out arthroscopic repair of Palmer B tears in 46 patients.18 The average age was 34 years (range, 10–58 yr). The average follow-up was 11 months (range, 6–23 mo), and the delay to surgery was 9.7 months. Postoperative range of motion (ROM) averaged 128 degrees 6 23 degrees for the extension/flexion arc of motion, 41 degrees 6 11 degrees for the radial/ulnar deviation arc of motion, and 171 degrees 6 19 degrees for the pronation/supination arc of motion. However, no relation could be found between ulna length and clinical outcome. The MMWS was rated excellent in 22 % of patients, good in 41%, fair in 27%, and poor in 10%. The average DASH score was 21.70 6 17.17 (range, 0–58.33). A delay to surgery did not affect clinical outcome. Estrella et al. reviewed 35 patients who underwent arthroscopic TFCC repair.19 The average age was 33 years (range, 13–51 yr). The average follow-up was 39 months (range, 4–82 mo). TFCC tears were classified by the Palmer classification as follows: 1B (11), 1C (5), and 1D (1). The remaining 18 were not classified according to the Palmer classification. Seventy-four percent of patients had a reduction in pain after surgery, with improvement in grip strength and daily activities (P ,.05). The MMWS was excellent in 54% of patients, good in 20%, fair in 12%, and poor in 14%. Of patients who were employed, 19 out of 28 returned to their original work. A neuritis of the dorsal sensory branch of the ulnar nerve occurred in 17% of patients. A second-look arthroscopy was performed on nine patients with healing of the TFCC tear seen in seven patients. Additional procedures were performed on 10 patients (29%) to improve the functional outcome. Tatebe et al. performed second-look arthroscopy in 32 patients with central TFCC tears treated with an USO.20 Interestingly, 10 out of 13 of the central TFCC tears had healed, confirming the role of synovial healing despite the lack of blood supply to the affected area. All inside arthroscopic repairs have been previously reported but clinical series are lacking. Yao and Lee, however, recently described the use of the FasT-Fix suture device (Smith and Nephew Endoscopy, Andover, MA), which uses two absorbable poly L-lactate (PLLA) blocks that are deposited outside the capsule.21 There were 12 patients with Palmer 1B tears with a mean age of 42 years (range, 19–69 yr) who underwent repair followed by an above-elbow cast for 6 weeks. At a mean follow-up of 17.5 months (range, 11–27 mo), 11 out of 12 patients demonstrated excellent subjective outcomes with a mean QuickDASH score of 11 (range, 0–43) and a mean PRWE score of 19 (range, 2–53). The wrist motion was normal and the mean supination was 78 degrees (range, 60–90 degrees), with a mean grip strength of 64% (range, 38–86%) of the other side. One patient required an ulnar shortening 1 year later for persistent pain. Osterman22 presented his results on a retrospective study of 19 patients with Palmer class ID TFCC lesions without DRUJ instability that compared the clinical outcomes after TFCC reattachment versus debridement. They concluded that debridement was equally effective as repair

in alleviating wrist pain, improving grip strength, and restoring range of motion. Nakamura identified four types of radial TFCC tears.22 Those that involve the central disk only are stable and can be treated with debridement. Those that involve a tear of the volar and/or dorsal radioulnar ligaments can cause DRUJ instability and require repair. If the DRUJ is unstable with noticeable clunking during forearm compression and passive rotation, the ulnar styloid fracture should undergo internal fixation. Wolf et al.17 followed five patients who experienced persistent ulno-carpal symptoms following an arthroscopic suture repair of a Palmer type 1B lesion. All patients had a dynamic ulna-positive variance and subsequently underwent an ulnar shortening at an average of 17 months (range 13–29 months) following the arthroscopic repair. Prior to ulnar shortening, the average static ulnar variance was 0.2 6 1.3 (range −1 to 2 mm), and the average dynamic ulnar variance was 1.4 6 0.5 mm (range 1 to 2 mm). The second follow-up took place 7 months (range 5–9 months) after the ulnar shortening. The average VAS pain scale after ulnar shortening was 2.2 (range 0.7–5.0). The average static ulnar variance was −3.4 (range −5 to −1 mm). Postoperative range of motion averaged 90% of the other side, with an extension/flexion arc of 80% and a pronation/ supination arc of 100%. The modified Mayo Wrist Score was excellent in three patients and fair in two patients. The average DASH score was 22 6 22 (range 0–53).

Longitudinal Split Tear of the Ulnotriquetral Ligament Relevant Anatomy and Biomechanics Tay et al. 23 described a lesion that is a cause of ulnar-sided wrist pain but does not cause DRUJ instability, which they termed a longitudinal split tear of the ulnotriquetral (UT) ligament (see Fig. 3.14). Although this lesion is not included in the Palmar classification, it is by definition an injury of

PR TFCC

4–5

FIGURE 3.14 View of a longitudinal split tear (arrows) in the ulnotriquetral (UT) ligament. PR, Prestyloid recess.

34  SECTION I I  |  Ulnocarpal Joint

Diagnosis Patients typically present with chronic ulnar-sided wrist pain that is worsened by gripping and with pronation and supination. It may be worsened by heavy lifting. The clinical diagnosis is based on a positive ulnar fovea sign10 consisting of abnormal tenderness to direct pressure in the ulnar fovea, which is the soft spot between the ulnar styloid process, flexor carpi ulnaris tendons, volar surface of the ulnar head, and the pisiform. The DRUJ should be stable. The authors found that this test had sensitivity of 95% and specificity of 87% for detection of a foval avulsion and/or a longitudinal split tear of the UT ligament. Wrist radiographs are noncontributory, but a high-resolution MRI can demonstrate signal changes that are consistent with fluid accumulation in the substance of the UT ligament, in the fovea, or both (Fig. 3.16). Ultimately however, wrist arthroscopy is the only way to confirm this diagnosis.

T

TFCC

6R

FIGURE 3.15 View of a normal pisotriquetral orifice (PTO) (arrow), which is just proximal to the triquetrum (T). the TFCC because the UT ligament arises from the palmar radioulnar ligament. The UT ligament normally contains two perforations. The prestyloid recess is located at the ulnar junction between the palmar radioulnar (PRU) ligament and the UT ligament.24 The pisotriquetral orifice (Fig. 3.15) is just distal and anterior to the prestyloid recess and anterior to the proximal articular surface of the triquetrum, and should not be mistaken for a TFCC tear. Tay et al.23 believe that the longitudinal UT ligament split tear occurs due to a combination of axial loading, radial deviation, and forearm supination.

Surgical Technique A repair can be performed with 18-gauge needles and 2-0   PDS suture (Video 3-6). The tear is best viewed from the 3,4 or 4,5 portal and may be obscured by proliferative synovitis that extends from the prestyloid recess to the pisotriquetral orifice. Once this is debrided, a longitudinal defect within the UT ligament is seen. The inner longitudinal fibers of the UT ligament can be seen on either side of the defect. An outside-in repair is performed by initially making a 1-cm incision just anterior to the ECU tendon, starting distal to the ulnar styloid. Then 18-gauge needles are placed on either side of the tear and 2-0 PDS sutures are inserted through one needle and then retrieved through the other needle with a suture lasso. The sutures are tied

Radial

UT tear F

UT tear

S T

A

B

L

Dorsal

FIGURE 3.16 (A) T2-weighted MRI. AP view demonstrating a fluid collection (arrow)

adjacent to the ulnar fovea. (B) T2-weighted MRI. Axial view at the level of the carpal canal again demonstrating the fluid collection due to an ulnotriquetral (UT) ligament tear (arrow) adjacent to the ulnar styloid. F, Flexor tendons; L, lunate; S, scaphoid; T, triquetrum.

CHAPTER 3  |  Triangular Fibrocartilage Tears  35

UT

UT

PR PR

*

TFCC 3–4

A

B T

T

PR

C

*

PR

D

FIGURE 3.17 (A) View of an ulnotriquetral (UT) ligament split tear. PR, Prestyloid re-

cess. (B) Insertion of an 18-gauge needle volar to the UT ligament split tear (asterisk). PR, Prestyloid recess. (C) Insertion of a second 18-gauge needle dorsal to the UT ligament split tear (asterisk). T, Triquetrum. (D) Traction on the sutures closes the split tear (arrow).

outside the capsule to close the split tear (Fig. 3.17A-D). Postoperatively, the patient’s wrist is immobilized in an above-elbow cast for 6 weeks, followed by range of motion and strengthening.

Outcomes The authors conducted a retrospective study of 36 patients who underwent surgical treatment.23 The average age was 30 years (range, 14–70 yr), 50% were male, and 1/3 were athletes. The average duration of pain was 14.9 months (range 14 days–6 yr). At an average follow-up of 28.2 months, the mean DASH score was 7.5 (SD 9.8) and the mean PRWE score was 14.8. Grip strength improved slightly and wrist motion was minimally changed. Ninety percent reported no activity-related limitations, with a patient satisfaction rate of 89%. Two patients, however, ultimately required an open tendon graft stabilization of the DRUJ.

References 1. Palmer AK. Triangular fibrocartilage complex lesions: a classification. The Journal of hand surgery. 1989;14(4):594-606.

2. Kauer JM. The articular disk of the hand. Acta anatomica. 1975;93(4):590-605. 3. Kleinman WB. Stability of the distal radioulna joint: biomechanics, pathophysiology, physical diagnosis, and restoration of function what we have learned in 25 years. J Hand Surg. 2007;32(7):1086-1106. 4. Thiru RG, Ferlic DC, Clayton ML, McClure DC. Arterial anatomy of the triangular fibrocartilage of the wrist and its surgical significance. J Hand Surg. 1986;11(2):258-263. 5. Bednar MS, Arnoczky SP, Weiland AJ. The microvasculature of the triangular fibrocartilage complex: its clinical significance. J Hand Surg. 1991;16(6):1101-1105. 6. Tatebe M, Nishizuka T, Hirata H, Nakamura R. Ulnar shortening osteotomy for ulnar-sided wrist pain. Journal of Wrist Surgery. 2014;3(2):77-84. 7. Gupta R, Nelson SD, Baker J, Jones NF, Meals RA. The innervation of the triangular fibrocartilage complex: nitric acid maceration rediskovered. Plastic and Reconstructive Surgery. 2001;107(1):135-139. 8. Adams BD, Samani JE, Holley KA. Triangular fibrocartilage injury: a laboratory model. J Hand Surg. 1996;21(2):189-193. 9. Abe Y, Tominaga Y, Yoshida K. Various patterns of traumatic triangular fibrocartilage complex tear. Hand Surg. 2012;17(2): 191-198. 10. Tay SC, Tomita K, Berger RA. The “ulnar fovea sign” for defining ulnar wrist pain: an analysis of sensitivity and specificity. J Hand Surg. 2007;32(4):438-444.

36  SECTION I I  |  Ulnocarpal Joint 11. Tomaino MM. Ulnar impaction syndrome in the ulnar negative and neutral wrist. Diagnosis and pathoanatomy. J Hand Surg. 1998;23(6):754-757. 12. Haims AH, Schweitzer ME, Morrison WB, et al. Internal derangement of the wrist: indirect MR arthrography versus unenhanced MR imaging. Radiology. 2003;227(3):701-707. 13. Joshy S, Ghosh S, Lee K, Deshmukh SC. Accuracy of direct magnetic resonance arthrography in the diagnosis of triangular fibrocartilage complex tears of the wrist. International Orthopaedics. 2008;32(2):251-253. 14. Bille B, Harley B, Cohen H. A comparison of CT arthrography of the wrist to findings during wrist arthroscopy. J Hand Surg. 2007;32(6):834-841. 15. Smith TO, Drew B, Toms AP, Jerosch-Herold C, Chojnowski AJ. Diagnostic accuracy of magnetic resonance imaging and magnetic resonance arthrography for triangular fibrocartilaginous complex injury: a systematic review and meta-analysis. J Bone Joint Surg Am. 2012;94(9):824-832. 16. Trumble TE, Gilbert M, Vedder N. Isolated tears of the triangular fibrocartilage: management by early arthroscopic repair. J Hand Surg. 1997;22(1):57-65. 17. Culp R OA, Kaufmann RA. Wrist Arthroscopy: Operative Procedures. In: Hotchkiss GD, Pederson WC, Wolfe SW, eds.

Green’s Operative Hand Surgery. Vol 1. Philadelphia: Elsevier, 2005:781-803. 18. Reiter A, Wolf MB, Schmid U, et al. Arthroscopic repair of palmer 1B triangular fibrocartilage complex tears. Arthroscopy. 2008;24(11):1244-1250. 19. Estrella EP, Hung LK, Ho PC, Tse WL. Arthroscopic repair of triangular fibrocartilage complex tears. Arthroscopy. 2007;23(7):729-737, e721. 20. Tatebe M, Horii E, Nakao E, et al. Repair of the triangular fibrocartilage complex after ulnar-shortening osteotomy: second-look arthroscopy. J Hand Surg Am. 2007;32(4):445-449. 21. Yao J, Lee AT. All-arthroscopic repair of Palmer 1B triangular fibrocartilage complex tears using the FasT-Fix device. J Hand Surg Am. 2011;36(5):836-842. 22. Nakamura T. Radial sided tears of the triangular fibrocartilage. In: Del Pinal F LR, Mathoulin C, eds. Arthroscopic Management of Distal Radius Fractures. Heidleberg: Springer-Verlag; 2010:89-98. 23. Tay SC, Berger RA, Parker WL. Longitudinal split tears of the ulnotriquetral ligament. Hand Clin. 2010;26(4):495-501. 24. Ishii S, Palmer AK, Werner FW, Short WH, Fortino MD. An anatomic study of the ligamentous structure of the triangular fibrocartilage complex. J Hand Surg. 1998;23(6):977-985.

CHAPTER

4

Foveal Tears and Arthroscopy of the Distal Radioulnar Joint Relevant Anatomy and Biomechanics Triangular Fibrocartilage Complex Anatomy The triangular fibrocartilage complex (TFCC) consists of the articular disc, the meniscus homologue, the palmar radioulnar ligament (PRUL) and dorsal radioulnar ligament (DRUL), the extensor carpi ulnaris subsheath (ECUS), the ulnar capsule, the ulnolunate ligament (ULL), and the ulnotriquetral (UT) ligament.1,2 The PRUL and DRUL are the principal stabilizers of the distal radioulnar joint (DRUJ). As each radioulnar ligament extends ulnarly, it divides into two limbs: a deep limb, which attaches to the fovea on the ulna; and a superficial limb, which attaches to the ulnar styloid. Thus the TFCC has four insertions on the ulna: the palmar and dorsal superficial radioulnar ligaments (RUL), and the palmar and dorsal RUL (Fig. 4.1A–B). The attachment of the dorsal superficial RUL is wider than that of the dorsal deep RUL and forms the floor of the ECUS, which overlaps the fovea. The ulnocarpal ligaments, which consist of the ulnotriquetral ligament, the ulnocapitate ligament, and the ulnolunate ligament, are confluent with portions of the PRUL. The medial fibers of the ulnotriquetral ligament insert into the styloid with the palmar superficial RUL and the ulnocapitate ligament inserts into the fovea with the deep palmar RUL.3 In a histological study, Nakamura et al.4 found that the deep RUL arose vertically through Sharpey’s fibers from a broad area in the ulnar fovea and more horizontally from a narrow area at the base of the ulnar styloid. The deep RUL consists of three portions: dorsal, central, and palmar,5 and can be

fan-shaped, -shaped, or funnel-shaped (Fig. 4.2A–D). The origin of the deep RUL coincides with the axis of forearm rotation, which passes through the fovea, and allows twisting of the fibers during 180 degrees of forearm pronation and supination. The floor of the extensor carpi ulnaris sheath originates from the dorsal side of the fovea by Sharpey’s fibers. Loosely oriented fibers, corresponding to a thickened ulnar joint capsule, arise from the hyalinelike cartilage matrix at the tip of the ulnar styloid and insert onto the triquetrum without Sharpey’s fibers. The ULL and UT ligament originate not from the ulna, but from the palmar side of the TFCC. The deep RUL is the primary intrinsic stabilizer of the DRUJ.6 Extrinsic stability is provided by dynamic tensioning of the ECU as its tendon crosses the distal head of the ulna, the ECU sheath, dynamic support provided by the superficial and deep heads of the pronator quadratus, and the distal interosseous membrane. In an anatomical study of 30 forearm specimens, Noda et al.7 identified that the interosseous membrane included five ligaments: the central band, the accessory band, the distal oblique bundle (DOB), the proximal oblique cord, and the dorsal oblique accessory cord.7 The DOB is an inconstant isometric ligament within the distal membranous portion of the interosseous membrane (IOM) that is found in approximately 40 percent of subjects. It originates from the distal one-sixth of the ulnar shaft, at the proximal border of the pronator quadratus muscle, blends into the capsule of the distal DRUJ, and inserts into the inferior rim of the sigmoid notch, DRUL, and PRUL. Moritomo et al.8 showed that the distal interosseous membrane (DIOM) or the DOB (if present) act as a secondary soft tissue stabilizer of the dorsal DRUJ (DDRUJ) when the TFCC, which is the primary stabilizer of DRUJ, is 37

38  SECTION I I  |  Ulnocarpal Joint

UC

*

FCU T

ECU

DRU

TFC

UH

*

PRUL UH

EDC EDM

A

FDS

B

FIGURE 4.1 Radioulnar Ligaments.  (A) Palmar aspect of the distal radioulnar joint

demonstrating the superficial palmar radioulnar ligament (PRUL) and the palmar deep radioulnar ligament (RUL) (asterisk). FDS, Flexor digitorum sublimis; FCU, flexor carpi ulnaris; T, triquetrum. (B) Dorsal aspect of the distal radioulnar joint (DRUJ) demonstrating the superficial dorsal radioulnar ligament (RUL) (asterisk) which is confluent with the extensor carpi ulnaris subsheath (ECUS) and the deep dorsal radioulnar ligament (DRUL). EDC, Extensor digitorum communis; EDM, extensor digiti minimi; UC, ulnocarpal joint, UH, ulnar head.

torn. A residual ulnar translation deformity of the proximal radial shaft has the potential to cause DRUJ instability when a TFCC injury is also present, because it may result in detensioning of the DIOM/DOB. Correction of ulnar translation of the proximal radial shaft is critical because it restores the DIOM/DOB tension, which then firmly holds the ulnar head in the concavity of the sigmoid notch. This explains why DRUJ instability that is associated with a distal radius fracture is often corrected by rigid fixation of the fracture. When examined from a coronal perspective, the ulnar styloid lies relatively dorsal on the end of the ulnar head. The DRUL drapes over the dorsal aspect of the ulnar head as it converges toward the fovea, which limits the field of view through a dorsal arthroscopic portal but makes possible clear views of the sigmoid notch and the adjacent surface of the ulnar head (Fig. 4.3A–D). There is more room on the volar ulnar aspect of the DRUJ for insertion of an arthroscope with relatively unimpeded views of the proximal articular disk and the foveal attachments. The DDRUJ portals remain useful, however, for outflow and for instrumentation. The foveal insertion has a greater effect on DRUJ stability than the styloid insertion.6 A recent in vivo motion analysis9 revealed that in forearm pronation, the dorsal superficial RUL and palmar deep RUL tighten, serving as restraints for DRUJ stability. In forearm supination, the palmar superficial RUL and dorsal deep RUL tighten, maintaining stability of the joint. The ulnocapitate ligament is stretched taut in wrist extension. This supports the notion that a foveal tear can be caused by excessive traction of the

ulnocapitate ligament due to hyperextension of the wrist from a fall on an outstretched hand. Moritomo et al.10 compared the surgical and clinical findings in 15 patients who underwent an open foveal reattachment with the mechanism of injury. They found that the most common mechanism of injury (10 patients) of foveal TFCC avulsion was forced wrist extension from a fall on the outstretched hand followed by forced forearm rotation (5 patients). They hypothesized that there were at least four basic injury mechanisms of foveal avulsion: (1) forced wrist extension with forearm pronation disrupting the foveal insertion first and then the superficial dorsal limb, (2) forced wrist extension with forearm supination disrupting the foveal insertion first and then the superficial palmar limb, (3) forced forearm pronation disrupting the superficial dorsal limb first and then the foveal insertion, and (4) forced forearm supination disrupting the superficial palmar limb first and then the foveal insertion. They postulated that this theory also explained why tenderness often exists predominantly on the palmar side (positive foveal sign) following this mechanism of injury, because the ulnocapitate ligament inserts into the palmar aspect of the fovea.

Diagnosis Kleinman11 has described a set of provocative maneuvers for testing the integrity of the deep fibers of the RUL. The examiner sits opposite the patient, with the patient’s elbow

CHAPTER 4  |  Foveal Tears and Arthroscopy of the Distal Radioulnar Joint  39

TFCC TFCC

p Fovea

uc

d

Prul

Drul

uc

UH 4–5

A

UH

B

TFCC

* *

* *

DC UH

C

VDRU

D

FIGURE 4.2 Different Morphology of the Deep Radioulnar Ligament.  (A) View from

the distal radioulnar joint (DRUJ) of the foveal attachment of the palmar (P) and dorsal (D) deep radioulnar ligaments (RUL) merging with the ulnocapitate (UC) ligament as they attach to the fovea. UH, Ulnar head; TFCC, undersurface of the triangular fibrocartilage complex. (B) View from the volar distal radioulnar (VDRU) joint portal of the fanshaped foveal attachment aptly demonstrating the conjoined insertion of the palmar (P) and dorsal (D) deep radioulnar ligaments (RUL) merging with the ulnocapitate (UC) ligament as they attach to the fovea. UH, Ulnar head; TFCC, undersurface of the triangular fibrocartilage complex. (C) View from the volar distal radioulnar (VDRU) joint portal of a funnel-shaped deep RUL (asterisk). UH, Ulnar head. (D) View from the volar distal radioulnar (VDRU) joint portal of the deep radioulnar ligament (RUL) (asterisk) which is being tented up by a 22-gauge needle in the dorsal distal radioulnar joint (DRUJ) portal. TFCC, Proximal surface of the triangular fibrocartilage complex; DC, dorsal DRUJ capsule.

on the examining table in full supination and his or her fingers toward the ceiling. In this position, the dorsal fibers of the deep RUL will be under maximum tension. The examiner then pushes the distal ulna toward the patient while pulling the radiocarpal unit toward himself. This maneuver introduces a superphysiologic load into the DRUJ. It will be painless only if the dorsal fibers of the deep RUL are healthy. If inflamed, or suffering from relatively minor injury, the two forearm bones will be grossly stable on stress testing, but the patient will experience considerable pain on

loading the DRUJ beyond its physiologic limits. If the deep dorsal fibers have been severely sprained and detached from the fovea, this maneuver will not only be painful but will lead to superphysiologic movement of the sigmoid notch off the seat of the ulna, resulting in subtle subluxation or even gross instability, depending on the magnitude of injury to the dorsal fibers. The palmar fibers of the deep RUL are then tested by applying a dorsally directed superphysiologic load to the distal ulna, with the forearm in full pronation. The hand-forearm unit is then pulled toward

40  SECTION I I  |  Ulnocarpal Joint

A

B

SN

*

Sigmoid notch

*

*

*

Ulnar head

UH

C

D

**

FIGURE 4.3 (A) Surface anatomy of the dorsal distal radioulnar joint (DDRUJ) portals. (B) Scope is in the proximal DDRUJ portal. Probe is in the DDRUJ portal. (C) View from the DDRUJ portal of the ulnar head and sigmoid notch. The dorsal superficial radioulnar ligament (RUL) (asterisk) drapes across the field of view. (D) View of the ulnar head (UH) and sigmoid notch (SN) through the DDRUJ. The probe is introduced through the volar DRUJ portal. Note the cartilage loss (asterisk) on the adjacent sides of the joint.

the examiner, while the examiner’s thumb pushes the ulna toward the patient. If the deep palmar fibers are either ruptured or attenuated, there will painful instability in full pronation (Fig. 4.4A–B). A complete foveal detachment would result in a situation in which no end point is found, demonstrating multidirectional DRUJ instability. A partial RUL tear would clinically present with a firm end point with increased excursion either in the dorsal or palmar direction. The palm press test, which presents as a floating ulnar head in the pronation position, may also help to   diagnose a foveal avulsion (Fig. 4.5A–B) (Video 4-1). Moritomo et al.10 classified DRUJ instability into four levels of severity: none (same as the contralateral side), mild (more unstable than the contralateral side but not subluxated), moderate (more unstable than the contralateral side and subluxated), and severe (dislocated). Jupiter

has noted that it is difficult to quantify distal radioulnar instability, and these methods suffer from subjectivity and lack of interobserver validity.12 A lateral radiograph may reveal dorsal or palmar translation of the distal ulna provided that it is a true lateral view of the wrist. The palmar cortex of the pisiform bone should overlie the central third of the interval between the palmar cortices of the distal scaphoid pole and the capitate head (Fig. 4.6A–B).13 This can result in a block to forearm rotation (Figure 4.6C). Similarly, an axial CT scan of the wrist in pronation and supination compared with the normal side can be used to assess the congruency of the DRUJ (Fig. 4.7A–B).14 MR imaging can detect these tears, which are evidenced by the presence of a high-intensity area on a T2-weighted scan of the fovea and/or pooling of dye at the fovea without a leakage to the radiocarpal joint on an arthrogram.15

CHAPTER 4  |  Foveal Tears and Arthroscopy of the Distal Radioulnar Joint  41

Increased increased dorsal translation

B

A

FIGURE 4.4 Distal Radioulnar Joint Instability.  (A) Ulnar head in reduced position with the forearm in pronation. (B) Ulnar head displaced dorsally when the hand-forearm unit is then pulled toward the examiner.

Sulcus

A

B FIGURE 4.5 Press Test.  (A) Normal position of the ulnar head. (B) Volar displacement of the ulnar head when the patient presses on the table, which creates a sulcus sign (arrow) in line with the extensor carpi ulnaris (ECU) tendon.

Patients who present with ulnar-sided wrist pain and DRUJ instability with normal radiographs and with tenderness over the periphery of the TFCC are initially immobilized. Further diagnostic modalities are instituted after 2 or 3 months of immobilization if the patient continues to be symptomatic. Arthroscopy is a sensitive and specific way of assessing the deep RUL. Ruch et al.16 first described the hook test as a way to test the foveal insertion of the TFCC during the arthroscopic treatment of distal radius fractures. A hook probe is inserted into the prestyloid recess and traction is   applied (Video 4-1). If the TFCC can be pulled upwards and radially, this is indicative of a foveal detachment (Fig. 4.8A–B).

Similarly, Tay et al.17 and Atzei and Luchetti18 have written that if one can drag the TFCC dorsally with an arthroscopic hook probe, this is indicative of a foveal detachment. In both methods, however, one must ultimately perform a DRUJ capsulotomy or DRUJ arthroscopy to directly observe the deep RUL fibers in order to definitively make the diagnosis. Atzei19 proposed a classification for foveal tears by subdividing the Palmer type B lesion into 5 classes: class 1, repairable distal tear; class 2, repairable complete tear (proximal and distal); class 3, repairable proximal tear; class 4, nonrepairable; and class 5, arthritic DRUJ (Fig. 4.9A–D).

42  SECTION I I  |  Ulnocarpal Joint Note the widened DRUJ

B

A Prominent ulnar head

FIGURE 4.6 Distal Radioulnar Joint.  Instability (A) AP view of a right wrist demonstrating widening of the distal radioulnar joint (DRUJ). (B) True lateral view demonstrating dorsal subluxation of the ulnar head (arrow). (C) Clinical appearance demonstrating a block to supination and dorsal prominence of the ulnar head.

C

Dorsal Note the dorsal subluxation

UH

* * A

B FIGURE 4.7 (A) Comparative axial CT scan views of a normal right wrist and a subluxated left wrist with a recent ulnar styloid fracture demonstrating dorsal subluxation of the ulnar head relative to the sigmoid notch. (B) Axial CT scan of a distal radius fracture demonstrating dorsal subluxation of the ulnar head (UH) relative to the sigmoid notch (asterisk).

CHAPTER 4  |  Foveal Tears and Arthroscopy of the Distal Radioulnar Joint  43

* * *

* * *

A

B FIGURE 4.8 Hook Test.  (A) View from the 3,4 portal of the triangular fibrocartilage

complex (TFCC) (asterisk) and the prestyloid recess (arrow). (B) Probe is used to pull the (TFCC) (asterisk) dorsally and radially, which is seen by dramatic widening of the prestyloid recess (arrow) as the TFCC is separated from the ulnar capsule.

TFCC

TFCC

UH VDRU

A

6R

B

TFCC

C

D FIGURE 4.9 Foveal Tears.  (A) View from the volar distal radioulnar (VDRU) joint portal of a proximal tear of the deep radioulnar ligament (RUL). UH, Ulnar head; TFCC, proximal surface of the triangular fibrocartilage complex. (B) Radiocarpal joint view from the 6R portal of a markedly unstable combined proximal and distal tear of the TFCC (arrows). UH, Ulnar head; TFCC, distal surface of the triangular fibrocartilage complex. (C) An 18-gauge needle is inserted through the fovea and used to pierce the unstable edge of the combined tear. (D) The tear is sutured back down to the fovea.

6R

44  SECTION I I  |  Ulnocarpal Joint

Technique of Distal Radioulnar Joint Arthroscopy The volar ulnar (VU) portal is established via a 2-cm longitudinal incision centered over the proximal wrist crease   along the ulnar edge of the finger flexor (Video 1-10). The tendons are retracted to the radial side and the radiocarpal joint space is identified with a 22-gauge needle. Blunt tenotomy scissors or forceps are used to pierce the volar capsule, followed by insertion of a cannula and blunt trocar, and then the arthroscope. Care is taken to situate the cannula beneath the ulnar edge of the flexor tendons and to apply retraction in a radial direction alone, in order to avoid injury to the ulnar nerve and artery. The interposed flexor tendons protect the median nerve. The palmar region of the lunotriquetral interosseous ligament (LTIL) can usually be seen   slightly distal and radial to the portal (Video 4-2). A hook probe is inserted through the 6R or 6U portal.

Volar Distal Radioulnar Portal The topographical landmarks and establishment of the volar distal radioulnar (VDRU) portal are identical to those

of the VU portal. The capsular entry point lies 5 to 10 mm proximally.20 The VDRU portal is accessed through the VU skin incision   (Video 4-3). A 1.9-mm small-joint arthroscope can be used as gaining access to the DRUJ can be difficult, especially in a small wrist, but I have found that a standard 2.7-mm scope provides a better field of view. The ulnocarpal joint is first identified as described earlier. It is useful to leave a needle or cannula in the ulnocarpal joint for reference during this step. The DRUJ is then located by angling a 22-gauge needle 45 degrees proximally, and then injecting the DRUJ with saline. Alternatively, the skin incision can be extended proximally by 1 cm so that it lies at the same level as the VDRU capsular entry point. Once the correct plane is identified, the volar DRUJ capsule is pierced with tenotomy scissors followed by a cannula with a blunt trocar, and then the arthroscope. Alternatively, a probe can be placed in the DDRUJ portal and advanced through the palmar incision to help locate the joint space. It can then be used as a switching stick over which the cannula is introduced. Initially, the DRUJ space appears quite confined, but over the course of 3 to 5 minutes the fluid irrigation expands the joint space, which improves visibility (Fig. 4.10A–B). A burr or thermal probe can be substituted

Probe in dorsal DRUJ portal

A

B TFCC

DC

* * C

FIGURE 4.10 (A) Arthroscopic cannula and trocar are in

UH DDRUJ

the volar ulnar (VU) portal. The distal radioulnar joint (DRUJ) is localized with a 22-gauge needle and injected with saline. (B) Probe is in the dorsal distal radioulnar joint (DDRUJ) portal and has been advanced volarly to exit through the volar DRUJ portal. (C) Dry arthroscopy through the volar DRUJ portal demonstrates an empty fovea sign with an absence of the deep radioulnar ligament (RUL) attachment (asterisk). DC, Dorsal capsule, UH, ulnar head.

CHAPTER 4  |  Foveal Tears and Arthroscopy of the Distal Radioulnar Joint  45

for the 3-mm hook probe through the DDRUJ portal as necessary. Dry arthroscopy can also be performed (Fig. 4.10C). Use of the direct foveal (DF) portal as described by Atzei   (Video 1-11) is useful for instrumentation to test the integrity of the deep RUL attachment to the fovea and provides views of the undersurface of the TFCC and ulnar head.19 This portal is established by making a 1-cm longitudinal incision just proximal to the 6U portal and volar to the ECU tendon (Fig. 4.11). The portal enters the DRUJ capsule immediately adjacent to the deep RUL attachment. If used for viewing, the scope is inserted with the wrist in full supination because the ulnar styloid and the ECU tendon displace dorsally and the fovea and the ulnar-most area of the distal ulna become subcutaneous. DRUJ arthroscopy can be done dry without fluid irrigation. In doubtful cases, DRUJ arthroscopy can aid in determining the degree of   DRUJ OA (Video 4-4) .

Dorsal Distal Radioulnar Portals The DRUJ can be accessed through a proximal and distal portal.21 The proximal distal radioulnar joint (PDRUJ) portal is located in the axilla of the joint, just proximal to the sigmoid notch and the flare of the ulnar metaphysis. This portal is easier to penetrate and should be used initially to prevent chondral injury from insertion of the trochar. The forearm is held in supination to relax the dorsal capsule and to move the ulnar head volarly. This also lifts the central disk distally from the head of the ulna. The joint space is identified by first inserting a 22-gauge needle horizontally at the neck of the distal ulna. Fluoroscopy facilitates the needle placement. The joint is infiltrated with saline and the capsule is spread with tenotomy scissors through a small incision. A cannula and trochar for the 1.9-mm- or 2.7-mm scope are introduced followed by insertion of a 1.9-mm or 2.7-mm 30-degree angle scope. Entry into this portal provides views of the proximal sigmoid notch cartilage and the articular surface of the neck of the ulna. One should systematically look for loose bodies or synovial hypertrophy. The DDRUJ portal is identified 6 to 8 mm distally from the PDRUJ with the 22-gauge needle, and just proximal to

DF

the 6R portal. This portal can be used for outflow drainage or for instrumentation. The TFCC has the least tension in neutral rotation of the forearm, which is the optimal position for visualizing the articular dome of the ulnar head, the undersurface of the TFCC, and the foveal insertion of the PRUL. Because of the dorsal entry of the arthroscope, the course of the DRUL is not visible until its attachment into the fovea is encountered.22

Arthroscopic-Assisted Reattachment of the Deep Radioulnar Ligament Indications Patients with acute and chronic ulnar-sided wrist pain, tenderness over the ulnar fovea, and a clinically unstable DRUJ that have not responded to conservative measures are appropriate candidates for an arthroscopic-assisted technique for up to 6 months from injury. Patients with a grossly unstable DRUJ following an injury or those with DRUJ instability that persists despite rigid fixation of an associated distal radius fracture or Galeazzi fracture require immediate treatment. In chronic cases of DRUJ instability of more than six months, where there is a poor prognosis for a foveal attachment, an   open DRUJ tendon graft should be considered (Video 4-5).

Contraindications A massive rupture with retraction of the TFCC that prevents reapproximation of the avulsed ligament to its anatomical position and chronic tears with poor quality tissue should be treated with tendon graft reconstruction. Subacute tears from 3 to 6 months after injury have unpredictable healing characteristics while chronic tears of more than 6 months usually have poor healing potential.18 Patients who are minimally symptomatic, patients with low physical demands who are not healthy enough for surgery, and patients who have degenerative changes of either the radiocarpal or distal radioulnar joint should be treated conservatively. Severe DRUJ instability and a positive ulnar variance 2 mm are relative contraindications.

VDRU

Arthroscopic-Assisted Suture Repair Techniques

FIGURE 4.11 Direct Foveal Portal.  A probe is placed in the direct foveal (DF) portal and advanced through the volar distal radioulnar joint (DRUJ) portal.

Iwaskaki and Minami23 described an arthroscopic-assisted transosseous technique for a foveal reattachment. The diagnosis of an avulsion of the foveal TFCC insertion is determined by a loss of the normal trampoline effect and a positive hook test. A 1.5-mm K-wire is used as a guide pin and percutaneously inserted from the ulnar neck to the

46  SECTION I I  |  Ulnocarpal Joint foveal region of the ulnar head under fluoroscopy. A 1.5-cm incision is made around the K-wire, and a 2.9-mm cannulated drill (DePuy, Warsaw, IN) is driven in just distal to the fovea over the inserted K-wire to create an osseous tunnel. Under arthroscopic guidance with the scope in the 3,4 portal, a 2-0 nonabsorbable suture (Prolene, Ethicon, Somerville, NJ) is passed into a 21-gauge needle and inserted into the TFCC through the osseous tunnel. A 2-0 nonabsorbable suture loop is advanced into the TFCC in the same manner. The suture end is captured by the loop and withdrawn through the osseous tunnel and pulled proximally to anchor the TFCC to the fovea. With the forearm in neutral rotation, the suture is tied onto the ulnar periosteum around the proximal entrance of the osseous tunnel. The patient is immobilized with a long-arm cast in 45 degrees of supination for 4 weeks postoperatively. A removable wrist brace is applied for an additional 2 weeks followed by range of motion and strengthening. Nakamura et al.24 have reported the use of a similar arthroscopic-assisted transosseous TFCC repair technique using a targeting device. The TFCC is observed via radiocarpal and DRUJ arthroscopy. After a foveal detachment of the TFCC is confirmed, the target device is inserted through the 4,5 or 6R portal. A 1-cm longitudinal incision is made on the ulnar side of the ulnar cortex, just 15 mm proximal to the tip of the ulnar styloid, and the periosteum is elevated. The small spike on the target device is set on the ulnar half of the TFCC. Two separate holes with 1.2-mm K-wires are made through the targeting jig from the ulnar cortex of the ulna to the ulnar half of the TFCC. A looped nylon 4-0 suture is passed through a 21-gauge needle that is passed through one tunnel from the outside, then is repeated through the other bone tunnel. Both loop sutures are retrieved through the 4,5 or 6R portal using mosquito forceps, and then two nonabsorbable 3-0 polyester sutures (Ticron, Covidien, Mansfield, MA) are threaded through the loop sutures and introduced into the radiocarpal joint. Proximal traction on the looped sutures then pulls the sutures through the TFCC and out the ulnar cortex of the ulna advancing the TFCC to the fovea. The TFCC is tightly sutured to the ulnar fovea with this technique, which restabilizes the DRUJ. Atzei and Luchetti18 use an arthroscopic-assisted foveal   repair technique with a suture anchor (Video 4-6). The scope is introduced through the 3,4 portal. The 6R and 6U portals are created for instrumentation. A DF portal is created 1 cm proximal to the 6U portal, just palmar to the ulnar styloid, with the forearm fully supinated. The scope is inserted with the wrist in full supination because the ulnar styloid and the ECU tendon displace dorsally and the fovea and the ulnar-most area of the distal ulna become subcutaneous. The edges of the tear are debrided through the 6R and DF portals. A 2.0-mm power shaver and/or a curette are used to debride the torn foveal fibers and to create a bleeding surface on the foveal attachment. A selftapping suture anchor with a pair of sutures (four strands) is inserted in the fovea via the DF portal. The radial strand of each suture is loaded into the tip of a 25-gauge needle or

Tuohy needle introduced into the DF portal with the scope in the DDRUJ portal. Aiming upwards, the needle is pierced through the palmar fibers of the deep RUL and then the superficial dorsal RUL, protruding into the radiocarpal joint. The scope is shifted to the 3,4 portal to confirm correct needle placement and the sutures are retrieved through the 6U portal. The same procedure is repeated with the ulnar strand of each suture, which is passed into the prestyloid recess, and retrieved through the 6U portal. A knot pusher is placed through the 6U portal to slide the knot down into the prestyloid recess, with the forearm in neutral rotation and without wrist traction. The arm is immobilized in a Munster splint for 4 weeks followed by range of motion and strengthening. Geissler developed an all-arthroscopic repair technique25   using a pushlock anchor (Fig. 4.12A–E) (Video 4-7). The wrist is suspended with 10 pounds of traction in a traction tower with the wrist flexed 20 to 30 degrees. The scope is placed in the 3,4 portal with a probe inserted through the 6R portal. An accessory 6R portal is made approximately 1.5 cm distally, in line with the 6R portal. This portal is located by inserting an 18-gauge needle distal to the 6R portal, aiming at the ulnar head, keeping the wrist flexed, which allows a more central location for insertion of the anchor. A suture lasso (Arthrex, Naples, FL) is inserted through the accessory 6R portal into the radiocarpal space and passed through the periphery of the tear through the articular disk in a proximal-to-distal direction. A wire suture passer is inserted through the suture lasso and retrieved through the 6R portal with a crochet hook. A 2.0 fiber wire suture is then placed through the suture retriever and pulled distally through the suture lasso out the handle. The suture lasso is then backed out of the articular disk (but not the joint) and reinserted anterior/posterior to the previous perforation so that a horizontal mattress suture is placed. As the suture lasso reperforates through the articular disk, a loop of suture will be found protruding from the articular disk into the radial carpal space. The loop of suture is then retrieved through the 6R portal with a crochet hook so that both limbs are exiting the 6R portal. A trocar and cannula are then inserted through the accessory 6R portal. A crochet hook is passed through the cannula and used to retrieve the two suture limbs distally through the cannula. The suture limbs are pulled out through the slot of the cannula during drilling. The cannula is firmly placed down onto the head of the ulna through the peripheral tear of the articular disk. A cannulated drill is inserted over the guide wire and a drill hole is made in the base of the ulna once the ideal location is confirmed fluoroscopically. While holding the cannula in place, the 2.0 fiber wire suture limbs are then inserted through the mini pushlock anchor (Arthrex, Naples, FL). The anchor is advanced into the drill hole and the sutures are tensioned. Once the sutures are tensioned, the anchor is advanced into the distal ulna. The wrist is then immobilized in slight supination in an above-elbow splint for approximately 3 to 4 weeks. A removable wrist splint is used for an additional 3 weeks.

CHAPTER 4  |  Foveal Tears and Arthroscopy of the Distal Radioulnar Joint  47

TFC

Fovea

A

B

C

D

E FIGURE 4.12 All-Inside Foveal Repair.  (A) View from the volar distal radioulnar

(VDRU) demonstrating an empty fovea. TFCC, Triangular fibrocartilage complex. (B) A suture lasso (Arthrex, Naples, FL) is inserted through the accessory 6R portal into the radiocarpal space and passed through the periphery of the tear through the articular disk in a proximal to distal direction. (C) A 2.0 fiber wire suture is then placed through the suture retriever and pulled distally through the suture lasso out the handle. (D) A 22-gauge needle is passed through the 6R portal to locate the ulnar head. (E) The 2.0 fiber wire suture limbs are tensioned by advancing the pushlock into the distal ulna, restoring the TFCC tension.

Outcomes Iwasaki et al.26 reviewed 12 patients who underwent an arthroscopic foveal reattachment. The mean age was 31 years (range, 20–50 yr). At a mean follow-up of 30 months, 6 patients had no pain, 5 had mild pain, and 1 had moderate

pain. The DRUJ instability was eliminated in all patients. The mean postoperative Modified Mayo Wrist Score (MMWS) was 92.5 6 7.5, with 8 excellent and 4 good results. The DASH scores significantly improved from 59.5 6 18.5 to 7.7 6 11.9 postoperatively (P ,.0001). Two patients

48  SECTION I I  |  Ulnocarpal Joint had occasional ECU tendinitis after surgery. Magnetic resonance images at 12 weeks postoperatively showed findings indicating attachment of the TFCC to the fovea. Nakamura et al.24 reported the results of 24 patients treated with the arthroscopic transosseous technique and 64 patients treated with an open transosseous repair. In the arthroscopic repair group, there were 13 males and 11 females, with a mean age of 27 years. The injured side included 13 right and 11 left wrists. The period between the initial injury and surgery averaged 8 months (range, 1 mo–4 yr). The ulnar variance was 12 mm in 5 wrists, 0 mm in 17 wrists, and -1 mm in 2 wrists. The follow-up averaged 3.5 years (range, 12–60 mo). After the repair, 15 out of 24 patients had no pain and 2 patients had severe pain. Pain recurred in 4 patients at 8 to 12 months post repair. There was no loss of range of rotation before surgery, but 1 patient had a 45-degree loss of supination. There was no postoperative DRUJ instability in 17 patients, with moderate to severe instability in 7 patients. In the open repair group, there were 36 males and 28 females, with a mean age of 31 years. The injured side included 37 right wrists, 25 left wrists, and 2 bilateral wrists. The period between the initial injury and surgery averaged 5 months (range, 0 mo–25 yr). Ulnar variance was positive in 13 wrists, neutral in 50 wrists, and negative in 3 wrists. The follow-up averaged 3 years (range, 24–108 mo). In the open group, 60 out of 64 patients were pain-free, with 2 patients having severe pain. One patient had a 45-degree loss of supination after surgery. There was no postoperative DRUJ instability in 56 out of 64 patients, with moderate to severe DRUJ instability noted in 4 patients. When analyzing their data using an author-generated DRUJ wrist outcome score, they determined that in the arthroscopic group, the cases with excellent and good results had surgery within 7 months of the injury (average 4 mos). Cases with fair and poor clinical results had an arthroscopic repair at an average of 19 months after the initial injury (range, 7 mo–4 yr). They also found only fair clinical results in the patients with a positive ulnar variance and now consider a 12 mm variance or greater to be a contraindication to an arthroscopic procedure. These patients are now treated with an open repair and ulnar shortening or wafer resection. There were no differences in time to surgery or positive ulnar variance in the open repair group, however. Shinohara et al.27 modified Nakamura’s technique by placing the osseous tunnels more precisely at the fovea using DRUJ arthroscopy. Eleven patients were evaluated after a mean follow-up of 30 months using the Hand20 score. DRUJ instability was eliminated in 9 patients and mild DRUJ instability persisted in 2 patients. Pain resolved completely in 7 patients and mild pain during activity persisted in 4 patients. The MMWS was excellent in 7 patients, good in 3 patients, and fair in 1 patient. They noted that their good results might be in part due to the fact that their patients had moderate DRUJ instability from a traumatic TFCC foveal tear without ulnar abutment. They

believed that if the patient had severe DRUJ instability, it was possible that not only the foveal insertion, but also the secondary stabilizers (i.e., the joint capsule, ulnocarpal ligaments, pronator quadratus, and distal interosseous membrane) were damaged and that the TFCC was not repairable. In patients with severe DRUJ instability, they recommended an open TFCC reconstruction rather than an arthroscopic foveal repair. Atzei and Luchetti28 reviewed 48 patients (28 males and 20 females) following an arthroscopic-assisted repair at an average follow-up of 33 months (range, 6–52 mo). The dominant hand was involved in 27 patients. The average age at surgery was 34 years (range, 17–54 yr). The mean period of time from the injury until the operation was 11 months (range, 5–19 mo). The mechanism of injury included an acute event (fall or violent twisting of the wrist) in all cases. There was a statistically significant improvement in pain at rest, with a preoperative visual analog pain scale mean of 3 6 2 compared with a postoperative mean of 1 6 1 (P ,.05). There was also a statistically significant improvement in pain during activity, with preoperative and postoperative mean of 8 6 3 and 3 6 3, respectively (P ,.05). Moderate pain persisted in 4 patients and severe pain persisted in 1 patient. The mean MMWS improved from a preoperative value of 48 6 13 to a postoperative value of 87 6 (P ,.05). Results were 35 excellent, 5 good, 6 fair, and 2 poor. The DASH score improved significantly from a mean preoperative value of 42 6 20 to a mean postoperative value of 15 6 15 (P ,.05). The DRUJ instability resolved in 44 out of 48 patients. Four patients showed persistence of a “soft end point” at the ballottement test and two of them also complained from the persistence of a painful click during forearm rotation. There was no statistically significant difference between preoperative and postoperative wrist motion and forearm rotation. Five patients had a transient neurapraxia of the dorsal sensory branch of the ulnar nerve (DSBUN).

References 1. Palmer AK, Werner FW. The triangular fibrocartilage complex of the wrist—anatomy and function. J Hand Surg [Am]. 1981;6(2):153-162. 2. Ishii S, Palmer AK, Werner FW, Short WH, Fortino MD. An anatomic study of the ligamentous structure of the triangular fibrocartilage complex. J Hand Surg [Am]. 1998;23(6):977-985. 3. Berger RA. The ligaments of the wrist. A current overview of anatomy with considerations of their potential functions. Hand clin. 1997;13(1):63-82. 4. Nakamura T, Takayama S, Horiuchi Y, Yabe Y. Origins and insertions of the triangular fibrocartilage complex: a histological study. J Hand Surg. 2001;26(5):446-454. 5. Nakamura T, Makita A. The proximal ligamentous component of the triangular fibrocartilage complex. J Hand Surg. 2000;25(5):479-486. 6. Haugstvedt JR, Berger RA, Nakamura T, Neale P, Berglund L, An KN. Relative contributions of the ulnar attachments of the triangular fibrocartilage complex to the dynamic stability of the distal radioulnar joint. J Hand Surg. 2006;31(3):445-451.

CHAPTER 4  |  Foveal Tears and Arthroscopy of the Distal Radioulnar Joint  49 7. Noda K, Goto A, Murase T, Sugamoto K, Yoshikawa H, Moritomo H. Interosseous membrane of the forearm: an anatomical study of ligament attachment locations. J Hand Surg. 2009;34(3):415-422. 8. Moritomo H, Omori S. Influence of ulnar translation of the radial shaft in distal radius fracture on distal radioulnar joint instability. J Wrist Surg. 2014;3(1):18-21. 9. Xu J, Tang JB. In vivo changes in lengths of the ligaments stabilizing the distal radioulnar joint. J Hand Surg. 2009;34(1):40-45. 10. Moritomo H, Masatomi T, Murase T, Miyake J, Okada K, Yoshikawa H. Open repair of foveal avulsion of the triangular fibrocartilage complex and comparison by types of injury mechanism. J Hand Surg. 2010;35(12):1955-1963. 11. Kleinman WB. Stability of the distal radioulna joint: biomechanics, pathophysiology, physical diagnosis, and restoration of function what we have learned in 25 years. J Hand Surg. 2007;32(7):1086-1106. 12. Jupiter JB. Commentary: the effect of ulnar styloid fractures on patient-rated outcomes after volar locking plating of distal radius fractures. J Hand Surg Am. 2009;34(9):1603-1604. 13. Yang Z, Mann FA, Gilula LA, Haerr C, Larsen CF. Scaphopisocapitate alignment: criterion to establish a neutral lateral view of the wrist. Radiology. 1997;205(3):865-869. 14. Mino DE, Palmer AK, Levinsohn EM. Radiography and computerized tomography in the diagnosis of incongruity of the distal radio-ulnar joint. A prospective study. J Bone Joint Surg Am. 1985;67(2):247-252. 15. Amrami KK, Felmlee JP. 3-Tesla imaging of the wrist and hand: techniques and applications. Semin Musculoskelet Radiol. 2008;12(3):223-237. 16. Ruch DS, Yang CC, Smith BP. Results of acute arthroscopically repaired triangular fibrocartilage complex injuries associated with intra-articular distal radius fractures. Arthroscopy. 2003;19(5):511-516.

17. Tay SC, Tomita K, Berger RA. The “ulnar fovea sign” for defining ulnar wrist pain: an analysis of sensitivity and specificity. J Hand Surg. 2007;32(4):438-444. 18. Atzei A, Luchetti R. Foveal TFCC tear classification and treatment. Hand clin. 2011;27(3):263-272. 19. Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg Eur vol. 2009;34(5):582-591. 20. Slutsky DJ. Distal radioulnar joint arthroscopy and the volar ulnar portal. Tech Hand Up Extrem Surg. 2007;11(1):38-44. 21. Whipple TL. Arthroscopy of the distal radioulnar joint. Indications, portals, and anatomy. Hand Clin. 1994;10(4):589-592. 22. Berger RA. Arthroscopic anatomy of the wrist and distal radioulnar joint. Hand Clin. 1999;15(3):393-413, vii. 23. Iwasaki N, Minami A. Arthroscopically assisted reattachment of avulsed triangular fibrocartilage complex to the fovea of the ulnar head. The Journal of hand surgery. 2009;34(7): 1323-1326. 24. Nakamura T, Sato K, Okazaki M, Toyama Y, Ikegami H. Repair of foveal detachment of the triangular fibrocartilage complex: open and arthroscopic transosseous techniques. Hand clin. 2011;27(3):281-290. 25. Geissler WB. Arthroscopic knotless peripheral ulnar-sided TFCC repair. Hand clin. 2011;27(3):273-279. 26. Iwasaki N, Nishida K, Motomiya M, Funakoshi T, Minami A. Arthroscopic-assisted repair of avulsed triangular fibrocartilage complex to the fovea of the ulnar head: a 2- to 4-year follow-up study. Arthroscopy. 2011;27(10):1371-1378. 27. Shinohara T, Tatebe M, Okui N, Yamamoto M, Kurimoto S, Hirata H. Arthroscopically assisted repair of triangular fibrocartilage complex foveal tears. J Hand Surg. 2013;38(2): 271-277. 28. Atzei A, Luchetti R, Braidotti F. Arthroscopic foveal repair of the triangular fibrocartilage complex. J Wrist Surg. 2015;4(1):22-30.

CHAPTER

5

Ulnocarpal Impaction Syndrome and Ulnar Styloid Impaction Syndrome Relevant Anatomy and Biomechanics Ulnar impaction can produce ulnar-sided wrist pain and can be related to ulnocarpal impaction (UCI) due to an ulnar-positive variance (Fig. 5.1). Palmer et al. demonstrated that there was an inverse relationship between the thickness of the triangular fibrocartilage (TFC) and the ulnar variance:1 The more positive the ulnar variance, the thinner the TFC. Hara et al.2 found that the forcetransmission ratio was 50% through the scaphoid fossa, 35% through the lunate fossa, and 15% through the TFC in the neutral position. Werner et al.3 demonstrated that lengthening the ulna by 2.5 mm increased the force borne by the ulna from 18.4% to 41.9% of the total axial load. Shortening of the ulna by 2.5 mm decreased the axial load borne by the ulna to 4.3%. Removal of the articular disk portion of the triangular fibrocartilage complex (TFCC) decreased the load on the intact ulna from 18.4% to 6.2%. The peak pressure at the ulnolunate articulation increased from 1.4 N/mm2 for the unaltered wrist to 3.3 N/mm2 when the ulna was lengthened by 2.5 mm. Degenerative central tears of the articular disk occur more frequently with advancing age. In a cadaver study of 180 wrist joints, Mikic noted an incidence of 53% over age 60 compared with 7% in the third decade.4 Clinical experience has shown, however, that not all of these tears are symptomatic. Most symptomatic degenerative tears of the TFCC are related to chronic overloading of the ulnocarpal joint. Primary ulnar impaction is related to an increased 50

ulnar variance. Viegas and Ballantyne5 dissected 100 cadaver wrists and found a 73% incidence of TFCC tears in specimens with an ulnar-positive variance versus 17% when there was a negative-ulnar variance. Acquired ulnar-positive deformities can occur with distal radius fractures that heal with radial shortening, distal radial growth arrest, and EssexLopresti and Galeazzi fractures. Ulnar impaction may also be dynamic and occur with power grip in the pronated position.6 This is because of the approximate 1.95 cm of radial shortening that occurs as the radius rotates across the ulna during pronation, which leads to a dynamic impingement.7 UCI syndrome consists of the triad of a TFCC tear, a lunotriquetral (LT) ligament tear, and an ulnar-positive   variance (Video 1-12). There is often chondromalacia of the proximal ulnar aspect of the lunate (i.e., a kissing lesion) and there may be chondromalacia of the ulnar head (Fig. 5.2A–E).

Mechanism and Classification Acquired ulnar-positive deformities can occur with distal radius fractures that heal with radial shortening, distal radial growth arrest, and Essex-Lopresti and Galeazzi fractures. Deformities can also occur following a radial head excision, due to congenital causes of ulnar-positive variance such as Madelung’s deformity, or due to a premature closure of the distal radius growth plate and following a wrist fusion. Ulnar impaction may also be dynamic and even occur in patients with an ulnar neutral or negative variance during power grip in the pronated position.6 Friedman

CHAPTER 5  |  Ulnocarpal Impaction Syndrome and Ulnar Styloid Impaction Syndrome  51 T

TFCC tented

A

B FIGURE 5.1 Arthroscopic view of tenting up of the triangular fibrocartilage complex (TFCC) in a patient with an ulnarpositive variance. T, triquetrum. et al. noted that a maximum grip effort resulted in an average increase in ulnar variance of 1.95 cm in asymptomatic volunteers. This is because of the approximate 1.95 cm of radial shortening that occurs as the radius rotates across the ulna during pronation which leads to a dynamic impingement.7 In Palmer’s classification, degenerative TFCC tears are subdivided into five categories: Type IIA: wearing of the TFCC without perforation or chondromalacia. Type IIB: wearing of the TFCC with chondromalacia of the lunate or ulna. Type IIC: true perforation of the TFCC with lunate chondromalacia. Type IID: TFCC perforation plus lunate and/or ulnar chondromalacia and lunotriquetral interosseous ligament (LTIL) tears without carpal instability. Type IIE: TFCC perforation with an LTIL tear and ulnocarpal arthritis.

Diagnosis Patients with UCI syndrome present with chronic ulnarsided wrist pain that may be increased by power grip, ulnar wrist deviation, and/or forearm rotation. They may complain

of intermittent clicking localized to the ulnar carpus and postactivity swelling, decreased strength, and a loss of wrist and forearm motion. They may experience tenderness over the fovea and possibly the triquetrum and ulnar head. Passive and active ulnar deviation produces pain. The ulnocarpal stress test diagnoses UCI syndrome and is performed by applying axial stress to a maximally ulnar-deviated wrist during pronation and supination. Ulnar styloid triquetral impingement (USTI) occurs in supination and may be confused with UCI (discussed later). Extensor carpi ulnaris (ECU) tendonitis may mimic USTI. The ECU synergy test8 was found to be highly specific and exploits an isometric contraction of the ECU during resisted radial abduction of the thumb with the wrist in neutral position and the forearm supinated. Recreation of pain along the dorsal ulnar aspect of the wrist is considered to be a positive test result for ECU tendonitis. Diagnostic local anesthetic injections may also help identify the pain generator. Standard wrist radiographs are obtained to assess for arthritis involving the carpus and distal radioulnar joint (DRUJ) and to measure the ulnar variance. When evaluating ulnar-sided wrist pathology, a zero rotation PA view is essential. This is performed with the shoulder abducted 90 degrees, the elbow flexed 90 degrees, and the wrist in neutral. Because ulnar variance is dynamic, stress PA views can help. A pronated grip view may reproduce a dynamic increase in the ulnar variance.6 Osteoarthritis changes such as joint space narrowing, sclerosis, and cystic changes or osteophytes can be seen along the ulnocarpal joint. MRI is the method of choice for diagnosing UCI syndrome.9 Degenerative tears of the TFCC may be seen as well as focal cartilage defects. Magnetic resonance with intravenous contrast is better for visualizing bone marrow pathology. Marrow edema typically affects the ulnar aspect of the lunate, with or without involvement of the radial aspect of the triquetrum and ulnar head. Subchondral cystic changes appear as low signal intensity on T1-weighted images and high signal intensity on T2-weighted images (Fig. 5.3).10 If sclerosis is present, low signal intensity on both T1- and T2-weighted images will be seen. A measurement of the ulnar variance using MRI is, however, not accurate because it is difficult to obtain a true anatomic position in the magnet gantry. MR arthrography can be performed by injecting gadolinium in the DRUJ to detect TFCC tears. A dedicated 23-mm wrist coil and 3.0 T magnet can improve the accuracy. One study found that the presence of MRI signs of UCI is a predictor of a good outcome following an arthroscopic wafer resection.11

Arthroscopic Wafer Resection Wnorowski et al.12 examined the biomechanical effects of an arthroscopic wafer resection in 9 ulnar-positive cadaver forearms. Each specimen was evaluated biomechanically using axial load cells and pressure-sensitive film to evaluate the effect of serial resection of the TFCC and distal ulna on axial load and ulnar carpal pressures. There was a statistically

52  SECTION I I  |  Ulnocarpal Joint

B LT

A

* * 4–5

C

TFCC

D

E

* *

FIGURE 5.2 Ulnocarpal Impaction.  (A) AP view demonstrating a bone cyst (arrow) along the proximal medial aspect of the lunate. (B) View from the 4,5 portal of a central triangular fibrocartilage complex (TFCC) tear with exposure of the ulnar head (arrow). (C) Elevator is placed underneath a lunotriquetral (LT) ligament tear. Note the fibrillated cartilage on the proximal lunate (arrow). (D) View from the 4,5 portal of an area of exposed subchondral bone (asterisk) with a full thickness cartilage tear long the proximal aspect of the lunate. (E) Debrided TFCC tear exposing an area of chondromalacia (asterisk) on the ulnar head. significant unloading of the ulnar aspect of the wrist after excision of the centrum of the TFCC and resection of the radial two-thirds width of the ulnar head to a depth of subchondral bone resection.

Indications Wrist arthroscopy and an ulnar shortening procedure is indicated in the patient with a neutral-to-positive ulnar variance and persistent ulnar-sided wrist pain despite conservative treatment with splints and NSAIDs 6 selected cortisone injections. The aim is to unload the ulnocarpal joint, either

through an ulnar shortening osteotomy or wafer resection of the ulnar head. In a biomechanical study, excision of 3 mm of subcondylar bone decreased the force transmitted across the ulnar head by 50%; further bone resection did little to decrease this force further.12 The goal is to resect sufficient ulna to produce a 2-mm negative-ulnar variance. An arthroscopically assisted ulnar shortening has the advantage of being less invasive and is not associated with complications associated with plate fixation of an osteotomy such as nonunion and the need for subsequent plate removal. Symptomatic incomplete TFCC tears (Palmer type IIA, IIB) are treated with debridement. The role of an ulnar

CHAPTER 5  |  Ulnocarpal Impaction Syndrome and Ulnar Styloid Impaction Syndrome  53

shortening or wafer resection does not address any LT or ulnocarpal ligament instability. In these cases, consideration can be given to performing an ulnar-shortening osteotomy, which has been shown to tighten the ulnocarpal ligaments experimentally and may aid in stabilizing the LT   joint (Video 5-1). T S

L

FIGURE 5.3 T2-weighted MRI showing an area of increased signal intensity of the proximal medial pole of the lunate (arrow). L, Lunate; S, scaphoid; T, triquetrum.

shortening procedure in this group is unsettled. Osterman and Terrill13 have recommended an ulnar shortening procedure in these patients. Tomaino and Elfar,14 on the other hand, have reported good results by creating a central defect in the intact articular disk followed by an arthroscopic wafer resection. A wafer resection through the DRUJ portals is another option. Patients with a complete TFCC tear (Palmer type IIC, IID) and a dynamic/static ulnar-positive variance are treated with debridement and an ulnar shortening procedure. Any associated LTIL tears are debrided if the LT joint is stable. If the LT joint is unstable it can be pinned for 6 to 8 weeks. Some authors recommend an open ulnar shortening, as this has been shown to tighten the ulnocarpal ligaments in a cadaver model,15 which may stabilize the LT joint. However, Iwatsuki et al.16 showed that the degree of the LT joint instability does not appear to affect the clinical outcomes. In a study on ulnar shortening osteotomy (USO), a second-look arthroscopy was performed in 25 patients with an LTIL tear (group A) compared with 25 patients without a tear (group B). Of the 25 wrists in group B, 11 wrists improved based on the Geissler grade, 9 wrists showed no changes, and 2 wrists became worse. Clinically, the patients demonstrated improvement after USO regardless of the degree of degenerative LT ligament changes.

Contraindications The limit for an arthroscopic wafer is 4 mm.17 If .4 mm of shortening is required an open ulnar shortening should be performed. Patients with significant ulnocarpal and/or distal   radioulnar joint OA (Video 4-7) (Palmer type IIE) are better suited for an excisional arthroplasty or ulnar head implant. Instability of the DRUJ must be treated before an ulnar shortening procedure. An arthroscopic ulnar

Surgical Technique—Arthroscopic Wafer Resection   (Video 5-2) After an initial arthroscopic radiocarpal and midcarpal survey, the scope is placed in the 4,5 portal. The 6R and 6U portals are used for instrumentation although it is useful to assess the completeness of ulnar head resection with the scope in the 6U portal. The volar ulnar (VU) portal may also be used for viewing while the burr is placed in the 4,5 or 6R dorsal portals, as this increases the space for triangulation of the instruments. Rapid irrigation clears the debris. The edges of the TFCC tear are debrided back to stable margins. A 2.9-mm burr is then used in a back-and-forth motion to resect 2 to 3 mm of the ulnar head (Fig. 5.4A–F). The diameter of the burr can be used to gauge the amount of bony resection, but this should also be checked fluoroscopically. The arm must be pronated and supinated to avoid leaving a shelf of bone. Care must be taken to avoid injury to the deep foveal insertion of the TFCC and the sigmoid notch. The LTIL is evaluated from the 6R portal and any tears are debrided. Midcarpal arthroscopy is used to assess the degree of LT joint instability. A Geissler grade III instability can be treated with LT joint pinning for 6 weeks, although this approach has been recently challenged.16 Any small areas of chondromalacia on the proximal lunate or triquetrum are observed. If there is full-thickness cartilage defect of 1 cm however, microfracture with a 0.045-mm K-wire can be performed in an attempt to stimulate fibrocartilage formation. A wafer resection can also be performed through the DRUJ portals when the TFCC is still intact (Palmer type IIA, IIB).18 When performed with a TFCC tear (Palmer type IIC) this allows for a more conservative TFCC debridement because the ulnar head resection is performed underneath   the TFCC tear and not through it (Video 5-3). The DRUJ wafer resection also facilitates preservation of the volar and dorsal RULs and the foveal attachment of the deep RUL   (Video 5-4). Postoperatively the patient is placed in a below-elbow splint for 4 weeks and started on protected range of motion including pronation and supination.

Alternative Procedures Yin et al.19 published a technique for an arthroscopic distal metaphyseal USO for ulnar impaction. This is based on the open technique for an osteochondral shortening osteotomy of the distal ulna as described by Slade and Gillon.20 A triangle “ABC” is drawn on the dorsal skin over the ulnar head, which depicts the osteotomy (Fig. 5.5A–C). Line AB is 3 mm proximal to the ulnar dome. Point A is just 1 mm in from the ulnar cortex. Line BC is the amount to be shortened (arrow). The amount of shortening can be calculated by the angle

54  SECTION I I  |  Ulnocarpal Joint

TFCC

UH

A

B

* * **

D

C

TFCC

E

F FIGURE 5.4 (A) AP view of a patient with ulnocarpal impaction (UCI) and an ulnarpositive variance. (B) View from the 4,5 portal of a central triangular fibrocartilage complex (TFCC) tear with exposure of the ulnar head (UH). (C) After a partial ulnar head resection demonstrating exposed bleeding along the subchondral bone (arrow) and a rim of articular cartilage (asterisk). (D) View from the volar distal radioulnar joint (DRUJ) portal with the burr removing a shelf of bone (asterisk) from the medial aspect of the ulnar head. (E) The TFCC tear is decompressed following the wafer resection (arrow). (F) AP radiograph view demonstrating an ulnar-minus variance.

CHAPTER 5  |  Ulnocarpal Impaction Syndrome and Ulnar Styloid Impaction Syndrome  55

the bone between the two K-wires while keeping the ulnar part of the cortex intact. The three K-wires are removed and the greenstick osteotomy is then closed by pressing on the dome of the ulnar head with a mosquito forceps in the distal DRUJ portal. A 1.2-mm screw introducer wire is drilled via the distal DRUJ portal, which is proximal to the TFCC, to fix the dome directed at a palmar and proximal direction. Therefore the TFCC is not perforated. A cannulated headless compression screw is used to maintain compression. The distal aspect of the screw engages but does not perforate the ulnar cortex. An above-elbow cast is applied for 4 weeks followed by mobilization.

Outcomes

FIGURE 5.5 (A) A triangle “ABC” is drawn to outline the osteotomy. (B) The bone is removed from between lines A and B and the osteotomy is closed. (C) The osteotomy site is held with a headless cannulated screw. Note the negative ulnar variance. CAB. Generally, if the angle is 15 degrees, the amount of shortening will be about 4 mm. Three K-wires are inserted percutaneously into the ulna according to the triangle that marks the borders of the osteotomy under fluoroscopic control. The arthroscope is then placed in the proximal DRUJ portal and the K-wires are identified. A 1.9-mm motorized burr inserted via the distal DRUJ portal is used to remove

Meftah et al.11 reviewed 26 patients with a mean age of 38.5 years (range 18–59 yr), from 1998 to 2005, with ulnar impaction syndrome who failed nonoperative treatments. Variables included patients’ age, history of previous wrist fracture, presence of MRI signs, and ulnar variance. Outcome measures were patients’ postoperative strength (compared with the contralateral wrist) and amount of pain relief. Twenty-two patients (84.6%) had either good or excellent pain relief (median 4, range 1–4). Significant correlation was found between MRI findings and postoperative pain relief (r 5 0.53, p , or 5 0.01). History of previous distal radius fractures was negatively correlated with pain relief (r 5 -0.50, p , or 5 0.01). No correlation was found between postoperative strength and any of the variables. Presence of MRI signs of UCI was a predictor of good outcome in arthroscopic wafer resection. The debate over whether to perform an arthroscopic wafer resection or an open USO rages on. In a study by Bernstein et al.,21 patients with ulnar impaction syndrome treated with arthroscopic TFCC debridement and arthroscopic wafer resections (11 patients) were compared with patients who were treated with arthroscopic TFCC debridement and an open USO (16 patients). At mean follow-up times of 21 and 15 months, respectively, 9 out of 11 patients showed good-to-excellent results after arthroscopic treatment compared with 11 out of 16 following an open USO. The authors concluded that a combined arthroscopic TFCC debridement and wafer procedure provides similar pain relief and restoration of function with fewer secondary procedures compared with an open USO. Vandenberghe et al.22 had similar conclusions. They reviewed the outcomes in 28 patients who underwent a USO compared with 12 patients who underwent an arthroscopic wafer resection. At a mean follow-up of 29 months (range, 7–60 mo) the mean DASH score in the ulnar shortening group improved from 40 to 26 (SD 5 18.3) (p ,.0.01) with the MMWS results of 11 excellent, 10 good, 6 fair, and 1 poor, and a mean VAS of 4.4 (SD 1.9). In the wafer group the mean DASH score was 34 (SD 5 19.4) (p ,.0.01) with the MMWS results of 4 excellent, 4 good, 4 fair, and a mean VAS of 4.6 (SD 5 2.65). Of significance was that 27 secondary procedures were required in 21 patients in the USO group, and there were 3 nonunions. The time off work was 7 months (range, 0.5–30 mo) in the USO group and 6.1 months (range, 0–26 mo) in the wafer group (p ,0.001).

56  SECTION I I  |  Ulnocarpal Joint

Ulnar Styloid Impaction Syndrome Relevant Anatomy and Etiology Ulnar styloid impaction (USI) syndrome is characterized by the impaction of the triquetrum against the ulnar styloid causing chondromalacia, synovitis, and ulnar-sided wrist pain. Anatomically, the tip of the ulnar styloid is covered by the meniscus homologue. When an excessively long ulnar styloid abuts against the triquetrum, in the presence of an intact anatomy, the meniscus homologue will be interposed between the tip of the ulnar styloid and the triquetrum. Therefore in the early stages when the TFCC is intact, a soft tissue impingement rather than bone-to-bone impaction is in effect with flexion and ulnar deviation of the wrist.23 Such a mechanism of impingement occurs with prolonged typing. USI occurs when the TFCC has eroded and exposes the tip of the ulnar styloid, which is in direct contact with the triquetrum. In full pronation, the volar aspect of the triquetrum faces the tip of the ulnar styloid. In full supination, the dorsal aspect of the triquetrum faces the tip of the ulnar styloid. Flexion and ulnar deviation of the wrist only

increases the distance between the triquetrum and the ulnar styloid; therefore in the supinated wrist, the impingement can only occur with wrist extension and ulnar deviation. Biyani et al.24 studied the x-rays of 400 patients without wrist symptoms and described 5 morphological variants, the most common being an elongated ulnar styloid process. They defined a standard ulnar styloid process to be 3 to 6 mm in length with a medial angulation not exceeding 15 degrees. Giachino et al.25 reviewed the x-rays of 1000 patients without bony trauma and found that the ulnar styloid length, measured from the base of the ulnar styloid to the tip in a line parallel with the long axis of the ulna, ranged from 0.0 to 14.8 mm with a mean of 6.31 mm (SD 5 1.82 mm). They identified 56 patients with USI and classified the etiologies as follows: 1. Impaction of the triquetrum by a long ulnar styloid. This occurs with a congenitally long ulnar styloid process, or distal radial growth arrest and Madelung’s deformity. USI can also occur from styloid overgrowth from a nonunion (Fig. 5.6A–K). 2. Impaction of the triquetrum on the ulnar styloid. This impaction occurs when the carpus moves proximally as in collapse of the proximal carpal row; the radius moves proximally as in distal radius malunions with a loss of

FIGURE 5.6 53-Year-Old Male with Ulnar Styloid Impingement.  (A) Ulnar styloid im-

pingement (USI) (white arrow) and preexisting early distal radioulnar joint (DRUJ) osteoarthritis (OA) (black arrow) plus a nonunion of the ulnar styloid tip. (B) Coronal CT scan shows preservation of the ulnocarpal joint space but a small osteophyte (arrow). (C) View from the 3,4 portal of a long flap tear of the triangular fibrocartilage complex (TFCC). T, Triquetrum. (D) Elevation of the triangular fibrocartilage complex (TFCC) tear reveals the ulnar head (UH). (E) The scope is advanced into the DRUJ to demonstrate an unstable flap of articular cartilage (arrow) which is separated off from the ulnar head (UH). The deep radioulnar ligament (RUL) is still firmly attached. (F) A wafer resection of the ulnar head is performed.

CHAPTER 5  |  Ulnocarpal Impaction Syndrome and Ulnar Styloid Impaction Syndrome  57

FIGURE 5.6, cont’d (G) The ulnar styloid is localized with a 22-gauge needle fluoroscopically. (H) The needle (arrow) is visualized from the 3,4 portal as it pierces the ulnar capsule overlying the tip of the ulnar styloid. (I) Position of the burr is checked fluoroscopically and arthroscopically. (J) The ulnar styloid is resected percutaneously. (K) Completion of a wafer resection and ulnar styloidectomy. radial length; the carpus ulnarly translocates; or the hand-wrist-radius complex moves ulnarly as one intact unit, which occurs after full or partial ulnar head excision. This can also occur following a wrist fusion and Kienböck disease. 3. Dynamic styloid impaction based on ligamentous laxity, instability, or loading activities such as racquet sports and golf. 4. A combination of the above.

Diagnosis USI occurs in supination because the carpus and radius rotate around the ulnar head, which moves the ulnar styloid radially and therefore closer to the triquetrum. The patient with symptomatic USI will typically complain of ulnarsided wrist pain, aggravated by wrist extension and certain positions, such as having their hands on their hips or in their back pockets; by movements like repetitively turned pages; or by positions that force the lower hand in the “slap-shot” position in ice hockey. There may be a history of trauma to the distal radius or ulna, prior wrist surgery to the carpus, or generalized ligamentous laxity. On examination, there is point tenderness to palpation of the ulnar styloid tip. Typically, pain is increased by direct palpation precisely over the tip of the ulnar styloid. The pain is deep and volar to the ECU tendon. USI may be confused

with UCI, which also presents as ulnar-sided pain. UCI is a consequence of ulnar head and lunate impaction. The pain is ulnar and dorsal, and increased by local palpation over the proximal ulnar aspect of the lunate. The tenderness is not over the ulnar styloid. UCI and USI may both be present. When seen on a lateral radiograph, the carpus is volar to the styloid. Wrist dorsiflexion brings the triquetrum closer to the styloid and can cause impingement. Topper et al.23 described a provocative test, which consists of wrist dorsiflexion and pronation followed by rotation of the forearm into full supination whilst maintaining dorsiflexion. Radiographic signs suggestive of USI include ulnar styloid sclerosis, growth, flattening, small “kissing” cysts, and occasionally loose bodies. A bone scan may show increased uptake about the styloid process. An MRI can show focal subchondral sclerosis and chondromalacia of the styloid tip and proximal triquetrum.

Treatment Non-operative treatment includes the use of NSAIDs, therapy, splinting, and corticosteroid injections. Operative management varies. In the presence of a long ulnar styloid an excision of the ulnar styloid suffices. When USI is the result of a combination of factors and when more than one diagnosis is present, the surgical treatment varies, and a simple excision of the ulnar styloid is no longer the only procedure necessary.

58  SECTION I I  |  Ulnocarpal Joint

Arthroscopic-Assisted Ulnar Styloid Excision Technique Bain and Bidwell26 have described an arthroscopic-assisted technique for an ulnar styloid excision in stylocarpal impaction, in which the long ulnar styloid affects the triquetrum. This can be combined with an arthroscopic wafer   resection (Video 5-5). With the arthroscope in the 3,4 portal, a 22-gauge needle is introduced into the 6U portal. This is then substituted by a 3.5-mm burr. The burr is placed onto the tip of the ulnar styloid, which is confirmed fluoroscopically. The resection is then done percutaneously until sufficient ulnar styloid has been removed to prevent impingement (Fig. 5.6A–K). In cases with a longstanding hypertrophic ulnar styloid non-union associated with an unstable DRUJ, a combination of an open styloidectomy and arthroscopic assisted repair can be useful.

recent meta-analysis of six studies involving 365 patients that compared the outcomes after distal radius fractures with a united versus a nonunited ulnar styloid process found no relation between the nonunion of the ulnar styloid process and function.27 Although ulnar styloid fractures are a common feature of the distal radius fracture pattern, symptomatic nonunions of the ulnar styloid are found in a minority of these injuries. They may occur in isolation or be associated with a TFCC tear. In this case it is uncertain whether the nonunion or the TFCC is the cause of pain. Similarly, it is unknown whether resecting the nonunion or repairing the TFCC or both are responsible for any pain relief. In these cases it is my preference to scope the DRUJ and evaluate the attachment of the deep RUL (Fig. 5.8).

Outcomes No reported series exist of an arthroscopic-assisted resection of the ulnar styloid. Topper et al.23 reported good results in seven out of eight patients following an open ulnar styloid excision and that the VAS pain score decreased from a preoperative average score of 3.5 to a postoperative score of 1.3. Zahiri et al. treated five patients with USI due to a long ulnar styloid with an ulnar styloidectomy. All five patients had complete relief of their wrist pain by 10 to 16 weeks after surgery. The patients remained symptomfree at a mean follow-up of 36 months.

Ulnar Styloid Nonunions An ulnar styloid nonunion occasionally results in symptomatic ulnar styloid impingement (Fig. 5.7A–B). A

A

FIGURE 5.8 Arthroscopic view from the volar distal radioulnar joint (DRUJ) portal of an intact deep radioulnar ligament (RUL) in a patient with an ulnar styloid nonunion. The conjoined palmar radioulnar ligament (PRUL), dorsal radioulnar ligament (DRUL), and ulnar collateral (UC) ligament are well attached to the ulnar head (UH).

B FIGURE 5.7 (A) AP radiograph view of impingement between the triquetrum and a nonunited ulnar styloid fragment (arrow). (B) Note the impingement with the triquetrum during ulnar deviation (arrow).

CHAPTER 5  |  Ulnocarpal Impaction Syndrome and Ulnar Styloid Impaction Syndrome  59

Reeves28 reviewed 197 patients with a prior distal radius fracture. He found that 7 of 12 patients with persistent wrist pain had radiographic evidence of an ulnar styloid nonunion. Four of the 7 patients had relief of their pain with excision of the ulnar styloid nonunion. Burgess and Watson29 reported on 9 patients with chronic ulnar-sided wrist pain and radiographic evidence of a hypertrophic ulnar styloid nonunion. All of the patients were treated with a subperiosteal excision of the nonunion fragment. This procedure relieved the localized pain without changing either radiocarpal or distal radioulnar joint stability. Hauck et al.30 classified type 1 as a nonunion associated with a stable DRUJ. Type 2 was defined as a nonunion associated with subluxation of the DRUJ. Eleven type 1 wrists were treated with excision.

Protopsaltis and Ruch31 reported on 8 patients (6 with a prior history of a distal radius fracture) with symptomatic ulnar styloid nonunions and TFCC tears who improved following an arthroscopic TFCC repair and open excision of the ulnar styloid fragment (Fig. 5.9A–F). The time from injury to surgery ranged from 8 to 120 months. Diagnostic arthroscopy demonstrated two consistent findings in all 8 patients. First, all of the patients were found to have avulsion of the ulnar margin of the TFCC from the extensor carpi ulnaris subsheath (ECUS). Second, there was a fullthickness chondral injury on the dorsum of the triquetrum. They then performed an arthroscopic-assisted repair using an outside-in technique, and placed three 2-0 absorbable sutures percutaneously to repair the peripheral margin of the avulsed articular disk to the capsule and the ECUS.

FIGURE 5.9 Ulnar Styloid Nonunion with Distal Radioulnar Joint Instability.  (A) A 39-year-old female with a symptomatic ulnar styloid nonunion and volar distal radioulnar joint (DRUJ) instability. (B) Radiocarpal view demonstrating a normalappearing triangular fibrocartilage complex (TFCC), but the hook test was positive. (C) DRUJ arthroscopy through the volar DRUJ portal demonstrates an empty fovea sign with an absence of the deep radioulnar ligament (RUL) attachment (asterisk). DC, Dorsal capsule; UH, ulnar head. (D) Arthroscopic-assisted foveal reattachment. Continued

60  SECTION I I  |  Ulnocarpal Joint

FIGURE 5.9, cont’d (E) Fluoroscopic view of the bone anchor and suture placement

using 18-gauge needles after an open excision of the nonunited ulnar styloid. (F) View of the TFCC reattachment with a horizontal mattress suture.

After placement of the sutures, the ulnar styloid fragment was dissected subperiosteally through a 1-cm incision and excised (Fig. 5.10A–F). The TFCC repair sutures were tied down to the capsule and retinaculum. The wrist was immobilized in 60 degrees of supination with a custommolded orthosis for 4 weeks followed by range of motion. A final follow-up evaluation of 7 out of 8 patients was conducted at an average of 23 months (range, 11–28 mo). The

mean postoperative DASH score was 3.69 (SD 5 9.68), which was a statistically significant improvement (p ,.05) over the mean preoperative DASH score of 32.3 (SD 5 11.5). The pain rating defined by the VAS improved from a preoperative mean of 6.14 (SD 5 1.49) to a postoperative mean of 1.0 (SD 5 0.83), a difference that was statistically significant (p ,.05). No patient had instability of the DRUJ at the time of the last office visit.

FIGURE 5.10 (A) Ulnar styloid nonunion (forceps). (B) Arthroscopic view demonstrating a triangular fibrocartilage complex (TFCC) tear with exposure of the ulnar head (arrow).

CHAPTER 5  |  Ulnocarpal Impaction Syndrome and Ulnar Styloid Impaction Syndrome  61

FIGURE 5.10, cont’d (C) Insertion of an absorbable suture. (D) Following suture repair of the TFCC tear. (E) Traction on the suture closes the TFCC tear. (F) AP view after an open resection of the nonunited styloid.

References 1. Palmer AK, Glisson RR, Werner FW. Relationship between ulnar variance and triangular fibrocartilage complex thickness. J Hand Surg Am. 1984 Sep;9(5):681-682. 2. Hara T, Horii E, An KN, Cooney WP, Linscheid RL, Chao EY. Force distribution across wrist joint: application of pressure-sensitive conductive rubber. J Hand Surg Am. 1992 Mar;17(2):339-347. 3. Werner FW, Glisson RR, Murphy DJ, Palmer AK. Force transmission through the distal radioulnar carpal joint: effect of ulnar lengthening and shortening. Handchir Mikrochir Plast Chir. 1986 Sep;18(5):304-308. 4. Mikic ZD. Age changes in the triangular fibrocartilage of the wrist joint. J Anat. 1978 Jun;126(Pt 2):367-384. 5. Viegas SF, Ballantyne G. Attritional lesions of the wrist joint. J Hand Surg Am. 1987 Nov;12(6):1025-1029.

6. Tomaino MM. Ulnar impaction syndrome in the ulnar negative and neutral wrist. Diagnosis and pathoanatomy. J Hand Surg Br. 1998 Dec;23(6):754-757. 7. Friedman SL, Palmer AK, Short WH, Levinsohn EM, Halperin LS. The change in ulnar variance with grip. J Hand Surg Am. 1993 Jul;18(4):713-716. 8. Ruland RT, Hogan CJ. The ECU synergy test: an aid to diagnose ECU tendonitis. J Hand Surg Am. 2008 Dec; 33(10):1777-1782. doi:10.1016/j.jhsa.2008.08.018. 9. Steinborn M, Schurmann M, Staebler A, Wizgall I, Pellengahr C, et al. MR imaging of ulnocarpal impaction after fracture of the distal radius. AJR Am J Roentgenol. 2003 Jul;181(1):195-198. doi:10.2214/ajr.181.1.1810195. 10. Cerezal L, del Pinal F, Abascal F. MR imaging findings in ulnar-sided wrist impaction syndromes. Magn Reson Imaging Clin N Am. 2004 May;12(2):281-299, vi. doi:10.1016/j.mric. 2004.02.005.

62  SECTION I I  |  Ulnocarpal Joint 11. Meftah M, Keefer EP, Panagopoulos G, Yang SS. Arthroscopic wafer resection for ulnar impaction syndrome: prediction of outcomes. Hand Surg. 2010;15(2):89-93. doi:10.1142/ S0218810410004631. 12. Wnorowski DC, Palmer AK, Werner FW, Fortino MD. Anatomic and biomechanical analysis of the arthroscopic wafer procedure. Arthroscopy. 1992;8(2):204-212. 13. Osterman AL, Seidman GD. The role of arthroscopy in the treatment of lunatotriquetral ligament injuries. Hand Clin. 1995 Feb;11(1):41-50. 14. Tomaino MM, Elfar J. Ulnar impaction syndrome. Hand Clin. 2005 Nov;21(4):567-575. doi:10.1016/j.hcl.2005.08.011. 15. Gupta R, Bingenheimer E, Fornalski S, McGarry MH, Osterman AL, et al. The effect of ulnar shortening on lunate and triquetrum motion—a cadaveric study. Clin Biomech. 2005 Oct;20(8):839-845. doi:10.1016/j.clinbiomech.2005.05.009. 16. Iwatsuki K, Tatebe M, Yamamoto M, Shinohara T, Nakamura R, et al. Ulnar impaction syndrome: incidence of lunotriquetral ligament degeneration and outcome of ulnar-shortening osteotomy. J Hand Surg Am. 2014 Jun;39(6):1108-1113. doi:10.1016/j.jhsa.2014.03.006. 17. Markolf KL, Tejwani SG, Benhaim P. Effects of wafer resection and hemiresection from the distal ulna on load-sharing at the wrist: a cadaveric study. J Hand Surg Am. 2005 Mar;30(2):351-358. doi:10.1016/j.jhsa.2004.11.013. 18. Slutsky DJ. Distal radioulnar joint arthroscopy and the volar ulnar portal. Tech Hand Up Extrem Surg. 2007 Mar;11(1): 38-44. 19. Yin HW, Qiu YQ, Shen YD, Xu JG, Gu YD, et al. Arthroscopic distal metaphyseal ulnar shortening osteotomy for ulnar impaction syndrome: a different technique. J Hand Surg Am. 2013 Nov;38(11):2257-2262. doi:10.1016/j.jhsa.2013.08.108. 20. Slade JF, 3rd; Gillon TJ. Osteochondral shortening osteotomy for the treatment of ulnar impaction syndrome: a new technique. Tech Hand Up Extrem Surg. 2007 Mar;11(1):74-82. 21. Bernstein MA, Nagle DJ, Martinez A, Stogin JM, Jr., Wiedrich TA. A comparison of combined arthroscopic

triangular fibrocartilage complex debridement and arthroscopic wafer distal ulna resection versus arthroscopic triangular fibrocartilage complex debridement and ulnar shortening osteotomy for ulnocarpal abutment syndrome. Arthroscopy. 2004 Apr;20(4):392-401. doi:10.1016/j.arthro.2004.01.013. 22. Vandenberghe L, Degreef I, Didden K, Moermans A, Koorneef P, et al. Ulnar shortening or arthroscopic wafer resection for ulnar impaction syndrome. Acta Orthop Belg. 2012 Jun;78(3):323-326. 23. Topper SM, Wood MB, Ruby LK. Ulnar styloid impaction syndrome. J Hand Surg Am. 1997 Jul;22(4):699-704. doi: 10.1016/S0363-5023(97)80131-1. 24. Biyani A, Mehara A, Bhan S. Morphological variations of the ulnar styloid process. J Hand Surg Br. 1990 Aug;15(3): 352-354. 25. Giachino AA, McIntyre AI, Guy KJ, Conway AF. Ulnar styloid triquetral impaction. Hand Surg. 2007;12(2):123-134. doi:10.1142/S0218810407003456. 26. Bain GI, Bidwell TA. Arthroscopic excision of ulnar styloid in stylocarpal impaction. Arthroscopy. 2006 Jun;22(6):677, e1-3. doi:10.1016/j.arthro.2006.04.083. 27. Wijffels MM, Keizer J, Buijze GA, Zenke Y, Krijnen P, et al. Ulnar styloid process nonunion and outcome in patients with a distal radius fracture: a meta-analysis of comparative clinical trials. Injury. 2014 Dec;45(12):1889-1895. doi:10.1016/j.injury. 2014.08.007. 28. Reeves B. Excision of the ulnar styloid fragment after Colles’ fracture. Int Surg. 1966 Jan;45(1):46-52. 29. Burgess RC, Watson HK. Hypertrophic ulnar styloid nonunions. Clin Orthop Relat Res. 1988 Mar;(228):215-217. 30. Hauck RM; Skahen J, 3rd; Palmer AK. Classification and treatment of ulnar styloid nonunion. J Hand Surg Am. 1996 May;21(3):418-422. doi:10.1016/S0363-5023(96)80355-8. 31. Protopsaltis TS, Ruch DS. Triangular fibrocartilage complex tears associated with symptomatic ulnar styloid nonunions. J Hand Surg Am. 2010 Aug;35(8):1251-1255. doi:10.1016/ j.jhsa.2010.05.010.

C Ganglion

S

VRM

A H

*

*

C

*

S

VR

B

DIC

L

A H

C

S

**

B

C

MCR

VRM

S

RSL

**

A

S

B

FCR

C

CHAPTER

18

Arthroscopic Radial Styloidectomy Pathophysiology An isolated tear of the scapholunate interosseous ligament (SLIL) changes carpal loading and kinematics even without demonstrable radiographic abnormalities. It can lead to attenuation of the secondary stabilizers and progressive dissociation and rotation of the scaphoid and the lunate. With axial loading over time, the capitate migrates proximally, further driving the scaphoid and lunate apart like a wedge. This results in midcarpal instability, loss of carpal height, and changes in the radiocarpal, intercarpal, and midcarpal joint contact areas and loads. These lead to a predictable scapholunate advanced collapse (SLAC) arthritis as described by Watson et al.1 This begins with radial styloid beaking and radial styloid-scaphoid joint narrowing (stage 1), then progresses proximally to alter the radial scaphoid facet proximal pole scaphoid articulation (stage 2), and finally to the midcarpal capitolunate joint (stage 3). A stage 4 was described recently, which includes the addition of radiolunate osteoarthritis (OA) or pancarpal OA.2 Vender et al.3 noted that a longstanding scaphoid nonunion leads to a similar sequence of arthritic degeneration known as scaphoid nonunion advanced collapse (SNAC)   (Video 18-1). It differs, however, in that the articulation between the proximal scaphoid fragment and radius is spared from arthritic changes. The distal scaphoid fragment is no longer attached to the dorsal intercarpal (DIC) ligament, which allows it to fall into flexion, which causes incongruity between the distal scaphoid fragment and the corresponding articular surface of the radius. The site of initial degenerative change is between the radius and distal scaphoid fragment (stage 1), which stops at the site of nonunion. Narrowing of the lunocapitate joint (stage 2)

occurs next, and with advanced midcarpal arthritis, narrowing of the capitate-distal scaphoid fragment (stage 3) occurs. The proximal radius scaphoid fragment and radiolunate joints remain normal, even with severe arthritis. These joints are preserved because both are spherical in nature, allowing perpendicular cartilage loading in all positions, and because the proximal scaphoid fragment is still attached to the lunate via an intact SL ligament. In a study of 104 scaphoid nonunions, Inoue et al.4 noted a prevalence of arthritis in 22% of cases if the nonunion was 1 to 5 years old, 75% of cases in nonunions that were 5 to 9 years old, and 100% of cases in nonunions that were 10 years old or more. Osteoarthritic changes occurred initially at the scaphoid–radial styloid joint, which were manifested by radial styloid pointing and/or dorsal radioscaphoid osteophyte formation, later progressing to the midcarpal joint. OA at the scaphoid–radial styloid joint was significantly associated with a dorsal intercalated segmental instability (DISI) deformity. The overall incidence of DISI deformity of the wrist was 56%, and the frequency of DISI pattern increased with a longer duration of nonunion. There was no correlation between symptoms of pain and the severity of arthritis or the duration of nonunion, but there was a good correlation between the duration of nonunion and reduced grip strength or decreased wrist motion. Nakamura et al.5 categorized scaphoid nonunions into 2 types based on 3-D CT scans: a volar type, in which the distal fragment overlaps the proximal fragment volarly; and a dorsal type, in which the distal fragment overlaps the proximal fragment dorsally. Moritiomo et al.6 demonstrated that the fracture location of a scaphoid nonunion relates to the fracture displacement, development of DISI deformity, and changes in the 189

190  SECTION V  |  Arthritis and Degenerative Disorders contact area of the bones in the radiocarpal joint. Eleven patients with scaphoid nonunions were examined with 3-D CT scans. Two patterns of displacement of scaphoid nonunions were demonstrated: 1 volar and 1 dorsal. In the volar type, the distal fragment was displaced volarly relative to the proximal fragment and became close to the radial styloid with the proximal fragment extended, resulting in a humpback deformity. All patients with a volar-type scaphoid nonunion had a DISI deformity. Only a few of the patients with a dorsal-type scaphoid nonunion, mostly in longstanding nonunions, had a DISI deformity. The fracture line was generally distal to the dorsal apex of the ridge of the scaphoid in the volar-type fractures and proximal in the dorsaltype fractures. The location of the dorsal apex of the ridge of the scaphoid coincides with the location of the attachment of the proximal part of the DIC ligament, which is just distal to the attachment of the dorsal component of the SLIL. These ligaments, along with the dorsal radiocarpal ligament (DRCL), probably afford indirect dorsal stability of the scaphoid. In the volar-type scaphoid nonunion, the fracture line is distal to the attachment of the DIC ligament and the dorsal component of the SLIL, which may affect the stability of the distal fragment. This could explain why the proximal pole extends and the distal pole flexes, resulting in a DISI deformity in the volar-type scaphoid nonunion. In the dorsal-type scaphoid nonunion, the ligamentous attachments remain on the distal fragment, which may offer some additional stability or ability for the distal fragment to resist flexion forces. In the cases with a longstanding scaphoid nonunion, however, even the dorsal-type scaphoid nonunion can develop a DISI deformity with degenerative changes at the articulation between the proximal fragment of the scaphoid and the capitate. They also looked at the proximity map, which is the visual representation of the distance from one bone to the nearest neighboring bone and gives a qualitative assessment of the inferred

contact area between the bones. In the volar-type scaphoid nonunion, the proximity map of the distal fragment of the scaphoid on the radius shifted radially compared with a normal wrist, placing it closer to the radial styloid. They called this the styloid pattern (Fig. 18.1A–C). In the dorsaltype scaphoid nonunion, the proximity map of the distal fragment of the scaphoid on the radius shifted dorsally compared with a normal wrist, placing it closer to the dorsal lip of the scaphoid fossa of the radius. They called this the dorsal lip pattern. Oka et al. studied the wrist kinematics in 13 patients with scaphoid nonunions during wrist flexion-extension and radioulnar deviation.7 Two clear patterns of interfragmentary motion of the scaphoid emerged based on the fracture location. In the mobile-type scaphoid nonunion (7 cases), the fracture was located distal to the apex of the scaphoid dorsal ridge and the distal scaphoid was unstable relative to the proximal scaphoid. The distal fragment showed a “bookopening” motion from wrist flexion to extension. In the stable-type scaphoid nonunion (6 cases), the fracture was located proximal to the scaphoid apex, and the interfragmentary motion was considerably less than with the distal type. In the displaced distal scaphoid fractures, the proximal fragment of the scaphoid, lunate, and triquetrum rotated into extension and supination. The distal fragment of the scaphoid and capitate translated dorsally without notable rotation. Most distal scaphoid nonunions had a DISI deformity pattern, whereas this occurred in only 1 case of a proximal fracture.

Diagnosis The diagnosis of SLAC or SNAC wrist arthritis is made by history, physical examination, and radiographs. The wrist examination often reveals a joint effusion, dorsal-radial

FIGURE 18.1 Styloid Pattern of Impingement.  (A) Distal scaphoid nonunion with

radial styloid impingement (arrow). (B) CT scan demonstrating the hypertrophic distal pole (arrow). (C) Lateral CT scan of the nonunion site (white arrow) with volar subluxation of the distal fragment (gray arrow).

CHAPTER 18  |  Arthroscopic Radial Styloidectomy  191

wrist swelling, and tenderness over the radioscaphoid joint. There may or may not be a positive scaphoid shift test. Chronic synovitis over the snuffbox may be misdiagnosed as a ganglion cyst. Wrist motion may be decreased, depending on the stage of degeneration. The definitive diagnosis is made radiographically. Standard posteroanterior, oblique, and lateral views should be performed. Marked changes as seen in SLAC and SNAC are easily identified. An AP grip view and radioulnar deviation views can magnify any SL diastasis. An MRI and/or CT scan may be useful to evaluate any midcarpal joint changes and DISI deformity, and to determine whether there is a styloid pattern or dorsal lip pattern of impingement.

Scaphoid

RSC

LRL

Probe

Radius

Treatment Symptomatic treatment with splints, modalities, and selected cortisone injections may provide symptomatic relief. A radial styloidectomy is most attractive to patients who wish for minimal surgical intervention, but it does not address the underlying cause and therefore may not be a long-term solution. Recommendations for the amount of bony resection have become more conservative with time due to several biomechanical studies that demonstrated increasing radial instability with the progressive loss of the volar radiocarpal ligaments.

Indications The indications for an arthroscopic radial styloidectomy are similar to the open procedure. Radial styloid impingement due to radioscaphoid arthritis is a common indication. This is often a consequence of longstanding SL dissociation or end-stage Kienbock disease. Patients who have painful radial deviation and a positive Watson test but have preserved wrist motion and good grip strength are ideal candidates. Chronic scaphoid nonunion is another common indication, where the hypertrophic distal scaphoid fragment impinges against the radial styloid during radial deviation. If an attempt is made to internally fix the scaphoid, this impingement must be addressed. Resection of the distal scaphoid fragment will obviate the need for a radial styloidectomy. Secondary radial styloid impingement is a common sequela of a scaphotrapeziotrapezoidal (STT) fusion when it is used to treat rotary subluxation of the scaphoid or scaphotrapezial (ST) OA. Watson observed this in more than one-third of his patients and now recommends a radial styloidectomy at the time of STT fusion.8 Impingement may also occur following a capitolunate fusion, which should be checked for at the time of surgery. Occasionally a limited styloidectomy is performed at the time of a proximal row carpectomy for treatment of radiocarpal OA.

Contraindications The main risk following a radial styloidectomy is ulnar translocation of the carpus. Siegal and Gelberman9 showed

FIGURE 18.2 Traumatic avulsion of radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments. View is from the 4,5 portal; probe is in the 3,4 portal.

that short oblique osteotomies were the least destructive, whereas vertical oblique and horizontal osteotomies removed 92% to 95% of the radioscaphocapitate (RSC) ligament and 21% to 46% of the long radiolunate (LRL) ligament. Nakamura et al.10 emphasized the importance of the RSC and LRL ligaments in preventing ulnar translocation. If too much of these ligaments are removed, the capitate is destabilized so that it no longer rests in the lunate fossa, resulting in radial instability. Biomechanical testing revealed a significant increase in radial translation under loading when 6 mm is removed or when the radial styloid was excised. Some specimens demonstrated moderate-to-severe palmar and ulnar translation. They recommended limiting the bony resection to no more than 4 mm to minimize this risk. Patients who do not have an intact RSC ligament due to distal radius fracture (DRF), or a radiocarpal dislocation (Fig. 18.2) with or without a fracture, are at risk for volar dislocation and/or ulnar translocation and are not candidates for this procedure, especially if a proximal row carpectomy is contemplated.11 Ulnar translocation is a frequent sequela of longstanding rheumatoid disease, hence any patient with chronic wrist involvement is a poor candidate for this procedure.

Equipment A 2.7-mm 30-degree angled scope along with a camera attachment is used. A 2.9-mm burr and/or a 4.0-mm abrader are integral to the procedure. A small osteotome may also be useful. The use of a motorized shaver is needed for debridement. Some type of diathermy unit may be useful as well as arthroscopic straight and curved knives for lysis of adhesions. Intraoperative fluoroscopy is employed to assess the adequacy of bone resection.

192  SECTION V  |  Arthritis and Degenerative Disorders

Surgical Technique An attempt should be made to determine whether a DISI deformity exists and whether a styloid pattern or dorsal lip pattern of impingement is present. This is one procedure where the 1,2 portal is particularly helpful. The patient is positioned supine on the operating table with the arm extended on a hand table. The fingers are suspended by Chinese finger traps with 10 to 15 pounds of countertraction. The relevant landmarks in the snuffbox are palpated and outlined including the distal edge of the radial styloid; and the abductor pollicis longus (APL), extensor pollicis brevis (EPB), and extensor pollicis longus (EPL) tendons; and the radial artery in the snuffbox (Fig. 18.3A–C). A tourniquet is elevated to 250 mm Hg. To minimize the risk of injury to branches of the superficial radial nerve (SRN) and the radial artery, the 1,2 portal

should be placed more palmar and proximal in the snuffbox.12 The entry site is outlined no more than 4.5 mm dorsal to the first extensor compartment and within 4.5 mm of the radial styloid. A 22-gauge needle is used to identify the joint space, followed by a small superficial skin incision. The tissue is spread down to the capsule, which is pierced by tenotomy scissors. A cannula and blunt trocar are inserted with the wrist in ulnar deviation to minimize damage to the proximal scaphoid, followed by a 3-mm hook probe   (Video 18-2). A 3,4 working portal is established in a similar fashion. I use the volar radial (VR) portal interchangeably with the 3,4 portal for viewing and instrumentation to gain complete access to the dorsoradial aspect of the styloid, especially when there is a dorsal lip pattern of   impingement (Fig. 18.4A–F) (Video 18-3). A large bore outflow cannula in the 4,5 or 6U portal is desirable, but intermittent irrigation and suction through the resector can

1,2 portal EPL

SR1 SR2

EPL S

1,2 portal

SR3

S APL EPB

RS

EPL

ECRL/B

A

ECRL/B

C

B

FIGURE 18.3 (A) Cadaver dissection of portal anatomy. APL, Abductor pollicis longus;

EPB, extensor pollicis brevis; EPL, extensor pollicis longus; SR1-3, superficial radial nerve branches. (B) Surface landmarks for the 1,2 portal. ECRL/B, Extensor carpi radialis longus/brevis; RS, radial styloid; S, scaphoid. (C) Superimposed field of view.

* *

Preop

Scaphoid

Scaphoid

VR portal

* Impingement

A

B

Radial styloid

RS

* * C

FIGURE 18.4 (A) Preoperative radiograph of chronic scapholunate (SL) dissociation

with stage 1 SL advanced collapse (SLAC). Note the radiocarpal narrowing. (B) View from the 1,2 portal with the probe introduced through the volar radial (VR) portal. Note the loss of cartilage (asterisk). (C) Probe is used to explore the bare area on the scaphoid.

CHAPTER 18  |  Arthroscopic Radial Styloidectomy  193 Postop 1,2 portal

Radial styloid

D

E

F

Styloidectomy

FIGURE 18.4, cont’d (D) An abrader is introduced through the 1,2 portal as seen from the VR portal. (E) View midway through the styloidectomy. (F) After the arthroscopic styloidectomy with no further impingement of the scaphoid and radial styloid.

be substituted. A standard radiocarpal and midcarpal survey are performed, with debridement and synovectomy as necessary. With the arthroscope in the 3,4 portal, the origins of the RSC and LRL ligaments on the distal radius are noted, which mark the ulnar extent of the resection. The diameter of the burr will give a rough guide as to the amount of bony resection, but this needs to be confirmed fluoroscopically. Various authors recommend from 4 mm to 7 mm of resection. The degree of bony resection should, however, be tailored to the individual and gauged at the time of surgery. Enough bone should be resected so that there is no residual

impingement between the scaphoid and the radial styloid when the wrist is radially deviated with the traction released. A small osteotome should be used judiciously because inadvertent penetration of the radial joint capsule carries the risk of radial artery perforation as it traverses the snuffbox. The   technique is identical for a SNAC wrist (Video 18-4). In this case, the VR portal is especially useful if there is a dorsal lip pattern of impingement. (Fig. 18.5A–K). Postoperatively, the patient is placed in a removable below-elbow splint for comfort, and protected wrist motion is instituted after the first week. Gradual strengthening

10°

A

B

C

D

FIGURE 18.5 Dorsal Lip Scaphoid Nonunion.  (A) Scaphoid nonunion with a hypertrophic distal pole impinging against a large osteophyte on the radial styloid (arrows). (B) CT scan demonstrating the site of impingement (arrows). (C) Lateral CT scan demonstrating a normal radiolunate angle of 10 degrees. (D) Lateral CT scan showing a dorsal lip impingement along with dorsal displacement of the distal fragment (black arrow). Continued

194  SECTION V  |  Arthritis and Degenerative Disorders S

RSC

E

F

G

H

I

J

K FIGURE 18.5, cont’d (E) View from the 3,4 portal demonstrating the synovitis obscuring

the bare area over the radial styloid (white arrow) and the chondromalacia on the scaphoid (red arrow). (F) View of the origins of the radioscaphocapitate (RSC) ligament. S, Scaphoid. (G) View from the volar radial (VR) portal of a resector in the 1,2 portal. (H) View from the 3,4 portal of a burr in the 1,2 portal. (I) Exposure of cancellous bone during the styloidectomy. (J) View of the completed styloidectomy under fluid irrigation. (K) Postoperative radiograph demonstrating the decompression of the radial styloid-scaphoid impingement (arrow).

exercises are added as tolerated by the third or fourth week. The direst complication is ulnar translocation due to excessive resection of the radial styloid and radiocarpal ligaments (Fig. 18.6). The SRN and radial artery are perpetually at risk with use of the 1,2 portal.

Outcomes An open radial styloidectomy has been employed for over 50 years. Despite this, there are no series on an isolated styloidectomy for SNAC or SLAC wrist. Arthroscopic

techniques are more recent. Because it is often used in combination with other procedures, reports of isolated radial styloidectomies are also scant. Herness and Posner13 reported improved wrist motion in 26 out of 41 patients with arthritic changes who underwent a radial styloidectomy in addition to bone grafting scaphoid nonunion. Stark et al. found that if there was moderate radiocarpal arthritis in patients with scaphoid nonunions who underwent K-wire fixation and bone grafting, progression seldom was seen if a radial styloidectomy was done. The principal benefit of the procedure was relief of pain rather than an increase either in motion of the wrist or grip strength.14

CHAPTER 18  |  Arthroscopic Radial Styloidectomy  195

A

B

FIGURE 18.6 (A) Early follow-up radiograph demonstrates normal carpal alignment

with no evidence of ulnar translocation. (B) Normal scapholunate (SL) angle with no evidence of a dorsal intercalated segmental instability (DISI) deformity.

References 1. Watson H, Ottoni L, Pitts EC, et al. Rotary subluxation of the scaphoid: a spectrum of instability. J Hand Surg. 1993;18: 62-64. 2. Weiss KE, Rodner CM. Osteoarthritis of the wrist. J Hand Surg. 2007;32:725-746. 3. Vender MI, Watson HK, Wiener BD, et al. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg. 1987;12:514-519. 4. Inoue G, Sakuma M. The natural history of scaphoid nonunion. Radiographical and clinical analysis in 102 cases. Arch Orthop Trauma Surg. 1996;115:1-4. 5. Nakamura R, Horii E, Tanaka Y, et al. Three-dimensional CT imaging for wrist disorders. J Hand Surg. 1989;14:53-58. 6. Moritomo H, Viegas SF, Elder KW, et al. Scaphoid nonunions: a 3-dimensional analysis of patterns of deformity. J Hand Surg. 2000;25:520-528. 7. Oka K, Moritomo H, Murase T, et al. Patterns of carpal deformity in scaphoid nonunion: a 3-dimensional and quantitative analysis. J Hand Surg. 2005;30:1136-1144. 8. Rogers WD, Watson HK. Radial styloid impingement after triscaphe arthrodesis. J Hand Surg. 1989;14:297-301.

9. Siegel DB, Gelberman RH. Radial styloidectomy: an anatomical study with special reference to radiocarpal intracapsular ligamentous morphology. J Hand Surg. 1991;16:40-44. 10. Nakamura T, Cooney WP 3rd, Lui WH, et al. Radial styloidectomy: a biomechanical study on stability of the wrist joint. J Hand Surg. 2001;26:85-93. 11. Van Kooten EO, Coster E, Segers MJ, et al. Early proximal row carpectomy after severe carpal trauma. Injury. 2005; 36:1226-1232. 12. Steinberg BD, Plancher KD, Idler RS. Percutaneous Kirschner wire fixation through the snuff box: an anatomic study. J Hand Surg. 1995;20:57-62. 13. Herness D, Posner MA. Some aspects of bone grafting for non-union of the carpal navicular. Analysis of 41 cases. Acta Orthopaedica Scandinavica. 1977;48:373-378. 14. Stark HH, Rickard TA, Zemel NP, et al. Treatment of ununited fractures of the scaphoid by iliac bone grafts and Kirschner-wire fixation. J Bone Joint Surg Am Vol. 1988;70: 982-991.

CHAPTER

19

Arthroscopic Partial Scaphoidectomy for Scaphoid Nonunion An arthroscopic resection of the distal scaphoid fragment can be regarded as a temporizing procedure for a chronic scaphoid waist nonunion or distal pole nonunion. It can relieve pain by alleviating the mechanical impingement between the hypertrophic distal pole and the radial styloid. It is especially indicated when the cartilage degeneration, osteophyte formation, and deformity are confined mainly to the radial styloid. It allows early wrist motion and does not burn any bridges with regards to more definitive salvage procedures.

Relevant Anatomy and Pathomechanics A number of factors predispose toward a nonunion. Because of the scaphoid’s narrow waist section where the trabeculae are thinnest and are more sparsely distributed,1 fracture site displacement decreases the bony contact area for union. Any waist fracture with displacement of greater than 1 mm or angulation of greater than 15 degrees may lead to a nonunion if left untreated. Because the scaphoid is largely covered by cartilage, any fracture heals by intramembranous ossification, so there is no fracture callus to provide any initial stability. Premature wrist loading results in bending, shearing, and translating forces, which cause progressive flexion and pronation of the distal pole. Inadequate fracture site immobilization may lead to volar bone resorption as a response to the continued loading, which may culminate in a nonunion with a secondary humpback deformity.2 Displacement of the fracture is a strong risk factor for delayed or failed union. 196

Singh et al.3 performed a meta-analysis of 1401 scaphoids and showed that displaced fractures of the scaphoid have a four times higher risk of nonunion than undisplaced fractures when treated in a plaster cast. Vender et al.4 noted that a longstanding scaphoid nonunion leads to a sequence of arthritic degeneration known as scaphoid nonunion advanced collapse (SNAC). It differs from that seen with chronic scapholunate (SL) dissociation in that the articulation between the proximal scaphoid fragment and radius is spared from arthritic changes. The distal scaphoid fragment is no longer attached to the dorsal intercarpal (DIC) ligament, which allows it to fall into flexion, which causes incongruity between the distal scaphoid fragment and the corresponding articular surface of the radius. The site of initial degenerative change is between the radius and distal scaphoid fragment (stage 1), which stops at the site of nonunion. Narrowing of the lunocapitate joint (stage 2) occurs next and with advanced midcarpal arthritis, narrowing of the capitate–distal scaphoid fragment (stage 3) occurs. The radius–proximal scaphoid fragment and radiolunate joints remain normal, even with severe arthritis. These joints are preserved because both are spherical in nature, allowing perpendicular cartilage loading in all positions and because the proximal scaphoid fragment is still attached to the lunate via an intact SL ligament. In a study of 104 scaphoid nonunions, Inoue et al.5 noted a prevalence of arthritis in 22% of cases if the nonunion was 1 to 5 years old, 75% of cases in nonunions that were 5 to 9 years old, and 100% of cases in nonunions that were 10 years old or more. Osteoarthritic changes occurred initially at the scaphoid–radial styloid joint, which were manifested by radial styloid pointing and/or dorsal radioscaphoid osteophyte formation, later progressing to the

CHAPTER 19  |  Arthroscopic Partial Scaphoidectomy for Scaphoid Nonunion  197

midcarpal joint. Osteoarthritis at the scaphoid–radial styloid joint was significantly associated with a dorsal intercalated segmental instability (DISI) deformity. The overall incidence of DISI deformity of the wrist was 56%, and the frequency of a DISI pattern increased with a longer duration of nonunion. There was no correlation between symptoms of pain and the severity of arthritis or the duration of nonunion, but there was a good correlation between the duration of nonunion and reduced grip strength or decreased wrist motion. Nakamura et al.6 categorized scaphoid nonunions into 2 types based on 3-D CT scans: a volar type, in which the distal fragment overlaps the proximal fragment volarly; and a dorsal type, in which the distal fragment overlaps the proximal fragment dorsally. Moritomo et al.7 demonstrated that the fracture location of a scaphoid nonunion relates to the fracture displacement, development of DISI deformity, and changes in the contact area of the bones in the radiocarpal joint. Eleven patients with scaphoid nonunions were examined with 3-D CT scans. Two patterns of displacement of scaphoid nonunions were demonstrated, 1 volar and 1 dorsal. In the volar type, the distal fragment was displaced volarly relative to the proximal fragment and became close to the radial styloid with the proximal fragment extended, resulting in a humpback deformity. All patients with a volar-type pattern scaphoid nonunion had a DISI deformity. Only a few of the patients with a dorsal-type pattern scaphoid nonunion, mostly in longstanding nonunions, had a DISI deformity. The fracture line was generally distal to the dorsal apex of the ridge of the scaphoid in the volar-type fractures and proximal in the dorsal displaced fractures. The location of the dorsal apex of the ridge of the scaphoid coincides with the location of the attachment of the proximal part of the DIC ligament, which is just distal to the attachment of the dorsal component of the SLIL. These ligaments, along with the dorsal radiocarpal

ligament (DRCL), probably afford indirect dorsal stability of the scaphoid. In the volar-type scaphoid nonunion, the fracture line is distal to the attachment of the DIC ligament and the dorsal component of the SLIL, which may affect the stability of the distal fragment. This could explain why the proximal pole extends and the distal pole flexes, resulting in a DISI deformity in the volar-type of scaphoid nonunion. In the dorsal-type scaphoid nonunion, the ligamentous attachments remain on the distal fragment, which may offer some additional stability or ability for the distal fragment to resist flexion forces. In the cases with a longstanding scaphoid nonunion, however, even the dorsal-type scaphoid nonunion can develop a DISI deformity with degenerative changes at the articulation between the proximal fragment of the scaphoid and the capitate. They also looked at the proximity map, which is the visual representation of the distance from one bone to the nearest neighboring bone and gives a qualitative assessment of the inferred contact area between the bones. In the volar-type scaphoid nonunion, the proximity map of the distal fragment of the scaphoid on the radius shifted radially compared with a normal wrist, placing it closer to the radial styloid. They called this the styloid pattern (Fig. 19.1A–D). In the dorsal-type scaphoid nonunion, the proximity map of the distal fragment of the scaphoid on the radius shifted dorsally compared with a normal wrist, placing it closer to the dorsal lip of the scaphoid fossa of the radius. They called this the dorsal lip pattern of proximity map (Fig. 19.2A–D). Oka et al. studied the wrist kinematics in 13 patients with scaphoid nonunions during wrist flexion-extension and radioulnar deviation.8 Two clear patterns of interfragmentary motion of the scaphoid emerged based on the fracture location. In the mobile type scaphoid nonunion

5

A

B FIGURE 19.1 Styloid Type of Nonunion.  Volar-type scaphoid nonunion. mal radiolunate angle.

Nor

-

Continued

198  SECTION V  |  Arthritis and Degenerative Disorders

C

D FIGURE 19.1, cont'd AP CT scan illustrating the hypertrophic distal fragment (arrow). Lateral CT scan demonstrating the nonunion site (white arrow) with volar subluxation of the distal fragment (gray arrow).

10°

A

B

C

D

FIGURE 19.2 Dorsal Lip Scaphoid Nonunion.  Scaphoid nonunion with a hypertrophic distal pole impinging against a large osteophyte on the radial styloid (arrows). AP CT scan highlighting the impingement site (arrows). Lateral CT scan demonstrating a normal scapholunate angle of 10 degrees. Lateral CT scan showing a dorsal lip impingement along with dorsal displacement of the distal fragment. (7 cases), the fracture was located distal to the apex of the scaphoid dorsal ridge and the distal scaphoid was unstable relative to the proximal scaphoid. The distal fragment showed a “book-opening” motion from wrist flexion to extension. In the stable-type scaphoid nonunion (6 cases), the fracture was located proximal to the scaphoid apex, and the interfragmentary motion was considerably less than with the distal type. In the displaced distal scaphoid fractures, the proximal fragment of the scaphoid, lunate, and triquetrum rotated into extension and supination. The distal fragment of the scaphoid and capitate translated dorsally without notable rotation. Most distal scaphoid nonunions had a DISI deformity pattern, whereas this occurred in only 1 case of a proximal fracture.

Diagnosis The diagnosis of a scaphoid nonunion is made by history, physical examination, and wrist radiographs. The typical patient complains of radial-sided wrist pain at rest that is exacerbated by radial deviation and by wrist extension, or with rotation and torque. The wrist examination may reveal dorsal-radial wrist swelling, tenderness over the radioscaphoid joint, and a painful scaphoid shift test. Wrist motion may be decreased, depending on the stage of degeneration. The definitive diagnosis is made radiographically. Standard posteroanterior (PA), 45-degree pronation and 45-degree supination oblique views, and a true lateral view are performed. A PA view in radial deviation extends the scaphoid and allows a

CHAPTER 19  |  Arthroscopic Partial Scaphoidectomy for Scaphoid Nonunion  199

better assessment of the nonunion site and degree of instability. The marked changes of an advanced SNAC wrist are easily identified. An MRI and/or CT scan may be useful to evaluate any midcarpal joint changes and DISI deformity as well as to determine whether there is a styloid pattern or dorsal lip pattern of impingement.

Treatment Nonoperative treatment consists of a thumb spica splint, NSAIDs, and activity modification. Activity modification consists of avoiding forceful gripping, torqueing, and heavy lifting. Corticosteroid injections may provide temporary relief. Surgical treatment is indicated after a failure to respond to conservative measures. Management options

A

C

7 yrs

include internal fixation and bone grafting of the scaphoid nonunion 6 a limited radial styloidectomy versus a distal scaphoid resection and early wrist mobilization.

Indications An arthroscopic distal scaphoid excision for a scaphoid nonunion is indicated in the patient with SNAC stage I with a longstanding nonunion of the waist or distal pole who does not wish to undergo internal fixation and grafting, especially in the face of previously failed surgery. The procedure can be   performed either as an open (Fig. 19.3A–D) (Video 19-1) or arthroscopic procedure according to surgeon preference. In selected cases this can be done as a temporizing procedure in the older patient who does not wish to undergo a formal   salvage procedure (Video 19-2).

B

D FIGURE 19.3 Longstanding scaphoid nonunion at 7 years postoperatively with mi gration of a scaphoid screw and no significant radial styloid osteoarthritis (OA). Lateral view demonstrates no dorsal intercalated segment instability (DISI) deformity. Open resection of distal fragment with screw removal. Postoperative radiograph.

-

200  SECTION V  |  Arthritis and Degenerative Disorders

Contraindications Advanced degenerative changes involving the entire scaphoid fossa or the capitolunate joint are contraindications to this procedure. An intact SL ligament and RSC ligament are prerequisites to the procedure to minimize the risk of a DISI deformity. Because of the increased midcarpal loads following a distal scaphoid resection, the procedure is relatively contraindicated when there is a DISI deformity due to the risk of an increased painful subluxation of the capitate.9 This procedure is not effective as an isolated procedure with a small proximal pole nonunion due to the global carpal instability that occurs following a scaphoidectomy, which mandates a midcarpal fusion.

STT-U

A

Surgical Technique The patient is positioned supine under general anesthesia with the arm abducted to 90 degrees. The thumb is suspended by finger traps from a wrist traction tower with 10 pounds of countertraction. Intraoperative fluoroscopy is employed to assess the adequacy of bone resection and for locating the portals as needed. An arthroscopic distal scaphoidectomy is performed through the midcarpal joint under tourniquet control. With the arthroscope introduced in the midcarpal ulnar (MCU) portal, a 2.5-mm shaver is inserted into the midcarpal radial (MCR) portal and used to debride the nonunion site. The scaphotrapeziotrapezoidal (STT) joint can be accessed through a number of portals. The MCR portal is found 1 cm distal to the 3,4 portal in line with the index metacarpal. The STT joint lies radially and can be seen by rotating the scope dorsally. The scaphotrapeziotrapezoidal-ulnar (STT-U) portal is located in line with the midshaft axis of the index metacarpal, just ulnar to the extensor pollicis longus (EPL) and radial to the insertion of the extensor carpi radialis brevis (ECRB) tendon into the base of the index metacarpal, at the level of the STT joint. Entry into this portal is facilitated by traction on the index finger. Leaving the EPL to the radial side of the STT portal protects the radial artery in the snuffbox from injury. The scaphotrapeziotrapezoidal-radial (STT-R) portal is radial to the abductor pollicis longus (APL) tendon at the level of the STT joint. The scaphotrapeziotrapezoidal-palmar (STT-P) portal is midway between the radial styloid and the base of the first metacarpal, 3 mm ulnar to the APL tendon and 6 mm radial to the scaphoid tubercle. The trocar is inserted into the STT joint aiming toward the base of the fifth metacarpal while holding the thumb in extension and adduction (Fig. 19.4A–C). A 2.9-mm arthroscopic burr and then a 3.5-mm arthroscopic burr are inserted into the MCR or STT-U portal and used to resect the distal scaphoid fragment starting at the nonunion site and moving toward the distal tubercle until the articular surfaces of the trapezoid and trapezium can be seen (Fig. 19.5A–B). This can be done using a dry technique with intermittent fluid irrigation and suction through the burr to remove the debris. To protect the adjacent chondral surfaces, the cancellous bone of the fragment

STT-P

STT-R

B T

S

C FIGURE 19.4 STT Portals.  View of the scope in the scaphotrapeziotrapezoidal-ulnar (STT-U) portal. Relative position of the scaphotrapeziotrapezoidal-palmar (STT-P) and STT-R portals. View from the STT-U portal with a resector in the STT-P portal. Note the marked loss of cartilage with exposed subchondral bone on the trapezium (T) and the distal scaphoid (S). can be resected from the inside while preserving the outer cartilage shell, which can then be removed piecemeal with arthroscopic forceps or a small rongeur by enlarging the portals, as described by Del Pinal et al.10 Fluoroscopy is used to monitor the completeness of resection (Fig. 19.6A–C).

CHAPTER 19  |  Arthroscopic Partial Scaphoidectomy for Scaphoid Nonunion  201

* * *

** *

A

B FIGURE 19.5 Distal scaphoid fragment at the nonunion site (asterisk) as seen from the midcarpal radial (MCR) portal. Partial resection of the distal fragment with exposed subchondral bone (asterisk).

A

B

* * FIGURE 19.6 Fluoroscopy with the scope in the

C

scaphotrapeziotrapezoidal (STT) portal and the burr in the midcarpal radial (MCR) portal. Following a distal scaphoid resection with the scope in the MCR portal and the burr in the STT portal. Following resection of the distal scaphoid (asterisk).

202  SECTION V  |  Arthritis and Degenerative Disorders

A

20

B FIGURE 19.7 Postoperative AP view of the wrist at 1 year postoperatively. Increased radiolunate angle.

An arthroscopic radial styloidectomy can be added if residual impingement is noted.

Complications The development of a dorsal midcarpal instability may lead to persistent wrist pain due to painful dorsal subluxation of the capitate (Fig. 19.7A–B).

Outcomes There are few reports of an arthroscopic styloidectomy. Ruch et al.11 described a technique of treating scaphoid nonunions with associated avascular necrosis (AVN) in 3 patients consisting of an arthroscopic resection of the distal pole of the scaphoid combined with a radial styloidectomy. The results at a 2-year follow-up showed all 3 patients to have complete relief of their mechanical pain, improvement

in their range of motion, and high satisfaction with the procedure. The Modified Mayo Wrist Scores (MMWS) were a mean preoperatively of 60 and postoperatively of 88. Postoperative radiographs showed no increase in the SL gap. The capitolunate angle, however, increased from a mean of 3 degrees to 13 degrees. There was no progression of degenerative changes noted. Ruch et al. also reported the outcomes of an open resection in 13 patients with a persistent scaphoid nonunion after previous unsuccessful surgical treatment.12 They performed an initial arthroscopic survey to assess the degree of cartilage loss and debrided any partial SL ligament tears. This was followed by an open resection of the distal scaphoid pole. Eleven patients achieved complete pain relief and 2 patients had mild pain only during strenuous activity. The mean wrist flexion improved by 23 degrees and extension increased by 29 degrees. The postoperative DASH score was 25 6 19 points. A significant increase in the radiolunate angle was reported, indicative of a DISI deformity in 6 patients. Soejima et al.13 treated 9 patients with an open distal scaphoid resection through a palmar Russe for a chronic scaphoid nonunion. The average patient age was 45.2 years (range, 23–68 yr). Seven of the 9 patients had undergone a mean of 2 previously failed attempts at bone grafting and internal fixation (range, 1–4 times). The average period from the initial injury to surgery was 94.3 months (range, 5–372 mo). Radiographically, 6 patients had distal pole radioscaphoid arthritis (SNAC stage I) and 6 patients also showed capitolunate arthritis (SNAC stage III). Preoperatively, 7 out of 9 patients reported pain with daily use and 2 patients reported mild pain with light work. At an average follow-up of 28.6 months (range, 12–52 mo), 4 patients had no wrist pain and 5 patients had only mild pain with strenuous activity. The composite wrist flexion/extension range of motion improved from 70 degrees (51.4% of the opposite wrist) to 140 degrees (94% of the opposite wrist). Grip strength improved from 18 kg (40% of the opposite wrist) to 30 kg (77% of the opposite wrist). The MMWS improved from 32 6 16 points before surgery (fair results in 2 patients and poor results in 7 patients) to 90 6 7 points after surgery (excellent results in 6 patients and good results in 3 patients), which was statistically significant (p , .0001). Radiographically, there was no progression of OA in 8 patients. RSC OA developed in 1 patient with a type II lunate. The radiolunate angle increased from −26 degrees 6 12 degrees to −27 degrees 6 12 degrees.

References 1. Bindra R, Bednar M, Light T. Volar wedge grafting for scaphoid nonunion with collapse. J Hand Surg. 2008;33:974-979. 2. Geissler WB, Slade JF. Fractures of the Carpal Bones. In: Wolfe SW, Hotchikis RN, Pederson, WC, et al., eds. Green’s operative hand surgery. 6th ed. Philadelphia, PA: Elsevier; 2011:639-708. 3. Singh HP, Taub N, Dias JJ. Management of displaced fractures of the waist of the scaphoid: meta-analyses of comparative studies. Injury. 2012;43:933-939.

CHAPTER 19  |  Arthroscopic Partial Scaphoidectomy for Scaphoid Nonunion  203 4. Vender MI, Watson HK, Wiener BD, et al. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg. 1987;12:514-519. 5. Inoue G, Sakuma M. The natural history of scaphoid nonunion. Radiographical and clinical analysis in 102 cases. Arch Orthop Trauma Surg. 1996;115:1-4. 6. Nakamura R, Horii E, Tanaka Y, et al. Three-dimensional CT imaging for wrist disorders. J Hand Surg. 1989;14:53-58. 7. Moritomo H, Viegas SF, Elder KW, et al. Scaphoid nonunions: a 3-dimensional analysis of patterns of deformity. J Hand Surg. 2000;25:520-528. 8. Oka K, Moritomo H, Murase T, et al. Patterns of carpal deformity in scaphoid nonunion: a 3-dimensional and quantitative analysis. J Hand Surg. 2005;30:1136-1144. 9. Malerich MM, Clifford J, Eaton B, et al. Distal scaphoid resection arthroplasty for the treatment of degenerative

arthritis secondary to scaphoid nonunion. J Hand Surg Am. 1999;24:1196-1205. 10. Del Pinal F, Klausmeyer M, Thams C, et al. Early experience with (dry) arthroscopic 4-corner arthrodesis: from a 4-hour operation to a tourniquet time. J Hand Surg. 2012;37: 2389-2399. 11. Ruch DS, Chang DS, Poehling GG. The arthroscopic treatment of avascular necrosis of the proximal pole following scaphoid nonunion. Arthroscopy. 1998;14:747-752. 12. Ruch DS, Papadonikolakis A. Resection of the scaphoid distal pole for symptomatic scaphoid nonunion after failed previous surgical treatment. J Hand Surg. 2006;31:588-593. 13. Soejima O, Iida H, Hanamura T, et al. Resection of the distal pole of the scaphoid for scaphoid nonunion with radioscaphoid and intercarpal arthritis. J Hand Surg. 2003; 28:591-596.

CHAPTER

20

Arthroscopic Partial Wrist Fusions Introduction The most common indications for a partial wrist fusion include scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) patterns. Other conditions include Kienböck disease, radiocarpal joint arthrosis secondary to a malunited distal radius fracture (DRF), and scaphotrapeziotrapezoidal (STT) osteoarthritis (OA). The pathophysiology of these conditions has been discussed in previous chapters. A variety of partial wrist fusions can be performed depending on the specific pathology and the joints that are involved. Chronic painful carpal instabilities with or without secondary degenerative changes are additional indications, including palmar midcarpal instability (PMCI) and ulnar translocation. There is a steep learning curve for performing these types of procedures arthroscopically with operative times of up to 4 hours. This is partly due to the lack of dedicated arthroscopic instrumentation needed for carpal bone resection. Miniarthrotomy incisions can help reduce the tourniquet time significantly by allowing the use of rongeurs for removal of carpal bone remnants. Fixation is typically performed using percutaneous headless screws and/or K-wires, which requires postoperative cast immobilization in many cases. Contraindications include conditions that preclude reduction of carpal malalignment such as severe arthrofibrosis, joint contractures, longstanding carpal collapse deformities, and sepsis.

Instrumentation and Methodology Every type of fusion has common features that require a similar setup. A 2.7-mm 30-degree angled arthroscope with 204

a camera attachment, traction tower, arthroscopic burrs ranging from 3.0 mm to 3.5 mm, a 4-mm shoulder abrader, 2.0-mm and 2.5-mm full-radius resectors, and a variety of arthroscopic forceps, small curettes, and straight and angled rongeurs. A diathermy probe may also be of use for debridement. A K-wire driver and 3.0-mm and 3.5-mm headless cannulated screws are requisite. Bone graft substitutes including cancellous allograft and demineralized bone matrix should be available. A minifluoroscopy unit or C-arm is integral to the procedure. The patient is positioned supine on the operating table with the arm abducted 90 degrees on an arm table and suspended in a traction tower with 10 to 15 pounds of traction. Either general anesthesia and/or a regional block are used due to the long operative times. A tourniquet is placed on the upper arm and inflated to 250 mm Hg. It is useful to start the procedure under portal site local anesthesia as described by Ong et al.,1 using 0.25% bupivacaine hydrochloride injection and 1:200,000 units of epinephrine to conserve the tourniquet time. The procedure can be alternated between saline irrigation using a pressure bag or pump, and dry arthroscopy as described by Del Pinal et al.2 Rather than using an outflow portal, it is my preference to use intermittent fluid irrigation through the arthroscope while using the full-radius resector and/or arthroscopic burr for intermittent suction. Debridement is simpler and faster without fluid irrigation to prevent the synovial fronds and fibrous tissue from floating in front of the arthroscope and obstructing the view. Similarly, any residual articular cartilage can be removed with intermittent irrigation. Fluid irrigation is often needed during the bony resection to keep down the joint temperature and to clear the debris. A quick joint survey can be performed using the standard dorsal portals including the 3,4, 4,5, midcarpal radial (MCR), and midcarpal ulnar (MCU) portals. Special-use

CHAPTER 20  |  Arthroscopic Partial Wrist Fusions  205

portals are used as an aid to bony resection and can include the STT, the triquetrohamate (TH), the volar radial (VR) and volar ulnar (VU), and the volar central portals. The specific articular surfaces that are to be fused are then decorticated using a 2.9-mm arthroscopic burr. It is easier to decorticate the articulations that will be fused before performing any carpal bone resection, because the distorted anatomy and residual carpal instability make this step more difficult. Any residual articular cartilage is removed and the subchondral bone is resected to a bleeding cancellous surface while maintaining the joint congruity. Next the carpal deformity is corrected using K-wires as joysticks and the fusion site is provisionally held with K-wires. The cancellous autograft or bone graft substitute is then inserted through a 4- to 5-mm arthroscopic cannula in the appropriate portal and used to fill any voids. If the final fixation is performed using headless cannulated screws, the traction is released before screw insertion.

Arthroscopic-Assisted Capitolunate Fusion and Scaphoidectomy Indications A capitolunate (CL) fusion is indicated in symptomatic patients with stage 2 or 3 SLAC or SNAC wrist who have failed nonoperative treatment with splinting, activity modification, and antiinflammatory medication. It can also be performed without a scaphoidectomy for symptomatic PMCI.

Contraindications A CL fusion is contraindicated in situations when there are degenerative changes that involve the lunate fossa, such as stage 4 SLAC. Patients with a generalized inflammatory disorder, such as rheumatoid arthritis, are relative contraindications due to the risk of future radiolunate degeneration.

Surgical Technique Once the joint survey is completed the scaphoid is resected. This is the most time-consuming part of the procedure. Care is taken to avoid damaging the radioscaphocapitate (RSC) ligament to prevent ulnar translocation. Del Pinal et al.3 have described the use of an enlarged SL arthroscopy portal and pituitary rongeurs to remove the scaphoid. A 1.5-cm transverse SL portal is created at a location between the 3,4 and MCR portals. This SL portal overlies the scaphoid pathology (SL gap or scaphoid nonunion). The scope is placed in the MCU portal and a straight and articulated rongeur is inserted through the SL portal. The proximal pole is first excised in piecemeal fashion and discarded   (Video 20-1). This exposes cancellous bone inside the scaphoid, which is cored out. Once the middle-third is emptied of cancellous bone, the scaphoid shell is removed

in piecemeal fashion and discarded. The process is repeated for the distal pole. Weiss et al.4 resects the scaphoid through the midcarpal portals. A 2.5-mm arthroscopic burr is introduced into the midcarpal joint through the MCR portal, with the MCU portal used for viewing (Fig. 20.1A–G). The burr is used to decorticate the medial corner of the scaphoid at the midcarpal SL joint. Once an adequate portion of the corner of the scaphoid is removed, the MCR portal is slightly enlarged and a 4.0-mm hooded burr or shoulder abrader is substituted, which facilitates a more rapid removal of bone. The scaphoid is then removed from the ulnar-to-radial and distal-to-proximal directions. The scaphotrapeziotrapezoidal-ulnar (STT-U) and scaphotrapeziotrapezoidal-palmar (STT-P) portals are used to facilitate removal of the distal pole of the scaphoid. Small bone fragments attached to the capsule tend to move away from the burr and are more easily resected using pituitary rongeurs. I prefer to connect the 3,4 and MCR portals to perform a miniarthrotomy for removal of any scaphoid remnants with a rongeur to decrease the operative time. This is performed near the end of the case, without fluid irrigation, and then the minicapsulotomy is closed with 3-0 nonabsorbable sutures. In the presence of a scaphoid nonunion, the proximal scaphoid pole alone can be excised if there is no impingement with the radial styloid. After scaphoid excision, the arthroscope is placed in the STT or MCR portal. The burr is placed in an enlarged MCR or MCU portal, and then the distal surface of the lunate and proximal capitate are decorticated. If a dorsal intercalated segmental instability (DISI) pattern is present, the next step is to correct the lunate hyperextension using the Linscheid maneuver.5 This is done by taking the wrist out of traction and then hyperflexing the wrist while the surgeon translocates the wrist radially. A 0.062-inch K-wire is inserted about 2 cm proximal to the 4,5 portal and directed slightly radially into the lunate. The wrist is extended to neutral which then keeps the lunate in a neutrallateral position. If there is no DISI, as in a proximal pole scaphoid nonunion, then the radiolunate pin is omitted. For retrograde screw insertion, a superficial incision is made over the base of the third metacarpal. A 0.045-inch guide wire is introduced into the capitate parallel to its radial border. This wire is inserted at an acute angle so that it is almost flush with the skin, to capture the center of the lunate. A second guide wire is inserted through another incision ulnar to this. The capitate is manually reduced over the lunate by ulnar translation of the wrist so that the capitate is concentrically reduced on the lunate in a neutral position on the posteroanterior (PA) and lateral fluoroscopic images. The guide wire is then advanced from the capitate into the lunate to capture the reduction. A cannulated drill is placed over the distal guide wire and used to ream the capitate and lunate. The drill should stop 2 mm from the proximal lunate cortex. The length is measured using a second guide wire. Once the length is determined, the guide wire is driven through the lunate into the radius to prevent the wire from dislodging when the cannulated drill is removed. The screw length is 4 mm shorter than the measured length. A headless

206  SECTION V  |  Arthritis and Degenerative Disorders

A

B C C

L

C

D

L

E

MCU

F

G FIGURE 20.1 Capitolunate Fusion.  (A, B) Chronic scapholunate (SL) dissociation (arrow) with radioscaphoid and midcarpal narrowing. (C) View of the capitate (C) from the midcarpal radial (MCR) portal showing a complete loss of cartilage with exposed subchondral bone. (D) Decorticated lunate (L) and capitate (C). (E) Insertion of demineralized bone matrix through a cannula in the MCR portal. (F, G) Retrograde insertion of a headless cannulated capitolunate screw.

CHAPTER 20  |  Arthroscopic Partial Wrist Fusions  207

compression screw is then inserted in a retrograde fashion over the guide wire, stopping 2 mm from the proximal articular surface of the lunate. Fluoroscopy is used to confirm proper screw placement and a neutral capitolunate alignment. The radiolunate K-wire is then removed. If there is sufficient radiocarpal impaction between the trapezium and the radial styloid with radial deviation of the wrist, an arthroscopic radial styloidectomy is then performed, with the burr in the 1,2 portal and the arthroscope in the 3,4 portal interchanged with the VR portal. Postoperatively, the patient’s wrist is immobilized in a volar wrist splint until there are signs of fusion at 6 to 8 weeks, at which time wrist motion and gradual strengthening are instituted.

Arthroscopic-Assisted 4-corner Fusion and Scaphoidectomy Using the technique of Del Pinal et al.3 the 6R, MCU, and SL portals are used interchangeably to resect any hypertrophic synovium. The scarred dorsal capsule (DC), which adheres to

the dorsal aspect of the extended lunate and tethers it, is resected to aid in correction of the lunate extension. A scaphoidectomy is performed as described earlier (Figure 20-2A–F). The cartilage and subchondral bone at the site of the 4-corner arthrodesis are now removed with a burr. Intermittent irrigation through the scope, alternating with suction through the burr, is used to clear debris. The hand is taken out of traction and the lunate is reduced as described earlier and held with a radiolunate pin. The hand is then placed back in traction. Cancellous graft is loaded into a 3.5- or 4.5-mm drill guide outside the wrist, and then inserted through the SL portal. A shoulder probe is used to push the graft into the joint, which is packed into the lunocapitate and TH joints. The hand is taken out of traction for guide wire insertion. The midcarpal joint is reduced by translating the capitate ulnarly. To prevent impingement between the screws, the capitolunate screw is directed from the dorsal-distal capitate to the volar-proximal lunate, the triquetrolunate screw is directed from the volar triquetrum to the dorsal lunate, and the triquetrocapitate screw is directed from the dorsal-distal triquetrum to the volar-distal   capitate (Video 20-2). A small transverse incision is made at the base of the long finger metacarpal for guide wire insertion and drilling of the capitate. The surgeon’s hand must

S

RSC

3,4

A

B

C

L

C

S

D

R

MCR

E

L

L

MCU

F

FIGURE 20.2 (A, B) 60 y.o. male with symptomatic SLAC stage III. (C) View from the 3,4 portal demonstrating the chondromalacia of the proximal scaphoid (S). RSC radioscaphoid ligament. (D) Preserved cartilage on the proximal lunate (L) and radius (R). (E) MCR view of the chondromalacia on the proximal capitate (C) but preserved distal lunate cartilage (L). (F) MCU view of a large diastasis between the scaphoid (S) and lunate (L) with marked cartilage loss of the distal scaphoid.

Continued

208  SECTION V  |  Arthritis and Degenerative Disorders

L

G

J

H

K

I

L

FIGURE 20.2, cont'd (G) Resection of distal lunate (L) down to subchondral bone. (H) Arthroscopic resection of triquetrohamate joint. (I) Scaphoid excision with a rongeur through a mini-open incision. (J) Insertion of radiolunate pin and guide wires. (K, L) Completed midcarpal fusion using three headless screws.

be oriented nearly parallel to the patient’s wrist during insertion of this guide wire. Correct placement of the guide wires is confirmed fluoroscopically followed by insertion of 3.0-mm headless cannulated screws. The radiolunate pin is removed and a radial styloidectomy is performed if there is any impingement. Postoperatively a volar wrist splint is applied until clinical signs of bony healing occur as manifested by absence of pain on palpation at the arthrodesis sites, at which time wrist range of motion is started at home. Active-assisted range of motion is started by 6 weeks.

Arthroscopic-Assisted Scaphocapitate Fusion with and without Lunate Excision Scaphocapitate (SC) fusion is typically indicated in advanced Lichtman stage IIIA or IIIB. Excision of the lunate is dependent on the number of functional surfaces as described by Bain et al.6 (see chapter: “The Use of Arthroscopy in Kienböck Disease”). It can also be used for chronic

scapholunate (SL) instability. The 4,5, 5,6, and 6R portals are used. The radiocarpal and midcarpal joints are examined with special emphasis on the lunate. If there are two nonfunctional surfaces, the lunate is excised using a burr   (Video 16-3). The proximal cartilage shell can be retained to protect the lunate fossa. Leblebiciog˘ lu et al.7 preferred to excise the distal capitate pole and leave the lunate in   place even with Lichtman stage IIIA and IIIB (Video 16-4). This is akin to a capitate shortening osteotomy. In this case, the proximal capitate pole is excised using burrs and shavers until the midcarpal surface of the lunate is free of the capitate pole. The arthroscope is then directed toward the SC joint, and the cartilage of the facing surfaces of the capitate and scaphoid are removed down to bleeding cancellous bone (Fig. 20.3A–M). This is facilitated by use of a scaphotrapezial (ST) portal. A 1-cm incision is made in the snuffbox to protect branches of the superficial radial nerve (SRN) and radial artery. The wrist is dorsiflexed and deviated ulnarly to extend the scaphoid, and the guide wires are inserted through the waist of the scaphoid into the capitate in a radial-to-ulnar, palmar-to-dorsal, and proximal-todistal direction. Bone graft or demineralized bone matrix is then packed between the two bone surfaces, but some authors do not use graft because the surfaces are so congruent.

CHAPTER 20  |  Arthroscopic Partial Wrist Fusions  209

A

B

C L

S L T

3,4 L

D

3,4

VR

E

F C

S

STT

G

H

I

FIGURE 20.3 Arthroscopic Scaphocapitate Fusion with Lunate Excision.  (A) Licht-

man Stage II Kienböck disease. (B) T-2 weighted lateral MRI shows a fracture through the subchondral bone (arrow), but no dorsal intercalated segmental instability (DISI). (C) T-2 weighted AP MRI shows a horizontal fracture plane (arrow). (D) Arthroscopic view of the lunate (L) from the midcarpal joint reveals the horizontal fracture line (arrow), which cleaves the lunate into volar and dorsal fragments. T, Triquetrum. (E) Arthroscopic view from the 3,4 portal shows a complete tear of the scapholunate (SL) ligament. (F) Softening and fibrillation of the proximal lunate (L) as seen from the volar radial (VR) portal. (G) Fluoroscopic view during an arthroscopic excision of the lunate showing placement of the scope and burr. (H) A rongeur is introduced into an enlarged 3,4 portal to complete the lunate excision. (I) View from the scaphotrapeziotrapezoidal (STT) portal of the removal of cartilage and subchondral bone between the adjacent surfaces of the scaphoid (S) and capitate (C).

Continued

210  SECTION V  |  Arthritis and Degenerative Disorders

J

K

L

M

FIGURE 20.3, cont'd (J) Fluoroscopic view confirming the position of the scope and burr.

(K) Percutaneous screw fixation of the scaphocapitate (SC) joint. (L, M) AP and lateral views of the complete SC fusion and lunate excision.

Two 3.0-mm screws are inserted down the guide wires under fluoroscopic control and the arthroscope is placed in the MCU portal to visualize the fusion site. Postoperatively, the wrist is immobilized in a short-arm splint in 15 degrees of dorsiflexion and 10 degrees of ulnar deviation for 6 to 8 weeks, followed by wrist motion.

Arthroscopic-Assisted Radioscapholunate Fusion A radioscapholunate (RSL) fusion is indicated for posttraumatic OA of the radiocarpal joint as a sequela of a malunited die punch or intraarticular DRF. It may also be performed in Kienböck disease with a nonfunctional proximal lunate surface, with or without degenerative changes of the radiolunate joint but with a preserved distal articular surface. Inflammatory arthritis, such as rheumatoid and psoriatic arthritis, is an additional indication. This leaves the patient with an intact dart-throwing motion, which is a pure midcarpal motion. A contraindication to this procedure therefore consists of degenerative changes affecting the midcarpal joint. A distal scaphoidectomy significantly improves the arc of motion. Some prefer to excise the triquetrum as well.8,9 It is easiest to perform the distal scaphoid resection first using the STT portals, because the RSL fusion significantly limits wrist motion. The STT-U portal is localized by finding the STT joint with a 22-gauge needle just ulnar to the extensor pollicis longus (EPL) tendon, in line with the index metacarpal. Tenotomy scissors are used to spread the soft tissues and pierce the capsule, and then a cannula and blunt trocar are inserted followed by the arthroscope. An identical procedure is used to establish the STT-P portal, which is identified roughly 3 mm ulnar to the abductor pollicis longus (APL) tendon and 6 mm radial to the scaphoid tubercle. Portal placement can be aided by advancing the scope through the STT-U portal, across the joint until it lights up the capsular interval. The angle between the two

portals is 130 degrees, which improves triangulation. Both portals are interchangeable for viewing and instrumentation. The MCR portal can also be used for viewing. Care is taken not to injure the cartilage on the capitate. After the distal pole resection, the scaphoid waist should still articulate with the capitate. The joint is debrided using a combination a full-radius resector. Once any residual articular cartilage has been removed, a 2.9-mm burr is applied to the distal scaphoid and used to resect the distal one-third of the scaphoid. The diameter of the burr and fluoroscopy provide a gauge as to the amount of bony resection. Next the scope is inserted in the 3,4 portal with a burr in the 4,5 portal, and the proximal surfaces of the scaphoid and lunate are debrided back to bleeding subchondral bone, as well as the scaphoid and lunate fossae of the distal radius. A temporary SL K-wire can be inserted through the snuffbox to maintain the joint relationship. The hand is taken out of traction and two guide wires are inserted through a small stab incision from the radius to the scaphoid and radius to the lunate. Biswas et al.10 described a technique to allow for central placement of the screws in the midcoronal plane. A dorsal corticotomy of the distal radius is performed through a small dorsal incision. A crescent-shaped corticotomy is made using a burr along the dorsal 30% of the distal radius. This should begin 2 cm proximal to the radiocarpal joint and extend approximately 1 cm proximally. Curettes are used to harvest cancellous bone graft from this metaphyseal trough, preserving at least 1.5 cm of bone proximal to the fusion site to maximize screw purchase within the subchondral bone of the distal radius. The scaphoid and lunate are reduced relative to the distal radius and the capitate, maintaining neutral rotation relative to the capitate. Manual compression is applied across the carpus while guide pins for the cannulated screws are inserted. The guide pins are placed with fluoroscopic guidance, antegrade through the dorsal corticotomy within the bone graft defect. Their trajectory begins just beneath the dorsal cortex and enters the scaphoid and lunate in their midpoints, as seen on PA and lateral fluoroscopic views. A cannulated depth gauge is placed over the guide pin to measure its length across the arthrodesis.

CHAPTER 20  |  Arthroscopic Partial Wrist Fusions  211

Actual screw length should be approximately 4 mm shorter than this measurement to allow for compression and countersinking. The hand is then placed back in traction and the wires are temporarily backed out while the bone graft is packed into the radioscaphoid fusion site through the 3,4 portal while viewing through the 4,5 portal. The instruments are switched and bone graft is packed into the radiolunate fossa. Alternatively, bone graft substitute and/or demineralized bone matrix can be used. The selected screw is then advanced over each guide wire. The hand is taken out of traction one last time while the guide wires are advanced distally into the scaphoid and lunate. Reaming and screw insertion are then performed. If the bone is very osteopenic, two additional K-wires can be inserted for the definitive fixation. Postoperatively the patient is placed in a short-arm cast or splint at the first postoperative visit. Range of motion is started once there is radiographic evidence of fusion, which typically occurs between 6 and 12 weeks.

Outcomes There is a paucity of reports on arthroscopic partial wrist fusion. Slade and Bomack11 initially described their technique for an arthroscopic-assisted capitolunate fusion in 2003. Slade et al12 reported on 10 patients treated with percutaneous capitolunate arthrodesis without bone graft using a headless cannulated compression screw. At a 38-month follow-up, 10 patients had solid fusions confirmed by CT scan. One patient had mild occasional pain at the radial styloid but declined treatment. The remaining patients were pain-free. All had functional range of motion with a 72% flexion-extension arc, 70% radioulnar deviation arc, and 92% supination-pronation arc. Grip strength was 90% of the opposite uninjured wrist. There were no complications. All patients returned to their prior work and avocations, including weight training, tennis, baseball, and recreational golf. Del Pinal et al.3 published their results with an arthroscopic-assisted scaphoidectomy and 4-corner fusion in 4 patients. The first patient was a 53-year-old with a SNAC wrist. He underwent a 4-hour operation: 2 hours of operating followed by 20 minutes of reperfusion time, and then 1 hour 45 minutes more of operating. The preoperative active extension and flexion were 40 and 50 degrees, and at a follow-up of 26 months, the postoperative extension and flexion were 55 and 33 degrees. The visual analog scale (VAS) pain score improved from 9.6 preoperatively to 0 postoperatively. Grip strength improved from 34 kg to 56 kg. The second patient was a 63-year-old who presented with a SNAC wrist, who had a 3-hour 10 minute procedure. At a follow-up of 15 months, the active extension and flexion improved from 20 and 26 degrees to 15 and 52 degrees. The VAS pain score improved from 8 preoperatively to 0.5 postoperatively. Grip strength improved from 26 kg to

40 kg. The third procedure, on a 47-year-old with a SNAC wrist, was completed in 1 hour 45 minutes. The preoperative active extension and flexion were 25 and 35 degrees and, at a follow-up of 9 months, the postoperative extension and flexion was 30 and 35 degrees. The VAS pain score improved from 9 preoperatively to 2 postoperatively. Grip strength improved from 28 kg to 40 kg. The fourth procedure, on a 34-year-old with a SLAC wrist, was completed in 1 hour 55 minutes. The preoperative active extension and flexion were 60 and 45 degrees, and at a follow-up of 6 months, the postoperative extension and flexion was 52 and 20 degrees. The VAS pain score improved from 9 preoperatively to 1.5 postoperatively. Grip strength was unchanged at 36 kg. They used bone graft from the radius in the first 2 patients, and bone graft from the scaphoid in the last 2 patients. No complications occurred and all patients healed uneventfully. Leblebiciog˘ lu et al.7 randomized 16 consecutive patients with a mean age of 31 years (range, 18–61 yr) presenting with Lichtman disease stage IIIA and stage IIIB to either an open SC fusion using cannulated screws and lunate revascularization using a pedicled dorsal metacarpal artery anastomosed to a vein graft inserted into the lunate (group I, 8 patients), or an arthroscopic SC fusion using cannulated screws and capitate pole excision (group II, 8 patients). The lunate was left in situ in all cases. The mean operating time (153 vs. 99 min), hospital stay (3.6 vs. 2.3 days), and return to unrestricted daily activities (15 vs. 5.8 wk) were shorter in group II. The average time to radiographically evident fusion was shorter in group I (7.25 vs. 9 wk). According to the MMWS, there were 4 fair and 4 good results in group I, and 2 fair and 6 good results in group II. Ho published his technique for partial wrist fusions in 2008 in 12 patients with an average follow-up of 70 months.13 His most recent experience consists of 23 patients.14 The indications included SLAC wrist in 6 patients, SNAC wrist in 5 patients, LT instability in 2 patients, Kienbock disease in 3 patients, posttraumatic arthrosis in 5 patients, and inflammatory arthritis in 2 patients. The average duration of symptoms was 34.2 months (range, 9–82 mo). The average patient age was 42 (range, 18–68 yr). Radiographic fusion was obtained in 19 out of 23 patients. This included STT fusion in 3 patients (1 nonunion), scaphoidectomy and 4-corner fusion in 5 patients, scaphoidectomy and capitolunate fusion in 4 patients, radiolunate fusion in 2 patients (1 nonunion), scaphocapitate fusion and lunate excision in 3 patients, radioscapholunate fusion in 4 patients, radiolunate fusion in 2 patients (1 nonunion), and a lunotriquetral fusion in 2 patients (2 nonunions). The final fixation was with multiple K-wires or cannulated screws. The average operative time was 185 minutes. The median time to radiographic union was 5 to 50 weeks. The average follow-up was 59.9 months (range, 11–112 mo). Three patients required further surgery for pain. Surgical complications included 2 pin tract infections, 1 skin burn, and 1 delayed union. One patient required screw removal.

212  SECTION V  |  Arthritis and Degenerative Disorders

References 1. Ong MT, Ho PC, Wong CW, et al. Wrist arthroscopy under portal site local anesthesia (psla) without tourniquet. J Wrist Surg. 2012;1:149-152. 2. Del Pinal F, Garcia-Bernal FJ, Pisani D, et al. Dry arthroscopy of the wrist: surgical technique. J Hand Surg. 2007;32:119-123. 3. Del Pinal F, Klausmeyer M, Thams C, et al. Early experience with (dry) arthroscopic 4-corner arthrodesis: from a 4-hour operation to a tourniquet time. J Hand Surg. 2012;37:2389-2399. 4. Weiss ND, Molina RA, Gwin S. Arthroscopic proximal row carpectomy. J Hand Surg. 2011;36:577-582. 5. Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to management. Clin Orthop Rel Res. 1980:90-97. 6. Bain GI, Begg M. Arthroscopic assessment and classification of Kienbock’s disease. Tech Hand Up Extrem Surg. 2006;10:8-13. 7. Leblebicioglu G, Doral MN, Atay Ao, et al. Open treatment of stage III Kienbock’s disease with lunate revascularization compared with arthroscopic treatment without revascularization. Arthroscopy. 2003;19:117-130.

8. Bain GI, Ondimu P, Hallam P, et al. Radioscapholunate arthrodesis—a prospective study. Hand Surg. 2009;14:73-82. 9. Berkhout MJ, Shaw MN, Berglund LJ, et al. The effect of radioscapholunate fusion on wrist movement and the subsequent effects of distal scaphoidectomy and triquetrectomy. J Hand Surg Eu Vol. 2010;35:740-745. 10. Biswas D, Wysocki RW, Cohen MS, et al. Radioscapholunate arthrodesis with compression screws and local autograft. J Hand Surg. 2013;38:788-794. 11. Slade JF III, Bomback DA. Percutaneous capitolunate arthrodesis using arthroscopic or limited approach. Atlas Hand Clin. 2003;8:149-162. 12. Slade JF III, Dodds SD, Flanagin B. Arthroscopic capitolunate arthrodesis using a limited approach. In: Slutsky DJ, Slade JF III, ed. The scaphoid. New York, Stuttgart: Thieme; 2010:333-343. 13. Ho PC. Arthroscopic partial wrist fusion. Tech Hand Up Extrem Surg. 2008;12:242-265. 14. Ho PC. Arthroscopic partial wrist fusion. In: Geissler WB, ed. Wrist and elbow arthroscopy. New York: Springer; 2015: 195-238.

CHAPTER

21

Arthroscopic Proximal Row Carpectomy Biomechanics and Kinematics A proximal row carpectomy (PRC) significantly alters the radiocarpal kinematics. Blankenhorn et al.1 found that following a PRC, wrist flexion and extension were accomplished by capitate rotation. In radioulnar deviation, capitate motion changed from predominantly midcarpal rotation in the intact wrist to a combination of rotation and translation at the radiocarpal joint. Overall flexion decreased 28%, extension decreased 30%, radial deviation decreased 40%, and ulnar deviation decreased 12%. Motion at the radiocarpal joint during flexion and extension after a PRC, however, was greater compared with motion at the radiocarpal and midcarpal joints of the intact wrist. Radial deviation was limited because of impingement between the trapezoid and the radial styloid. Hogan et al.2 examined radiocarpal loading following a PRC in 7 cadaver wrists. The contact area increased 37% in the lunate fossa and the average contact pressure increased 57%. The location of the contact moved radially 5.5 mm. With wrist motion between 40 degrees of extension and 20 degrees of flexion, the volar-dorsal excursion of the lunate fossa contact point increased 108%. They postulated that the increased radiocarpal excursion with wrist motion might explain the low incidence of radiocapitate arthritis in patients who have had a PRC. This was echoed by Tang et al.3 They compared the contact biomechanics of the intact wrist with PRC wrist in 6 cadaver wrists. In the intact wrist, scaphoid contact pressure averaged 1.4 megapascals (MPa), and lunate contact pressure averaged 1.3 MPa. Scaphoid contact in the intact wrist moved dorsal and ulnar in flexion, and volar and radial in extension. Lunate contact moved dorsal in flexion. The contact pressure after

a PRC was 3.8 times that of the intact wrist, and the contact area was approximately 26% that of the intact wrist. After a PRC, the capitate contact (7.5 mm) translated more than did the scaphoid contact (5.6 mm) and had about equal translation to that of the lunate (7.3 mm). This provided quantitative support of the theory that translational motion of the PRC may explain its good clinical outcomes. At the radiocarpal joint, the radius of curvature of the capitate head is approximately two-thirds of the radius of curvature of the lunate fossa.4 Over time, the capitate appears to conform better to the lunate fossa.

Diagnosis The diagnosis of SLAC or SNAC wrist arthritis is made by history, physical examination, and radiographs. The wrist examination often reveals a joint effusion, dorsalradial wrist swelling, and tenderness over the radioscaphoid joint. There may or may not be a positive scaphoid shift test. Chronic synovitis over the snuffbox may be misdiagnosed as a ganglion cyst. Wrist motion may be decreased, depending on the stage of degeneration. The definitive diagnosis is made radiographically. Standard posteroanterior, oblique, and lateral views should be performed. Marked changes as seen in SLAC and SNAC are easily identified. An AP grip view and radioulnar deviation views can magnify any SL diastasis. An MRI and/or CT scan may be useful to evaluate any midcarpal joint changes and DISI deformity, and to determine whether there is a styloid pattern or dorsal lip pattern of impingement. 213

214  SECTION V  |  Arthritis and Degenerative Disorders

L

**

*

A

B

*

C

3,4

FIGURE 21.1 (A) Chronic scapholunate (SL) dissociation. The scaphoid has worn a trough in the articular surface of the distal radius (arrow) but the radiolunate joint (asterisk) is still preserved. (B) Lateral radiograph view. (C) Arthroscopic view of the scaphoid fossa demonstrating the marked loss of articular cartilage (asterisk) as well as the relatively preserved cartilage in the lunate fossa (L).

Treatment Symptomatic treatment with splints, modalities, and selected cortisone injections may provide symptomatic relief. An arthroscopic PRC avoids an open capsulotomy, thus allowing for early postoperative mobilization of the wrist. With less soft tissue disruption, there may be a faster recovery compared with the open procedure, and reduced postoperative pain and scarring. In addition, with the relative sparing of the capsular ligaments, there may be enhanced postoperative stability.

preserved lunate fossa and normal cartilage on the capitate head; therefore SLAC stage 3 and 4 and SNAC stage 3 are contraindications. An unstable carpus, such as a preexisting ulnar translocation (common in rheumatoid patients), is a relative contraindication, as is a previous radial styloidectomy of more than 4 mm due to the risk of previous injury to the radioscaphocapitate (RSC) ligament, which can result in ulnar translocation. Although proximal row carpectomy has been successfully performed on patients under 35 years of age, some authors have noted a high risk of failure in patients who were younger than 35 years old at the time of surgery.5

Indications The indications for an arthroscopic PRC (APRC) are identical to an open PRC. Only patients with symptoms reasonably explained by their arthritis should be considered for surgical treatment. Persistent severe wrist pain, after having failed antiinflammatory medication and immobilization, is the most common indication for surgical intervention. An APRC is indicated for a wide range of conditions that culminate in radiocarpal arthrosis, including longstanding scapholunate (SL) instability with radioscaphoid osteoarthritis (OA) (stage 1 or 2 SLAC) (Fig. 21.1A-C), scaphoid nonunion collapse with radioscaphoid OA (stage 1 or 2 SNAC), chronic unreduced lunate and perilunate dislocation, and early Kienbock disease.

Contraindications When the head of the capitate and/or the lunate fossa of the distal radius shows a loss of articular cartilage, a PRC should not be performed. The prerequisite for this procedure is a

Surgical Technique Culp et al.6 have described the APRC procedure in detail. An initial arthroscopic survey is performed to assess the cartilage on the lunate fossa and proximal pole of the   capitate (Video 21-1). The SL and lunotriquetral interosseous ligaments (LTIL) are excised through the 4,5 and/or 6R portals. The scarred dorsal capsule (DC), which adheres to the dorsal aspect of the extended lunate and tethers it, is resected to increase the working space. Next, the core of the lunate is removed with a 4.0-mm arthroscopic burr. Care is taken to avoid damaging the lunate fossa and proximal capitate by leaving an “eggshell” rim of lunate, which is morselized with a pituitary rongeur under direct vision and/or with image intensification. Next, using the 3,4 or 4,5 portal as a working portal, the scaphoid and triquetrum are fragmented with an osteotome and burr under fluoroscopy and removed piecemeal with the rongeur. Coring out

CHAPTER 21  |  Arthroscopic Proximal Row Carpectomy  215

S

pp

A

B FIGURE 21.2 (A) Fluoroscopic view of an arthroscopic burr inserted through the midcarpal radial (MCR) portal. (B) View from the midcarpal ulnar (MCU) after the proximal pole (PP) has been resected. S, Scaphoid.

and fragmenting the carpal bones allows for easy removal and protection of the articular cartilage. Great care is taken to avoid damaging the volar extrinsic ligaments, especially the RSC ligament, which will be responsible for maintaining the stability of the capitate in the lunate fossa. Del Pinal et al.7 have described the use of an enlarged SL arthroscopy portal and pituitary rongeurs to remove the scaphoid. A 1.5cm transverse SL portal is created at a location between the 3,4 and midcarpal radial portals. This SL portal overlies the scaphoid pathology (SL gap or scaphoid nonunion). The scope is placed in the midcarpal ulnar (MCU) portal, and a straight and articulated rongeur is inserted through the SL portal. The proximal pole is first excised piecemeal and discarded. This exposes cancellous bone inside the scaphoid, which is cored out. Once the middle-third is emptied of cancellous bone, the scaphoid shell is removed in piecemeal fashion and discarded. The process is repeated for the distal pole. Weiss et al.8 perform the APRC through the midcarpal portals. After diagnostic and operative arthroscopy, a small joint arthroscopic burr is introduced into the midcarpal joint through the MCR portal, with the MCU portal used for viewing. The burr is used to decorticate the medial corner of the scaphoid at the midcarpal SL joint, with care being taken not to injure the articular cartilage of the head of the capitate (Fig. 21.2A–B). Once an adequate portion of the corner of the scaphoid is removed, the MCR portal is slightly enlarged and a 4.0-mm hooded bur is substituted, which facilitates a more rapid removal of bone. The scaphoid is then removed from ulnar to radial and distal to proximal The STT-ulnar (STT-U) and STT-palmar (STT-P) portals (Fig. 21.3A–B) are used to facilitate

removal of the distal pole of the scaphoid. Under arthroscopic visualization a fine synovial rongeur is useful to remove tiny fragments of bone or cartilage that remain adherent to the capsule (Fig. 21.4A–B). After scaphoid excision, the arthroscope is placed in the STT or MCR portal. The burr is placed in an enlarged MCR or MCU portal, and then the lunate is excised from distal to proximal (Fig. 21.5A–C) and then the triquetrum is sequentially removed (Fig. 21.6A–B). Confirmation of a complete APRC is made with fluoroscopy (Fig. 21.7A–B). Traction is then released, and arthroscopy and fluoroscopy are used to confirm seating of the head of the capitate in the lunate fossa (Fig. 21.8A–B). If there is sufficient radiocarpal impaction between the trapezium and the radial styloid with radial deviation of the wrist, an arthroscopic radial styloidectomy is then performed, with the burr in the 1,2 portal and the arthroscope in the 3,4 portal. Postoperatively, the wrist is splinted for comfort for the first week followed by protected wrist motion, and then strengthening.

Outcomes There are few clinical series of an APRC. It was first suggested by Roth and Poehling9 and then described in greater detail by Culp et al.6 but no detailed patient information was presented. Weiss et al.8 examined 17 patients (10 men and 7 women) who underwent an APRC at an average followup of 24 months (range, 12–48 mo). The average operative

216  SECTION V  |  Arthritis and Degenerative Disorders

Tp Tm

* * STT

A

B

FIGURE 21.3 (A) View from the scaphotrapeziotrapezoidal-ulnar (STT-U) portal with

the probe in the scaphotrapeziotrapezoidal-palmar (STT-P) portal before resection of the distal scaphoid pole (asterisk). Tm, Trapezium; Tp, trapezoid. (B) Radiograph appearance.

A

B

FIGURE 21.4 (A) Rongeur is used to remove scaphoid fragments. (B) Following resection of scaphoid fragments.

time for the procedure was 70 minutes (range, 34–110 min). The mean wrist flexion-extension arc was 94 degrees (range, 50–130 deg), or 80% of the contralateral side. The average radioulnar deviation arc was 40 degrees (range, 20–55 deg), or 78% of the contralateral side. The average maximum grip strength was 81% of the contralateral side. The average DASH score was 21 points (range, 0–61 pts).

Five patients reported no pain, 5 had mild pain, and 6 had moderate pain. They concluded that although the wrist range of motion and strength may recover faster in an APRC, the long-term results appear comparable to the open procedure, and there may not be a long-term clinical benefit to the arthroscopic procedure over an open PRC.

CHAPTER 21  |  Arthroscopic Proximal Row Carpectomy  217

L

** A

B

C

FIGURE 21.5 (A) Arthroscope and probe are used to evaluate the lunate. (B) View of the lunate articular surface (L) with exposed subchondral bone (asterisk). (C) Burr is used to resect the medial lunate through the midcarpal ulnar (MCU) portal.

Tq

A

B

FIGURE 21.6 (A) Arthroscope and probe are used to evaluate the triquetrum. (B) After partial resection of the distal triquetrum (Tq).

218  SECTION V  |  Arthritis and Degenerative Disorders

FIGURE 21.7 (A, B) Completed resection.

A

B FIGURE 21.8 (A, B) Postoperative radiographs.

References 1. Blankenhorn BD, Pfaeffle HJ, Tang P, et al. Carpal kinematics after proximal row carpectomy. J Hand Surg. 2007;32:37-46. 2. Hogan CJ, McKay PL, Degnan GG. Changes in radiocarpal loading characteristics after proximal row carpectomy. J Hand Surg. 2004;29:1109-1113. 3. Tang P, Gauvin J, Muriuki M, et al. Comparison of the “contact biomechanics” of the intact and proximal row carpectomy wrist. J Hand Surg. 2009;34:660-670. 4. Imbriglia JE, Broudy AS, Hagberg WC, et al. Proximal row carpectomy: clinical evaluation. J Hand Surg. 1990;15:426-430. 5. Wall LB, Stern PJ. Proximal row carpectomy. Hand Clin. 2013;29:69-78.

6. Culp RW, Lee Osterman A, Talsania JS. Arthroscopic proximal row carpectomy. Tech Hand Up Extrem Surg. 1997;1:116119. 7. Del Pinal F, Klausmeyer M, Thams C, et al. Early experience with (dry) arthroscopic 4-corner arthrodesis: from a 4-hour operation to a tourniquet time. J Hand Surg. 2012;37:23892399. 8. Weiss ND, Molina RA, Gwin S. Arthroscopic proximal row carpectomy. J Hand Surg. 2011;36:577-582. 9. Roth JH, Poehling GG. Arthroscopic “-ectomy” surgery of the wrist. Arthroscopy. 1990;6:141-147.

SECTION

VI

Small Joint Arthroscopy

22

Metacarpophalangeal Joint Arthroscopy

23

Arthroscopic Treatment of First Metacarpal Base Fractures

24

Arthroscopic Reduction and Percutaneous Fixation of Fifth Carpometacarpal Fracture Dislocations

25

Arthroscopic Treatment of Trapeziometacarpal Osteoarthritis

26

Arthroscopic Treatment of Scaphotrapeziotrapezoidal Osteoarthritis

219

CHAPTER

22

Metacarpophalangeal Joint Arthroscopy The metacarpophalangeal (MCP) joint is ideally suited for arthroscopic evaluation. The MCP joint represents a single compartment, the bony and tendinous landmarks are easy to identify, and the neurovascular structures are remote from the portals; hence there is a short learning curve. It is mostly used for synovectomy and loose body removal but it has some applications following trauma as well.

Anatomy and Methodology Ropars et al.1 investigated the course of the superficial radial nerve (SRN) and the potential risk for injury during trapeziometacarpal (TM) or thumb MCP joint arthroscopy. They dissected the SRN in 30 forearms and measured the distances of the 3 major branches of the nerve (SR1, SR2, and SR3) from the radial metacarpophalangeal (MCP-r) and ulnar metacarpophalangeal (MCP-u) portals. The MCP-r portal was always situated dorsally and very closely to SR3, at a mean distance of 1 mm (range, 0–5 mm). The MCP-u portal was also situated dorsally to SR2-D1 at a mean distance of 3.7 mm (range, 1.5–6.5 mm). Rozmaryn and Wei2 studied 24 MCP joints in 6 cadaveric hands using a 2.5-mm small-joint arthroscope and 5 pounds of overhead traction using a radial portal and an ulnar portal. The number of arthroscopic observations they describe include: (1) a consistent tripartite configuration of the main radial and ulnar collateral ligaments with characteristic changes in relative fiber orientation as the digit goes from extension to flexion; 220

(2) nonvisualization of the accessory collateral ligament from inside the joint; (3) transitional amorphous capsular fibers connecting the collateral ligaments to the volar plate and dorsal capsule (DC); (4) four synovial recesses (radial, ulnar, volar, and dorsalproximal); (5) a metacarpal head and proximal phalanx; (6) a consistent circumferential meniscal equivalent around the margin of the proximal phalanx articular surface; (7) the sesamoid-metacarpal articulation in the thumb MCP joint. Hidalgo-Diaz et al.3 compared horizontal and vertical traction for MCP joint arthroscopy in the fingers other than the thumb in 8 patients. Arthroscopy was performed using dorsomedial and dorsoradial portals. The average duration of patient set-up was 17.75 minutes in the horizontal traction group and 32 minutes in the vertical traction group. The average tourniquet time was 56.75 minutes in the horizontal traction group and 71 minutes in the vertical traction group.

Physical Examination and Imaging The examination of the finger MCP joints is straightforward. Inspection should include observation for swelling, synovitis, volar joint subluxation, and ulnar drift. The collateral ligaments are tested by applying radial and ulnar stress with the MCP joints in full flexion. The sagittal band fibers should be

CHAPTER 22  |  Metacarpophalangeal Joint Arthroscopy  221

inspected to rule out any ulnar subluxation of the extensor mechanism or incomplete MCP extension. Standard AP, lateral, and oblique radiographs should be performed to evaluate the joint surfaces and look for periarticular erosions. MRI can be useful in detecting any significant joint synovitis.

Indications Inflammatory Arthritis MCP joint arthroscopy is useful in evaluating the status of the articular cartilage and synovial proliferation, especially in rheumatoid arthritis (RA) (Fig. 22.1). A synovial biopsy and synovectomy can be performed without the need for   arthrotomy (Video 22-1). Acute Ulnar Collateral Ligament Injury of the Thumb Although arthroscopic reduction of a complete ulnar collateral ligament tear of the thumb MCP joint was first

described by Ryu and Fagan in 1995,4 it has not achieved widespread use. They used MCP arthroscopy to both identify and aid in reducing a Stener lesion by flipping the torn proximal ulnar collateral ligament from its position dorsal to the adductor aponeurosis back into the joint so that it could heal primarily with the distal torn end after thumb spica cast immobilization for 4 weeks. Slade et al.5 described a similar technique but used bone anchors to repair the collateral ligament. Reduction of Metacarpophalangeal Joint Fractures MCP arthroscopy has applications in the treatment of some simple articular fractures of the metacarpal head and the   proximal phalangeal base (Video 22-2). The fracture fragments are directly visualized, reduced with a probe, and held with percutaneous pin fixation (Fig. 22.2A–D). Posttraumatic Volar Plate Adhesions Choi et al. described painful volar plate adhesions of the thumb MCP joint in 15 patients, which were confirmed by an intraoperative arthrogram.6 Congruent joint flexion was accomplished after a synovectomy and release of the volar plate adhesions using a Freer elevator. Removal of Loose Bodies Loose bodies are commonly seen in patients with inflammatory arthritis or in cases with posttraumatic cartilage damage and can result in painful locking. The loose bodies are frequently lodged in the radial and ulnar synovial recesses.

FIGURE 22.1 Arthroscopic view of metacarpophalangeal (MCP) joint synovitis

Arthroscopic Assisted Reduction of MCP Joint Dislocation Kodama et al7 described an arthroscopic reduction of a complex dorsal metacarpophalangeal joint dislocation of the index finger. This can avoid the need for a palmar incision with the risk of radial digital nerve injury   (Video 22-3).

FIGURE 22.2 (A) Salter III fracture of the base of the thumb proximal phalanx. Continued (B) Arthroscopic view of the fracture line.

222  SECTION VI  |  Small Joint Arthroscopy

C

D

FIGURE 22.2, cont’d (C) Prepositioned K-wires. (D) Anatomic reduction captured by

advancing the K-wires.

Contraindications Irreducible extensor tendon dislocation, or subluxation, is a relative contraindication due to the risk of tendon damage during portal placement. Similarly, an unstable joint or poor soft tissue coverage, which precludes the use of finger trap traction, are contraindications.

Surgical Technique The patient is placed supine with the arm abducted on an arm board, under tourniquet control, using general or regional anesthesia. A sterile finger trap is applied to the finger or thumb and 10 pounds of traction is applied using a traction tower or overhead traction. A dorsal-radial portal and dorsal-ulnar portal are used. They are established on either side of the central extensor tendon by first identifying the joint space with a 22-gauge needle, followed by joint distension with saline, and a superficial skin incision (Fig. 22.3). The procedure can also be performed dry, using intermittent saline irrigation as necessary. Fluoroscopy can aid this step in difficult cases. Careful wound-spread technique is used because there is no internervous plane. Tenotomy scissors are used to dissect through the sagittal band fibers and DC between the extensor tendon and the collateral ligaments, which arise from the palpable tubercles at the base of the proximal phalanx. A 1.9-mm or 2.7-mm 30-degree small joint arthroscope is inserted in one portal and a 3-mm hook probe in the other portal, which are interchanged as necessary. A pressure bag is often needed for fluid inflow through the arthroscope. The collateral ligaments can be visualized, running obliquely from the metacarpal head to the base of the proximal phalanx (Fig. 22.4). The volar plate can be partially seen palmar to the metacarpal head. The volar recess is hidden from view but can be reached with a probe or Freer elevator

FIGURE 22.3 Clinical photo of metacarpophalangeal (MCP) joint arthroscopy with the scope in the ulnar portal and probe in the radial portal.

* *

FIGURE 22.4 View of the ulnar collateral ligament (asterisk).

CHAPTER 22  |  Metacarpophalangeal Joint Arthroscopy  223

when releasing adhesions between the volar plate and the metacarpal head. The radial, ulnar, and dorsal synovial recesses can be visualized when searching for loose bodies or when performing a synovectomy. Small chondral defects can be drilled to stimulate fibrocartilage formation. In the case of fracture reduction, two 1-mm K-wires are prepositioned in the fracture fragment. The joint is visualized arthroscopically and reduced with the aid of K-wires used as joysticks, and a Freer elevator or dental pick. Once the articular surface is reduced, the K-wires are advanced to capture the reduction. After the procedure, the portals

A

are sutured and a splint is applied. In the case of an irreducible MCP joint dislocation, the volar plate is usually entrapped between the base of the proximal phalanx and metacarpal head (Fig. 22.5A-K). The scope is inserted in the radial portal with a shaver in the ulnar portal. Performing the procedure without fluid irrigation can improve the joint visualization and decrease the postoperative MCP joint swelling. Any interposed osteochondral fragments are removed with forceps. The joint is debrided until the base of the proximal phalanx is seen. The volar plate is attached to the base of the proximal phalanx and

C

B

RCL

** D

E

F PP

PP

***

G

MP

H

I

FIGURE 22.5 Irreducible dorsal MCP dislocation (A), AP x-ray of a dorsal dislocation of the MCP joint. Note the widened joint space (arrow). (B), Oblique view demonstrating the dorsal metacarpal head defect (short arrow) and the displaced osteochondral fracture fragment (long arrow). (C-D), Insertion of a 2.7 mm arthroscope and probe in the MCP joint. (E), View of the radial collateral ligament (RCL) after joint debridement. (F), Osteochondral fragment (*) entrapped in the MCP joint. (G), View of the base of the proximal phalanx (PP) and metacarpal head (MCP). (H), Proximal border of the volar plate interposed between the proximal phalanx base and metacarpal head. (I), Arthroscopic biting forceps used to free up the volar plate. Continued

224  SECTION VI  |  Small Joint Arthroscopy

J

K

FIGURE 22.5, cont’d (J-K), One week postop with a congruent joint reduction. Note the dorsal metacarpal head defect (arrows). can be seen draped over the metacarpal head. Arthroscopic forceps are used to partially remove the volar plate and divide the attachment between the volar plate and collateral ligament. This exposes the flexor tendons. A hook probe is then used to push the volar plate palmarly out of the joint, which permits a joint reduction.

Complications Because the joint capsule is relatively thin, the skin, neurovascular bundles and tendons are especially at risk during thermal shrinkage. Choi et al. reported one case of flexor pollicis longus (FPL) rupture 3 weeks after thermal shrinkage of the volar plate.6 The risk can be minimized by maintaining an adequate fluid inflow, short duration bursts of heat, and use of minimal wattage. Articular cartilage damage is also a risk due to the small joint volume; hence instrumentation must be applied gently.

Outcomes Sekiya et al.7 performed arthroscopy on 27 proximal interphalangeal (PIP) joints and 16 MCP joints of 21 patients with RA (mean age, 47.2 yr; range, 26–62 yr). After arthroscopic examination, 24 joints were treated with joint irrigation only and 19 were treated with an arthroscopic synovectomy. The diameter of the arthroscope was 1.5 mm, and miniforceps and a minishaver system with a 2.5-mm cutter were used for biopsy and synovectomy. The articular cartilage and synovial membrane of the PIP and MCP joints were well visualized, and arthroscopy revealed cartilage changes and synovial proliferation. Because the PIP joint space was not wide enough to insert the arthroscope into the palmar cavity, the palmar part of the articular surfaces

and the volar synovium could not be inspected. Synovial biopsy of the dorsal joint capsule was easily performed under arthroscopic visualization. Synovectomy of the dorsal joint capsule and both the radial and ulnar recesses were also possible using the 2-portal technique with a minishaver system. No intraoperative or postoperative complications were encountered. Sekiya et al.8 in a later paper described their experience with an arthroscopic synovectomy using a 1.5-mm scope in 45 finger joints (18 MCP joints, 26 PIP joints), and 1 interphalangeal (IP) thumb joint in 23 patients with RA. They could not access the palmar recess, but there was resolution of the joint space swelling in the short term with no postoperative complications. Ostendorf et al.9 described miniarthroscopy (MA) of the MCP joints in patients with RA. They used 1.0-mm 0-degree and 1.9-mm 30-degree angled arthroscopes in a 2-portal technique, initially in 20 cadaver hands, and then in 20 MCP joints, using local anesthesia. In all cases, MA provided visualizing and magnification of intraarticular features of MCP joints in RA and allowed grading of synovial alterations, chondromalacia, and bony alterations. Synovial surface changes, thickness, and fibrosis were related to disease duration, as was damage to cartilage and bone. The degree of acute inflammatory reactions like vascularity and hyperemia varied independently of chronic changes; synovial proliferation was reflected to some extent by C-reactive protein. In 2 patients with early RA, synovitis criteria were found macroscopically and histologically. In 18 out of 20 joints, biopsies were taken under visual control; in the other 2 joints, progression of disease (Larsen score 3) limited arthroscopy to 1.0-mm scope imaging only. Sample sizes were sufficient for histologic and molecular analysis. Ostendorf et al.10 compared MRI findings in the MCP joints of patients with RA with miniarthroscopy. The second MCP joint of the dominant hand of 22 patients with various RA activities/stages was examined by MRI followed by MA. Erosions and pre-erosions were detected in 17 out of 22 patients by MRI; 2 of the other

CHAPTER 22  |  Metacarpophalangeal Joint Arthroscopy  225

5 patients (all early RA) displayed bony changes on MA. All 10 joints with pre-erosions on MRI exhibited significant cartilaginous and bony pathology on MA. Synovial membrane pathology was detected in all but 1 patient by MRI and in all patients by MA. The extent of synovitis/synovial proliferation shown by MA and MRI were significantly correlated with each other, but not with any other activity or damage parameter analyzed. In RA, both MRI and MA findings support early detection and staging of synovial changes. Borisch11 used a 1.9-mm, 30-degree angle arthroscope in 106 MCP joint arthroscopies with high patient satisfaction. The best results were obtained in RA, even in advanced radiologic changes (Larsen stages 1–3). In early stages of degenerative arthritis (Kellgren-Lawrence grades 0–2), patient satisfaction was also very high; however, decreased rapidly with increasing degree of radiologic changes. Kodama et al.7 described the use of arthroscopy to remove an entrapped volar plate in an irreducible MCP joint dislocation in an 11-year-old boy. During the reduction, they used a probe to push the torn proximal attachment of the volar plate palmarly while also pressing the metacarpal head dorsally. Postoperatively, they immobilized the finger in 60 degrees of flexion for 10 days. The patient regained full range of motion 3 weeks after surgery without any complications.

References 1. Ropars M, Fontaine I, Morandi X, et al. Preserving the superficial branch of the radial nerve during carpometacarpal and metacarpophalangeal joint arthroscopy: an anatomical study. Surg Radiol Anat. 2010 Mar;32(3):271-276, doi: 10.1007/ s00276-010-0622-8.

2. Rozmaryn LM, Wei N. Metacarpophalangeal arthroscopy. Arthroscopy. 1999 Apr;15(3):333-337. 3. Hidalgo-Diaz JJ, Ichihara S, Taleb C, et al. Metacarpophalangeal joint arthroscopy in the fingers other than the thumb: Retrospective comparison of horizontal versus vertical traction. Chir Main. 2015 Jun;34(3):105-108, doi: 10.1016/j. main.2015.02.003. 4. Ryu J, Fagan R. Arthroscopic treatment of acute complete thumb metacarpophalangeal ulnar collateral ligament tears. J Hand Surg Am. 1995 Nov;20(6):1037-1042, doi: S03635023(05)80156-X [pii]10.1016/S0363-5023(05)80156-X. 5. Slade JF 3rd, Gutow AP. Arthroscopy of the metacarpophalangeal joint. Hand Clin. 1999 Aug;15(3):501-527. 6. Choi AK, Chow EC, Ho PC, et al. Metacarpophalangeal joint arthroscopy: indications revisited. Hand Clin. 2011 Aug;27(3):369-382, doi: 10.1016/j.hcl.2011.05.007. 7. Sekiya I, Kobayashi M, Taneda Y, et al. Arthroscopy of the proximal interphalangeal and metacarpophalangeal joints in rheumatoid hands. Arthroscopy. 2002 Mar;18(3):292-297. 8. Sekiya I, Kobayashi M, Okamoto H, et al. Arthroscopic synovectomy of the metacarpophalangeal and proximal interphalangeal joints. Tech Hand Up Extrem Surg. 2008 Dec;12(4):221225, doi: 10.1097/BTH.0b013e31818ee8d4. 9. Ostendorf B, Dann P, Wedekind F, et al. Miniarthroscopy of metacarpophalangeal joints in rheumatoid arthritis. Rating of diagnostic value in synovitis staging and efficiency of synovial biopsy. J Rheumatol. 1999 Sep;26(9):1901-1908. 10. Ostendorf B, Peters R, Dann P, et al. Magnetic resonance imaging and miniarthroscopy of metacarpophalangeal joints: sensitive detection of morphologic changes in rheumatoid arthritis. Arthritis Rheum. 2001 Nov;44(11):2492-2502. 11. Borisch N. Metacarpophalangeal joint arthroscopy. Oper Orthop Traumatol. 2014 Dec;26(6):564-572, doi: 10.1007/ s00064-014-0313-4.

CHAPTER

23

Arthroscopic Treatment of First Metacarpal Base Fractures According to Edmonds,1 in 1882 Bennett first described a two-part intraarticular fracture at the base of the thumb metacarpal, which now bears his name. The Bennett fracture refers to an intraarticular fracture separating the volarulnar aspect of the metacarpal base from the remaining thumb metacarpal. The volar-ulnar fragment (Fig. 23.1) is held in place by its ligamentous attachment to the trapezium via the anterior oblique ligament (AOL) (a.k.a. the beak ligament).2 The injury is typically the result of an axial load on a partially flexed metacarpal. The metacarpal shaft subluxates in a dorsal, proximal, and radial direction due to the pull of the abductor pollicis longus (APL), extensor pollicis longus (EPL), extensor pollicis brevis (EPB), and the adductor pollicis longus (AdPL).

Ligament Anatomy and Biomechanics Imaeda et al.3 dissected the trapeziometacarpal (TM) joint of 30 cadaver specimens and described the anatomy and properties of 3 major ligaments. Bettinger et al.2 revisited this and further described 16 ligaments stabilizing the TM joint. The AOL is a two-part ligament that consists of a superficial portion and an intraarticular deep portion (Fig. 23.2). The superficial anterior oblique capsular ligament (sAOL) is immediately deep to the thenar musculature, which overlies the volar aspect of the TM joint and is superficial to the deep anterior oblique ligament (dAOL). 226

The ligament originates 0.5 mm proximal to the articular surface at the volar tubercle of the trapezium and inserts broadly over the volar-ulnar tubercle of the thumb metacarpal base, 2 mm distal to the volar styloid process. The sAOL is lax throughout most of the TM range of motion and becomes taut at the extremes of thumb pronation and extension. In a biomechanical study of 17 cadaver hands, Colman et al.4 found that the broad, loose, and curtain-like superficial portion of the ligament plays only a minor role in joint stability, does not prevent dorsal metacarpal subluxation, and limits the joint’s motion only in pronation. The dAOL, formerly known as the volar beak ligament, is an intraarticular ligament that lies deep to the sAOL. It originates from the volar central apex of the trapezium, ulnar to the ulnar edge of the trapezial ridge, and inserts into the articular margin ulnar to the volar styloid process (volar beak) of the thumb metacarpal base. The dAOL becomes taut with increasing thumb abduction, pronation, and extension. Colman et al.4 found the intraarticular dAOL to be a major stabilizer of the joint. Because it is the closest ligament to the center of the joint, it acts as a pivot point to guide the metacarpal during the pronation that occurs as a part of thumb opposition. Its intraarticular fibers run obliquely from distal-ulnar to proximal-radial; thus this ligament is positioned to prevent an ulnar shift of the metacarpal that would tighten the oblique fibers whereas a radial shift would slacken them. The sulcus between the sAOL and dAOL can often be palpated with an arthroscopic probe.

CHAPTER 23  |  Arthroscopic Treatment of First Metacarpal Base Fractures  227

compressed into its recess area in the trapezium. This dynamic force couple changes the TM joint from incongruity to congruity and from laxity to rigid stability. It changes a normally lax TM joint into a stable TM joint to support the powerful forces on the thumb in power pinch and grasp. Biomechanical studies performed by Cullen et al.7 noted that 2 mm of residual displacement at the articular surface resulted in an overall increase in contact area at the TM joint, with a dorsal shift in contact pressures over the trapezial surface. In addition, no important increase in contact pressure was seen in the area of the articular stepoff. The authors concluded that a 2-mm articular step-off is acceptable and should be well tolerated as long as the metacarpal was reduced. Such cadaveric studies are limited due to the constraints involved with use of contactpressure film.

* * * AOL

FIGURE 23.1 View of the volar ulnar fragment (asterisk) from the 1R portal, which is still attached to the anterior oblique ligament (AOL).

MTC

sAOL

dAOL

Diagnosis In addition to a physical examination, radiographic imaging is an essential part of a complete evaluation after thumb trauma. Because the thumb sits out of plane from the rest of the hand and fingers, special radiographic views are necessary. A true anteroposterior (AP) view of the thumb can be obtained with the hand hyperpronated so that the dorsum of the thumb lies against the radiographic plate. To obtain a true lateral radiograph of the TM joint, the palm of the hand must be placed flat on the cassette with the hand pronated 15 to 35 degrees; the x-ray beam is then directed 15 degrees in the distal-to-proximal direction. This image allows one to evaluate the TM joint and the 3 additional articulations of the trapezium: the trapezoid, the scaphoid, and index metacarpal. Gedda8 classified Bennett fractures into 3 types: Type 1 represents a fracture with a large single ulnar fragment and subluxation of the metacarpal base; type 2 represents an impaction fracture without subluxation of the thumb metacarpal; and type 3 represents an injury with a small ulnar avulsion fragment in association with metacarpal dislocation.

FIGURE 23.2 View of the right thumb from the dorsal portal looking volarly and radially. The superficial anterior oblique ligament (sAOL) and deep anterior oblique ligament (dAOL) seen from the 1-U portal. MTC, Metacarpal base.

Treatment

Edmunds6 emphasized the point that in the static resting position, the prominent volar beak of the thumb metacarpal is disengaged from its recess in the trapezium, the TM joint space is relatively large, and both the volar beak ligament and the dorsal ligament complex are lax. In the final phase of opposition during either active or passive screw-home torque rotation, the dorsal ligament complex tightens, the volar beak ligament becomes even more lax and redundant, the TM joint is compressed, and the volar beak of the thumb metacarpal is tightly

Nonoperative treatment has been associated with a bad outcome because external immobilization alone cannot control the radial subluxation of the thumb metacarpal. Surgical treatment options include a closed reduction with percutaneous pinning to the index metacarpal and/or to the trapezium with possible direct fixation of the fragment; an open reduction with either K-wires or interfragmentary fixation; and pinning combined with external fixation. Fracture reduction requires palmar abduction of the thumb and pronation of the metacarpal base, which places tension on the dorsal ligament complex. Direct pressure on the

228  SECTION VI  |  Small Joint Arthroscopy

A

B FIGURE 23.3 (A) Anatomically reduced fracture on fluoroscopy is found to have a 2-mm articular gap. (B) There is no further gap after an arthroscopic-assisted reduction.

metacarpal base may also be needed. Thumb extension causes fracture displacement. A Rolando fracture is a Y- or T-pattern fracture that includes the volar-ulnar Bennett fragment in addition to a dorsal radial fragment. This fracture pattern is more difficult to treat and has a worse prognosis than that of the Bennett fracture. It often requires an open reduction but the fracture is occasionally amenable to percutaneous techniques. The use of arthroscopy allows one to assess the articular reduction and to assess for any hardware penetration. The use of standard radiographs and fluoroscopy lead to an underestimation of the degree of articular incongruity. There are no published long-term, large prospective randomized studies, but most authors consider #2mm of intraarticular incongruity to be acceptable. In a recent study in 8 freshly frozen cadaveric hands, Capo et al. artificially created a Bennett fracture and then performed a closed reduction and pinning.9 Under fluoroscopic examination, the measured fracture step-off and displacement were less than 1.5 mm in all specimens. Standard radiographs demonstrated an average displacement of 0 mm on the AP view, a 0.1-mm gap on the lateral view, and an articular step-off of 1.1 mm. A direct examination of the joint surface, however, showed an average displacement of 3.1 mm on the AP view, an average articular gap of 0.9 mm, and an average step-off of 2.1 mm (Fig. 23.3A–B).

Surgical Technique The TM portals are well described in previous chapters. The 1-R portal and the 1-U portal are used interchangeably, but the fracture line is seen at right angles, which sometimes makes it difficult to judge the quality of the reduction. The modified radial portal provides an ideal view of the thumb metacarpal base because it is in the same

plane as the fracture line, which facilitates the reduction   (Fig. 23.4A–D) (Video 23-1). The D-2 portal is most useful for instrumentation wherein a Freer elevator can be used to mobilize the medial fragment, especially when there is a delay to surgery. The thumb alone is placed in traction. This tends to place the thumb in some abduction and pronation and when combined with the traction it often provisionally reduces the fracture in the proximal-distal plane. The fracture fragments remain malrotated though because the metacarpal shaft fragment is extended and supinated. Keeping the portals open help prevent fogging. Intermittent irrigation is used as needed by attaching a 10-mL saline-filled syringe to the inflow portal and using a full radius resector for suction and debridement of hematoma. Blunt elevators and curettes can be used, but a dental pick is useful for both fracture manipulation and reduction. Two 0.45-mm K-wires are prepositioned at the metacarpal base but not crossing the fracture site. They can be used to manipulate the main shaft fragment in to pronation and abduction while holding the volar-ulnar fragment   reduced with the tip of the dental pick (Video 23-2). Once an acceptable reduction has been achieved, it is captured by driving the K-wires across the fracture line (Fig. 23.5A–G). One K-wire is usually insufficient to control rotation. In early malunions, a Freer elevator can be placed into the D-2 portal and used to mobilize the medial fragment   (Fig. 23.6A–F) (Video 23-3). After the elevator is placed, the fracture is reduced and pinned as described earlier. In the case of a T-condylar fracture, the D-2 portal can be used for direct reduction of the medial fragment (Fig. 23.7A–D). If there is significant metaphyseal comminution, as in a Rolando fracture, the thumb metacarpal is distracted and pinned to the index metacarpal to maintain the reduction of the comminuted shaft fragments (Fig. 23.8A–E). Articular pinning may also be necessary. A thumb spica splint is used for 4 to 6 weeks followed by K-wire removal and range of motion exercises.

CHAPTER 23  |  Arthroscopic Treatment of First Metacarpal Base Fractures  229

MTC

sAOL

Tm A

B

MTC

**

**

MTC AOL Tm

C

D FIGURE 23.4 (A) Bennett fracture with a small medial fragment and lateral subluxation

of the thumb metacarpal. (B) View from the 1-R portal of a needle being inserted through the modified radial portal. MTC, Metacarpal base; sAOL, superficial anterior oblique ligament; TM, trapezium. (C) View of the reduction of the metacarpal base against the medial articular fragment (asterisk) from the 1-R portal. Note that the fracture line is 90 degrees to the angle of view. AOL, Anterior oblique ligament; MTC, metacarpal base. (D) View from the modified radial portal of the reduction of the metacarpal base (MTC) against the medial articular fragment (asterisk). Note that the fracture line is parallel to the angle of view.

Outcomes There are no published series on the arthroscopic treatment of Bennett fractures. A review of the results of open treatment, though, can provide some insights. Closed reduction and casting have a poor outcome. Cannon et al.10 reviewed 25 patients treated with plaster immobilization at a mean follow-up of 9.6 yrs. Of these patients, 10 were asymptomatic but there was a loss of motion in 21 patients, malrotation of the thumb in 5 patients,

and varus angulation in 23 patients. There was a .1 mm gap in 16 patients. Oosterbos et al.11 reviewed the treatment and results of 20 patients with Bennett fractures, treated by closed reduction and plaster immobilization. At a 13-year follow-up, 18 patients had a subjectively satisfactory outcome, 7 patients had osteoarthritis (OA) on radiographs (with a nonanatomic reduction in 6 out of 7), and 2 out of 7 patients had severe impairment. The current standard of treatment is for some type of surgical fixation. Timmenga et al.12 reviewed 18 patients

230  SECTION VI  |  Small Joint Arthroscopy

MTC

A

B

C

E

D

F

G

FIGURE 23.5 (A) AP view of a Bennett fracture. (B) View from the 1R portal with the dental pick in the fracture line. MTC, Metacarpal base. (C) Reduction is held with the dental pick while the K-wires are driven in to capture the reduction. (D) Reinsertion of the scope. (E) Anatomic reduction of the fracture line (arrow). (F) Thumb metacarpal is pinned to the index metacarpal with direct fixation of the fragment with two additional wires. (G) Healed fracture in an anatomic position.

CHAPTER 23  |  Arthroscopic Treatment of First Metacarpal Base Fractures  231

4 wks A

B

C

D

E

F FIGURE 23.6 (A) AP fluoroscopic view of a 4-week-old malunited Bennett fracture.

(B) Arthroscopic view from the 1-U portal illustrating the step-off and exposed cancellous bone. (C) A dental pick is being used to break down the malunion from within the joint. (D) A Freer elevator used to pry apart the early metaphyseal callus in the D-2 portal. (E) Anatomical reduction of the articular surface viewed from the 1-U portal. (F) AP fluoroscopic view after K-wire fixation.

232  SECTION VI  |  Small Joint Arthroscopy

FIGURE 23.7 (A) T-condylar fracture of the thumb metacarpal base. (B) Arthroscopic assessment reveals the articular comminution. (C) A Freer elevator is used to aid the articular reduction in the D-2 portal. (D) K-wire fixation of the fragments.

with Bennett fractures at a mean follow-up of 10.7 years. Treatment consisted of closed reduction and K-wire fixation in 7 cases, and open reduction with osteosynthesis in 11 cases. The strength of the affected hand was decreased in all patients regardless of the type of treatment. OA was found to correlate with the quality of reduction of the fracture, but had developed in almost all cases even after an exact reduction. Demir et al.13 reviewed 30 patients treated with percutaneous pinning (4) or internal fixation (26). Twenty-five patients were examined at an average followup of 39 months. Radiographically, the metacarpal base intraarticular gap/step-off was ,1 mm in 63%, between 1 and 2 mm in 27%, and .2 mm in 10%. Only 12 out of 25 were free of symptoms. A total of 64% had TM OA. Kjaer-Petersen et al.14 reported on 41 patients with Bennett fractures. An excellent position was obtained in 5 out of 9 fractures treated by closed reduction and plaster

immobilization, in 4 out of 6 fractures treated by percutaneous K-wire fixation, and in 18 out of 26 fractures treated by open reduction. After a median interval of 7.3 years, 15 out of 18 of the reviewed patients with fractures that had healed in excellent position were free of symptoms, but this was so in only 6 out of 13 fractures with residual displacement. OA was found in 3 out of 14 patients with excellent reduction and in 7 out of 10 patients with residual displacement. From these studies it is evident that the quality of the reduction correlates with the development of OA at the TM joint, which makes a strong argument for an arthroscopic-assisted reduction, because fluoroscopy underestimates the residual degree of incongruity. Like other joints, however, the radiographic appearance of TM OA is not directly correlated with the patient’s symptoms at the medium term follow-up.

CHAPTER 23  |  Arthroscopic Treatment of First Metacarpal Base Fractures  233

MTC

**

A

B

MTC

**

C

D

E

FIGURE 23.8 (A) AP radiograph of a Rolando fracture. (B) Arthroscopic view of the volar fracture line through the 1-U portal. (C) Reduction of volar ulnar fragment (asterisk). MTC, Metacarpal shaft. (D) The radial articular fragment is reduced with ligamentotaxis by K-wiring the distracted thumb metacarpal to the index metacarpal. (E) Healed fracture with some residual articular incongruity laterally.

References 1. Edmunds JO. Traumatic dislocations and instability of the trapeziometacarpal joint of the thumb. Hand Clin. 2006;22:365-392. 2. Bettinger PC, Linscheid RL, Berger RA, et al. An anatomic study of the stabilizing ligaments of the trapezium and trapeziometacarpal joint. J Hand Surg. 1999;24:786-798. 3. Imaeda T, An KN, Cooney WP 3rd, et al. Anatomy of trapeziometacarpal ligaments. J Hand Surg Am. 1993;18: 226-231. 4. Colman M, Mass DP, Draganich LF. Effects of the deep anterior oblique and dorsoradial ligaments on trapeziometacarpal joint stability. J Hand Surg Am. 2007;32:310-317. 5. Bettinger PC, Smutz WP, Linscheid RL, et al. Material properties of the trapezial and trapeziometacarpal ligaments. J Hand Surg Am. 2000;25:1085-1095. 6. Edmunds JO. Current concepts of the anatomy of the thumb trapeziometacarpal joint. J Hand Surg. 2011;36:170-182. 7. Cullen JP, Parentis MA, Chinchilli VM, et al. Simulated Bennett fracture treated with closed reduction and percutaneous

pinning. A biomechanical analysis of residual incongruity of the joint. J Bone Joint Surg Am Vol. 1997;79:413-420. 8. Gedda KO. Studies on Bennett’s fracture; anatomy, roentgenology, and therapy. Acta Chir Scand Suppl. 1954;193:1-114. 9. Capo JT, Kinchelow T, Orillaza NS, et al. Accuracy of fluoroscopy in closed reduction and percutaneous fixation of simulated Bennett’s fracture. J Hand Surg Am. 2009;34:637-641. 10. Cannon SR, Dowd GS, Williams DH, et al. A long-term study following Bennett’s fracture. J Hand Surg. 1986;11:426-431. 11. Oosterbos CJ, de Boer HH. Nonoperative treatment of Bennett’s fracture: a 13-year follow-up. J Orthop Trauma. 1995;9:23-27. 12. Timmenga EJ, Blokhuis TJ, Maas M, et al. Long-term evaluation of Bennett’s fracture. A comparison between open and closed reduction. J Hand Surg. 1994;19:373-377. 13. Demir E, Unglaub F, Wittemann M, et al. Surgically treated intraarticular fractures of the trapeziometacarpal joint—a clinical and radiological outcome study. Der Unfallchirurg. 2006;109:13-21. 14. Kjaer-Petersen K, Langhoff O, Andersen K. Bennett’s fracture. J Hand Surg. 1990;15:58–61.

CHAPTER

24

Arthroscopic Reduction and Percutaneous Fixation of Fifth Carpometacarpal Fracture Dislocations Rationale Arthroscopy of the first carpometacarpal (CMC) joint has become routine. The literature contains multiple reports of arthroscopic-guided reduction and percutaneous pin fixation of Bennett fractures involving the first CMC joint. The same techniques can be applied to fracture dislocations involving the fifth CMC joint. This is one situation where arthroscopy is especially beneficial because the articular fracture fragment is often volar and difficult to visualize and reduce from a dorsal approach.

Anatomy and Pathomechanics Nakamura et al. studied 80 cadaver arms and described the CMC joint detail.1 Two distinct dorsal ligaments were identified that attached to the dorsal aspect of the fifth metacarpal (MC). One of these extended from the ulnar base of the fifth MC to the hamate (fifth MC ulnar side base to hamate ligament) and the other from the radial base of the fifth metacarpal to the hamate and sometimes to the fourth metacarpal ulnar base (fourth MC ulnar side base to fifth MC radial side base ligament). An intermetacarpal ligament attached the radial base of the fifth metacarpal to the ulnar base of the fourth metacarpal. One volar ligament 234

attached to the fifth MC base and extended either to the hook of the hamate or to the ulnar base of the fourth MC. There were no intraarticular ligaments except for one ligament that was located between the third and fourth MC and the capitate/hamate. Dzwierzynski et al. also studied the intermetacarpal ligament anatomy.2 They noted that the alignment of the interosseous ligaments between the fourth and fifth metacarpals differed from the ligament alignment between the second and third and third and fourth metacarpals, which allows a greater degree of motion in the fifth CMC joint (approximately 25 degrees of flexion/extension) compared with the fourth CMC joint (approximately 15 degrees of flexion/extension). They also observed that when these metacarpals flex at the CMC joints, as in grasping, the dorsal interosseous ligament tightens and the anterior interosseous ligament relaxes. When the metacarpals extend at the CMC joints, the anterior ligament tightens and the posterior ligament relaxes, which retains a rigid interconnection between the bones. An axial load to the fourth and fifth metacarpal heads secondary to a clenched fist blow is often cited as the most common mechanism of injury of a fracture dislocation of the fifth CM joint. In one clinical study, the authors postulated that flexion during impact results in a dorsal dislocation of the small finger MC base, dorsal CMC ligament disruption, and oftentimes a hamate dorsal rim fracture.3

CHAPTER 24  |  Arthroscopic Reduction and Percutaneous Fixation  235

Yoshida et al. attempted to reproduce the mechanism of injury in a cadaver study by dropping an 8 kg weight from various heights onto the fourth and fifth metacarpal heads in a specially designed jig.4 The hand was placed in the clenched fist position with the ring CMC joint in 20 degrees of flexion, the small CMC joint in 30 degrees of flexion, and the wrist in 20 degrees of extension. A dorsal hamate fracture occurred in 45% of the specimens, whereas a fracture of the volar aspect of the ring and small finger MC base was present in 40% and 20% of the specimens, respectively. The small metacarpal volar-based fracture fragment remained attached to the ring MC ulnar-side base–small MC radial-side base ligament.

Imaging Anteroposterior (AP) and lateral radiographs do not allow for an accurate assessment because the ring and small CMC joints are obscured by overlap of the hamate on the MC bases. Cain et al. noted that a 45-degree pronation oblique view allowed for a good assessment of injuries to both the ring and small metacarpals.3 Occasionally a 15-degree pronation oblique projection is required to assess damage to the dorsal portion of the small finger CMC joint.4

Equipment and Implants Generally, a 2.7-mm 30-degree angled scope along with a camera attachment is used, although a 1.9-mm scope can be substituted. A 3-mm hook probe is needed for palpation of intracarpal structures. At least 10 to 15 pounds of traction is crucial to the success of the procedure, either with a

traction tower or some other type of overhead traction. A motorized 2.9-mm full-radius resector is needed for debridement of hematoma, and small curettes and a dental hook are required for manipulation of the fracture fragments. The procedure is done with a fluoroscopic assist.

Surgical Technique The patient is positioned supine on the operating table with the arm extended on a hand table. The small and ring fingers are suspended by Chinese finger traps with 10 to 15 pounds of countertraction. The relevant landmarks are outlined, including the proximal and dorsal edge of the fifth metacarpal base, the extensor carpi ulnaris (ECU) tendon and, if possible, the extensor tendons to the small and ring fingers. The procedure is performed with a tourniquet elevated to 250 mm Hg. It is my preference to use a dry technique with intermittent saline irrigation through the scope using a 10 mL syringe and suction using the full-radius resector, akin to the technique described by Del Pinal for wrist arthroscopy.5 Two main portals are used (Fig. 24.1A–B): the ulnar portal, or fifth metacarpohamate portal (5-MH), which is located between the fifth MC ulnar side base—hamate ligament and the extensor digiti quinti tendon, at the level of the CMC joint; and the radial portal, or the fourth metacarpo-hamate portal (4-MH), which is just radial to the fourth MC ulnar side base—hamate ligament extensor tendon to the ring finger. Each joint is localized with a 22-gauge needle followed by injection of 2 mL of saline. This step may be facilitated by fluoroscopy. A small transverse skin incision is made followed by wound-spread technique with tenotomy scissors. The capsule is pierced, and a cannula and blunt trocar are inserted followed by the arthroscope. The portals are interchangeably used to systematically inspect the joint, which is facilitated by judicious

5-A portal 6U portal

ECU

DCBUN

H DCBUN

A

EDM

FCU

B

FIGURE 24.1 (A) Cadaver dissection demonstrating the position of the two dorsal ar-

throscopy portals at the base of the 4th and 5th metacarpal bases (radio buttons) in relation to the metacarpo-hamate (MH) ligaments (in white). DCBUN, Dorsal cutaneous branch of the ulnar nerve; EDM, extensor digiti minimi; H, hamate. (B) Lateral view demonstrating the relative position of the 5-A (accessory) portal, which is located at the level of the fifth carpometacarpal (CMC) joint, volar to the extensor carpi ulnaris (ECU). FCU, Flexor carpi ulnaris; UN, ulnar nerve.

UN

236  SECTION VI  |  Small Joint Arthroscopy

FIGURE 24.2 (A) AP view of a fracture dislocation of the fifth metacarpal (MC) car-

pometacarpal (CMC) joint. (B) Lateral view shows the dorsal subluxation of the fifth metacarpal base and a comminuted dorsal hamate rim fracture. (C) Lateral CT scan demonstrating the volar articular fragment.

use of a 2.9-mm resector. An accessory portal (5-A) can facilitate triangulation and is located along the ulnar base of the fifth metacarpal just dorsal to the hypothenar muscles and approximately 1 cm distal to the 6-U wrist arthroscopy portal. There is no internervous plain, and injury to the dorsal cutaneous branch of the ulnar nerve (DCBUN) is a risk with all of these portals, hence careful wound-spread technique is mandatory. Fig. 24.2 shows the characteristic radiographic appearance of a fracture subluxation of the fifth CMC joint. The dorsal subluxation of the fifth metacarpal base can be reduced by inserting a Freer elevator through the 5-MH portal at the base of the fifth metacarpal (Fig. 24.3A–C). The 4-MH portal is established as previously described, followed by insertion of the blunt trocar and cannula, and then the arthroscope. A 2.9-mm full-radius resector is inserted through the 5-MH portal and interchanged with a curette for debridement of the fracture debris. The 4-MH can be used as the viewing portal with the 5-MH as the working portal. A 0.045-mm K-wire can be inserted into the volar articular fragment and metacarpal base, and used to

manipulate the fragments. The volar articular fragment often remains attached to the fourth MTC base through an intact intermetacarpal ligament (Fig. 24.4A–C). This prevents displacement of the volar articular fragment, similar to the Bennett fracture fragment, which remains attached to   the first intermetacarpal ligament (Video 24-1). A useful maneuver is to pull the volar articular fragment dorsally with a dental pick while pushing volarly on the metacarpal base to reduce the fracture gap. Prepositioned K-wires inserted in both of the fracture fragments are then advanced to capture the reduction. It is often necessary to cross pin the fifth CMC joint to the hamate or capitate for 4 to 6 weeks to prevent recurrent dorsal subluxation (Fig. 24.5A–C).

Postoperative Management The small and ring fingers are immobilized in a finger spica splint for 4 weeks followed by protected finger motion. If

FIGURE 24.3 (A) Percutaneous insertion of a Freer elevator. (B) Lateral view with the Freer elevator in the fifth carpometacarpal (CMC) joint. (C) Percutaneous reduction of the dorsal subluxation of the fifth metacarpal (MC) base.

CHAPTER 24  |  Arthroscopic Reduction and Percutaneous Fixation  237

MC base

VF

**

**

VF

A

B

MC base

VF

C

the fixation is stable, passive and active MCP joint flexion can be instituted early on. The K-wires are removed at 6 weeks postoperatively. Strengthening ensues once motion has been restored. Clenched fist striking, and contact and ball sports are allowed at 12 weeks but may be permitted sooner if a playing cast or orthosis is used.

FIGURE 24.4 (A) View of the volar articular fragment (VF) of the fifth metacarpal (MC) base with the scope in the fourth metacarpo-hamate (4-MH) portal demonstrating the attached intermetacarpal ligament (asterisk). (B) The fracture gap (asterisk) is visualized by angling the scope dorsally and distally. MC base, Dorsal metacarpal base. (C) Reduction of the fracture gap. MC base, Dorsal metacarpal base; VF, volar articular fragment.

subluxation of the fifth metacarpal base can be minimized by temporary K-wire fixation of the fifth CMC joint to allow ligamentous healing and internal fixation of any significant sized dorsal hamate rim fractures.

Outcomes Complications Potential complications of this procedure include injury to the DCBUN, which cloaks the operative field. Direct or indirect extensor tendon injury or postoperative extensor tendon adhesions can be minimized by careful operative technique during the establishment of the portals and insertion of the K-wires, and by the institution of early finger motion. Iatrogenic articular damage can be minimized by using smalljoint instruments and joint distraction. Recurrent dorsal

No series of this technique have been published at this time. Early results with this procedure are encouraging though (Fig. 24.6A–D).6 The technique of small-joint arthroscopy is especially useful because the fifth MC volar articular fragment can usually only be visualized by retraction of the dorsal MC base, which can be quite arduous. In addition, once the fracture fragments are reduced through an open incision, the fracture lines can no longer be directly visualized without forceful manual distraction of the fifth MC. The use of arthroscopy provides a magnified

238  SECTION VI  |  Small Joint Arthroscopy

FIGURE 24.5 (A) Postoperative AP view demonstrating an anatomic reduction of the fracture fragments. (B) 15-degree pronation oblique view highlighting the reduction of the dorsal subluxation of the fifth metacarpal base. (C) Lateral view showing a congruent joint reduction.

B

A

6 wks

FIGURE 24.6 (A) AP view at 6 weeks after K-wire removal showing an anatomic union of the fracture fragments. (B) Lateral view demonstrating maintenance of the joint reduction. (C, D) Clinical photographs demonstrating normal finger range of motion at 6 weeks.

C

6 wks

D

6 wks

CHAPTER 24  |  Arthroscopic Reduction and Percutaneous Fixation  239

view of the fracture line and the ability to directly visualize the quality of the articular reduction. Akin to other joints, however, an anatomic reduction of the articular surface is desirable but there are no data to establish that this results in improved clinical outcomes. Long-term follow-up is unavailable as yet, hence this procedure should be viewed as a useful adjunctive technique in the treatment of a fracture dislocation of the fifth CMC joint, but it is unlikely to supplant the more time-tested open procedures.

References 1. Nakamura K, Patterson RM, Viegas SF. The ligament and skeletal anatomy of the second through fifth carpometacarpal joints and adjacent structures. J Hand Surg Am. 2001;26:1016-1029.

2. Dzwierzynski WW, Matloub HS, Yan JG, et al. Anatomy of the intermetacarpal ligaments of the carpometacarpal joints of the fingers. J Hand Surg Am. 1997;22:931-934. 3. Cain JE Jr, Shepler TR, Wilson MR. Hamatometacarpal fracture-dislocation: classification and treatment. J Hand Surg Am. 1987;12:762-767. 4. Yoshida R, Shah MA, Patterson RM, et al. Anatomy and pathomechanics of ring and small finger carpometacarpal joint injuries. J Hand Surg Am. 2003;28:1035-1043. 5. Del Pinal F, Garcia-Bernal FJ, Pisani D, et al. Dry arthroscopy of the wrist: surgical technique. J Hand Surg Am. 2007; 32:119-123. 6. Slutsky DJ. Arthroscopic reduction and percutaneous fixation of fifth carpometacarpal fracture dislocations. Hand Clin. 2011;27:361-367.

CHAPTER

25

Arthroscopic Treatment of Trapeziometacarpal Osteoarthritis Biomechanics and Anatomy One longitudinal radiographic study of 751 patients over a 24-year period showed that in those without osteoarthritis (OA) at baseline, women had more incidence of disease than men in almost all hand joints, but the joints most frequently affected were the same in both sexes: the distal interphalangeal (DIP), followed by the base of the thumb.1 In another radiographic study of 3327 men and women between the ages of 40 and 80 1, 21% had involvement of the trapeziometacarpal (TM) joint.2 The age-adjusted prevalence of carpometacarpal (CMC) arthritis based on radiographic evidence has been reported to be 15% for the female population and 7% for the male population.3 The prevalence increases to 33% for the postmenopausal female population. OA is not merely a wear-and-tear or age-related phenomenon; it is a common disease of articular cartilage that becomes more prevalent with advancing age. The deep anterior oblique ligament (dAOL) and the dorsoradial ligament (DRL) have been shown to be the principal checkreins to dorsal subluxation during physiologic motion of the TM joint. During key pinch, the incongruity of the articular surfaces causes apex loading on the volar articular surface of the trapezium, which transmits loads that are as high as 13 times the joint reactive force. In a biomechanical study, Cooney and Chao demonstrated that a pinch force of 1 kilograms at the thumb tip was amplified to 3.68 kilograms at the interphalangeal (IP) joint, 6.61 kilograms at the metacarpophalangeal (MCP) joint, and up 240

to 13.42 kilograms at the TM joint. The typical joint compression forces averaged 3 kilograms of force at the IP joint, 5.4 kilograms at the MCP joint, and 12.0 kilograms at the TM joint during simple pinch. Compression forces of as much as 120 kilograms can occur at the TM joint during strong grasp.4 Because of the repeated eccentric loading, osteoarthritic changes begin volarly. Any laxity or incompetence to the anterior oblique ligament (AOL) allows this fulcrum to move dorsally and adds to the eccentric force concentration. The alterations in the contact forces, which may occur after injury or surgery to the TM joint due to ligamentous insufficiency, can lead to even higher forces that can accentuate the wear on the articular cartilage. Posttraumatic OA can also be seen after malreduced intraarticular fractures or sepsis. Imaeda et al. from the Mayo clinic biomechanics lab dissected the TM joint of 30 cadaver specimens and described the anatomy and properties of three major ligaments.5 Bettinger et al. from the Mayo group revisited this and further described 16 ligaments stabilizing the TM joint.6 The AOL is a two-part ligament that consists of a superficial portion and an intraarticular deep portion. The superficial anterior oblique capsular ligament (sAOL) is immediately deep to the thenar musculature, which overlies the volar aspect of the TM joint and is superficial to the dAOL. The ligament originates 0.5 mm proximal to the articular surface at the volar tubercle of the trapezium, and inserts broadly over the volar ulnar tubercle of the thumb metacarpal base, 2 mm distal to the volar styloid process. The sAOL is lax throughout most of the TM range of motion and becomes taut at the extremes of thumb pronation and extension. In a

CHAPTER 25  |  Arthroscopic Treatment of Trapeziometacarpal Osteoarthritis  241

biomechanical study of 17 cadaver hands, Colman et al.7 found that the broad, loose, and curtainlike superficial portion of the ligament plays only a minor role in joint stability, does not prevent dorsal metacarpal subluxation, and limits the joint’s motion only in pronation. The dAOL, formerly known as the volar beak ligament, is an intraarticular ligament that lies deep to the sAOL. It originates from the volar central apex of the trapezium, ulnar to the ulnar edge of the trapezial ridge, and inserts into the articular margin ulnar to the volar styloid process (volar beak) of the thumb metacarpal base. The dAOL becomes taut with increasing thumb abduction, pronation, and extension. Colman et al.7 found the intraarticular dAOL to be a major stabilizer of the joint. Because it is the closest ligament to the center of the joint, it acts as a pivot point to guide the metacarpal during the pronation that occurs as a part of thumb opposition. Its intraarticular fibers run obliquely from distal-ulnar to proximal-radial; thus this ligament is positioned to prevent an ulnar shift of the metacarpal, which would tighten the oblique fibers whereas a radial shift would slacken them. The sulcus between the sAOL and dAOL can often be palpated with an arthroscopic probe. Fenestrations of tears of the AOL permit arthroscopic views of the flexor carpi radialis (FCR). The ulnar collateral ligament (UCL) is an extracapsular ligament that is slightly ulnar to and superficial to the sAOL. It originates from the flexor retinaculum, then runs obliquely from a palmar-proximal position and attaches to the palmar-ulnar tubercle of the first metacarpal base. It is taut in extension, abduction, and pronation, and helps prevent volar subluxation of the metacarpal base. Arthroscopically, it is identified by its oblique fibers running ulnarly to the AOL. Tears of the UCL will reveal the thenar muscle fibers that run behind it. The dorsal aspect of the thumb is covered by two main ligaments. The posterior oblique ligament (POL) is an intracapsular ligament that originates from a fan-shaped base on the dorsoulnar side of the trapezium immediately ulnar to the DRL. It runs obliquely to insert into the dorsoulnar aspect and palmar-ulnar tubercle of the first metacarpal base. This ligament is taut at the extremes of abduction, opposition, and supination, which prevent ulnar translation of the thumb metacarpal base during opposition and abduction. The DRL is the shortest, thickest, and widest ligament that spans the joint. The DRL is a fan-shaped capsular ligament that arises from the dorsoradial tubercle of the trapezium and has a broad insertion into the dorsal base of the thumb metacarpal. It is believed to be the most important stabilizer that resists dorsal translation of the thumb metacarpal base and is a checkrein against radial subluxation. In a biomechanical study by Bettinger et al.8 the ultimate load to failure of the DRL (205.5 6 60.2 N) was significantly greater than the other ligaments, which they believed was due to the size and bulk of the ligament. The stiffness for the DRL (78.3 6 21.9 N/mm) was significantly higher than for the AOL (24.16 13.3 N/mm), and therefore likely to be the most significant restraint to lateral dislocation. The

AOL demonstrated the least stiffness and the greatest hysteresis, and was thought to be a poor stabilizer of the TMC joint. Edmunds emphasizes the point that in the static resting position, the prominent volar beak of the thumb metacarpal is disengaged from its recess in the trapezium, the TM joint space is relatively large, and both the dAOL and the dorsal ligament complex are lax. In the final phase of opposition, during either active or passive screw-home torque rotation, the dorsal ligament complex tightens, the dAOL becomes even more lax and redundant, the TM joint is compressed, and the volar beak of the thumb metacarpal is tightly compressed into its recess area in the trapezium. This dynamic force couple changes the TM joint from incongruity to congruity and from laxity to rigid stability. It changes a normally lax TM joint into a stable TM joint to support the powerful forces on the thumb in power pinch and grasp.9 If the dorsal ligament complex is cut or torn (as occurs in a pure TM dislocation) gross instability of the TM joint results, and the joint dislocates even if the dAOL is intact.

Trapeziometacarpal Joint Portals   (Video 25-1) Menon initially presented his work on arthroscopy of the TM joint at a meeting exhibit in 1994.10 He then published his experience with the arthroscopic management of TM arthritis in 1996.11 He described two working portals, a volar portal just radial to the abductor pollicis longus (APL) tendon and a dorsal portal that is just ulnar to the APL along the line of the joint. Berger independently developed his technique for arthroscopic evaluation of the first carpometacarpal joint, which he first presented as an instructional course in 1995. He then published his clinical work in 1997. He named the volar radial portal the 1-R portal and the dorsoulnar portal the 1-U (Fig. 25.1A–D).12 Orrellana and Chow described a modified radial portal (RP) for improving the radial view of the TM joint.14 The RP is located just distal to the oblique ridge of the trapezium following a line along the radial border of the FCR tendon rather than the APL (Fig. 25.2A–C). A thenar portal was subsequently described by Walsh et al.14 This portal is placed by illuminating the thenar eminence with the arthroscope in the 1-U portal, and then inserting an 18-gauge needle through the bulk of the thenar muscles at the level of the TM joint, approximately 90 degrees from the 1-U portal. Access to medial osteophytes may sometimes be difficult; hence I have found the use of a distaldorsal (D-2) accessory portal to be of some value.15 Its main utility is that it allows one to look down on the trapezium rather than across it, which facilitates resection of medial osteophytes (Fig. 25.3A–E). This accessory portal allows views of the dorsal capsule (DC) with rotation of the scope, and it facilitates triangulation of the instrumentation. It is situated in the dorsal aspect of the first web space. An anatomical study of 5 cadaver hands revealed that the D-2 portal surface landmark is ulnar to the extensor

242  SECTION VI  |  Small Joint Arthroscopy

D-2 1-U

1-R

EPL

STT-R APL

EPB

RA

A

B

MTC

sAOL

sAOL

Trapezium

C

dAOL

D FIGURE 25.1 (A) Surface landmarks for trapeziometacarpal (TM) and scaphotrapeziotrapezoidal (STT) portals. APL, Abductor pollicis longus; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; RA, radial artery. (B) Direction scope in 1-R portal. (C) View of the trapezium from the 1-R portal (sAOL). (D) View of the superficial anterior oblique ligament (sAOL) and deep anterior oblique ligament (dAOL).

pollicis longus (EPL) tendon and 1 cm distal to the -shaped cleft at the juncture of the index and thumb metacarpal bases. The portal lies just distal to the dorsal intermetacarpal ligament (DIML). There is no true safe zone for the D-2 portal due to the first dorsal metacarpal artery and its branches, and branches of the superficial radial nerve (SRN);16 therefore wound-spread technique is paramount. Hugging the ulnar border of the thumb metacarpal and moving 1 cm distal to the thumb/index metacarpal juncture increases the space between the portal and the radial artery.

Diagnosis The patient who presents with basal joint arthritis may complain of palmar-sided pain, which is frequently localized to the thenar eminence and may radiate up the radial wrist. Complaints of thumb weakness and clumsiness with fine manipulation tasks are common. On inspection, one may see a prominent TM joint due to lateral subluxation of the thumb metacarpal base with or without marginal osteophytes and synovitis. There is often a loss of joint motion, especially thumb retropulsion, and a contracted first web

CHAPTER 25  |  Arthroscopic Treatment of Trapeziometacarpal Osteoarthritis  243

MTC

A

sAOL MTC

Tm

B

TM

C FIGURE 25.2 (A) Outside view of the scope in the modified radial portal and the probe

in the 1-U portal. (B) Arthroscopic view from the 1-U portal of a 22-gauge needle inserted through the modified radial portal. MTC, Metacarpal base; Tm, trapezium. (C) The modified radial portal allows one to look across the articular surface of the distal trapezium (TM). MTC, Metacarpal base.

1-R

1-U

D-2

D-2

1 cm

A

B

C

FIGURE 25.3 (A) Drawing of the relative position of the D-2 portal. (B) Angle of instru-

ments in the D-2 portal. Note how the angle looks down on the medial trapezium, which facilitates resection of medial osteophytes. (C) Needle placement for the D-2 portal. Continued

244  SECTION VI  |  Small Joint Arthroscopy

Needle Scope

D

E FIGURE 25.3, cont’d (D) Fluoroscopic view of scope and needle. (E) View of the medial trapezium from the D-2 portal after resection of the medial osteophyte.

space that interferes with grasping large objects. MCP joint hyperextension may occur as an adaptive response to increase the first web space span. Thenar muscle weakness and atrophy due to misuse might be present. A concomitant carpal tunnel syndrome, however, should be sought by history of sensory loss in the median nerve distribution and through physical findings, which include a Tinel sign over the carpal tunnel, and a positive Phalen test or median nerve compression test. On palpation, the patient will often have tenderness localized to the TM joint and the scaphoid tuberosity, and a positive scaphoid shift test, but this may also occur with scapholunate (SL) instability or scaphotrapeziotrapezoidal (STT) OA, which should be ruled out. FCR tendinitis can also present with tenderness over the scaphoid tuberosity. The TM grind test will be positive in the face of TM OA and can help to distinguish these entities. The test is performed by applying an axial load to the thumb metacarpal combined with manipulation of the metacarpal in a dorsal and volar direction. A positive test produces variable degrees of crepitus and pain depending on the stage of arthritis. Alterations in grip and pinch strengths are documented to gauge the effects of treatment, but are nonspecific findings. The radiographic evaluation of the thumb CMC joint includes a true anteroposterior (AP) view, which is performed by placing the forearm in maximum pronation with the dorsal aspect of the thumb resting on the radiograph table and taking a true lateral view. A radial stress view of the thumb can be performed by asking the patient to push the radial borders of their thumbs together. This can demonstrate the degree of joint laxity by the amount of lateral subluxation of the metacarpal base. Littler and Eaton described a radiographic staging classification of TM OA.17 Stage I comprises normal articular surfaces without joint space narrowing or sclerosis. Less than one-third subluxation of the metacarpal base might be present. Stage II reveals mild joint space narrowing, mild sclerosis, or osteophytes ,2 mm in diameter. Instability is evident on stress

views with greater than one-third subluxation. The STT joint is normal. In stage III, there is significant joint space narrowing, subchondral sclerosis, and peripheral osteophytes .2 mm in diameter but a normal STT joint. In stage IV there is pantrapezial OA with narrowing, sclerosis, and osteophytes involving both the TM and STT joints. Badia proposed a more specific classification based upon the arthroscopic changes.18 Stage I included intact articular cartilage, stage II included eburnation on the ulnar onethird of the metacarpal base and central trapezium, and stage III comprised widespread full-thickness cartilage loss on both surfaces.

Treatment Nonoperative Similar to other joints, the radiographic severity of osteoarthritic changes at the TM joint do not correlate with the severity of clinical symptoms. The main thrust of treatment is pain management. A trial of activity modification and splinting should in general be undertaken in any patient before any surgical consideration. This involves avoidance of any repetitive pinching or grasping activities and the use of assistive devices as needed. Therapy may be useful for retaining range motion and augmenting thumb stability whereas strengthening exercises are generally avoided while the patient has pain. NSAIDs are commonly used in addition to a limited number of selected cortisone injections in the TM joint for flare-ups or persistent pain that is unresponsive to conservative measures. Hyaluronic acid injections are still investigational but do not appear to be superior to steroid injections. The use of splints can provide pain relief and help enforce activity modification. In general, a forearm-based thumb spica splint with the thumb held in palmar abduction can be used on a full-time basis until the pain has been controlled, and then it can be

CHAPTER 25  |  Arthroscopic Treatment of Trapeziometacarpal Osteoarthritis  245

used intermittently as needed. Whether the IP joint is immobilized is largely dependent on patient and surgeon preference. A palmar-based thumb spica splint that immobilizes the TM joint by abducting the thumb can provide pain relief and may be more functional.

Arthroscopic Treatment Indications The main indication for surgery is basilar thumb pain that is unresponsive to conservative treatment. As a general rule, any patient who is an appropriate candidate for a hemiresection arthroplasty of the TM joint would also be suitable for an arthroscopic hemitrapeziectomy. This typically includes patients in Eaton stage II and stage III with unremitting pain despite appropriate conservative measures. This form of treatment does not preclude an open trapeziectomy and/or ligament reconstruction at a later date as a salvage procedure for failed arthroscopic surgery. The presence of Eaton stage IV disease is a relative contraindication to a hemitrapeziectomy, although a small series on successful arthroscopic resection arthroplasty for combined CMC and STT OA has been recently published.19

Precautions Any significant lateral subluxation of the thumb metacarpal base will not be corrected without some type of ligament reconstruction or capsular shrinkage, and may compromise the long-term result if not corrected. Conventional teaching has stated that MCP joint hyperextension must also be corrected to prevent recurrent TM subluxation, although this notion has been recently challenged.20

Contraindications Contraindications include distortion of the anatomy due to swelling, unstable or friable skin that would preclude the use of traction, and recent infection. Ehler-Danlos syndrome is a relative contraindication for this procedure although a successful arthroscopic tendon arthroplasty has been reported.21

Surgical Technique The patient is positioned supine on the operating table with the arm extended on a hand table. The thumb is suspended by Chinese finger traps with 10 to 15 pounds of countertraction, which forces the wrist into ulnar deviation. The relevant landmarks are outlined including the proximal and dorsal edge of the thumb metacarpal base, the tendons of the APL and EPL, and the radial artery in the snuffbox. The procedure is performed with a   tourniquet elevated to 250 mm Hg (Video 25-2). Saline

inflow irrigation is provided through the arthroscope and a small joint pump or pressure bag. I prefer using a 2.7-mm 30-degree angled scope with a camera attachment although others prefer the smaller 1.9-mm scope. A 3-mm hook probe is needed for palpation of intracarpal structures. A diathermy unit is required if capsular shrinkage is contemplated. Intraoperative fluoroscopy is employed to assess the adequacy of bone resection and for locating the portals as needed. To establish the 1-R portal, the thumb metacarpal base is palpated and the joint is identified with a 22-gauge needle just radial to the APL, followed by injection of 2 mL of saline. This step may be facilitated by fluoroscopy. A small skin incision is made followed by wound-spread technique with tenotomy scissors. The capsule is pierced and a cannula and blunt trocar are inserted, followed by the arthroscope. An identical procedure is used to establish the 1U portal, just ulnar to the EPB tendon, followed by insertion of a 3-mm hook probe. The portals are interchangeably used to systematically inspect the joint. The D-2 portal is used to facilitate resection of medial osteophytes (Fig. 25.4A–D). To establish the D-2 portal, the intersection of the base of the index and thumb metacarpal are identified just distal and ulnar to the EPL tendon. A 22-gauge needle is inserted 1 cm distal to this juncture and angled in a proximal, radial, and palmar direction, hugging the thumb metacarpal while viewing from either the 1-R or 1-U portal. A small skin incision is made and tenotomy scissors are used to spread the soft tissue and pierce the joint capsule. This is followed by insertion of a blunt trocar and cannula, and then the arthroscope or alternatively a hook probe, motorized shaver, or 2.9-mm burr.

Arthroscopic Debridement and Capsular Shrinkage The essence of arthroscopic capsular shrinkage is akin to that of a volar oblique ligament reconstruction. It relies on thermal heating of the collagenous fibers in the surrounding ligaments and capsule, followed by a period of joint   immobilization in a reduced position (Video 25-3). A motorized shaver is used to debride any synovitis and to expose   the capsular ligaments (Video 25-4). A diathermy probe is then employed to paint the volar oblique ligament and surrounding capsule, taking care to leave bands of tissue in between. The probe is kept away from the joint surfaces to prevent cartilage necrosis. In light of the meager joint volume, the outflow fluid temperature is frequently monitored to prevent overheating. Use of an 18-gauge needle in an accessory portal enhances fluid circulation, which minimizes this risk.

Arthroscopic Partial or Complete Trapeziectomy with Interposition After a partial or complete resection of the trapezium, autogenous tendon graft such as the palmaris longus, half of the FCR, or a slip of the APL is harvested through multiple

246  SECTION VI  |  Small Joint Arthroscopy

D-2 1-R

1-U

A

B

C

D FIGURE 25.4 (A) Outside view demonstrating triangulation of the instruments in all

three portals. (B) Fluoroscopic view of a residual medial osteophyte. (C) View from the D-2 portal of a resection of the medial osteophyte with the burr in the 1-R portal. (D) Fluoroscopic view demonstrating resection of the osteophyte.

transverse incisions. Landstrom recently reported a technique for harvesting an accessory slip of the APL by enlarging the 1-R portal.22 Alternatively, some other form of interposition material can be substituted. Menon reported a high incidence of cystic change following the use of Gortex, which is no longer recommended.11 An absorbable suture is placed in the leading end of the tendon graft and wedged onto a large curved needle, which is used to pass the graft through the joint. The needle is passed through the 1-U portal and brought out though the volar capsule and bulk of the thenar eminence. Traction on the suture pulls the graft into the joint. The remaining graft is packed in with forceps and the portals are closed. The thumb is K-wired in abduction for 4 weeks.

Arthroscopic Partial or Complete Trapeziectomy without Tendon Interposition The 1-R and 1-U portals are established as described. This procedure is often done dry with intermittent fluid irrigation to keep the subchondral bone moist and prevent a

  snowstorm effect (Video 25-5). The AOL is identified and preserved. After joint debridement, a 2.9-mm burr is applied in a to-and-fro manner to resect 3 to 4 mm of the   distal trapezium (Video 25-6). The diameter of the burr along with fluoroscopy provide a gauge as to the amount of bony resection. A larger 3.5-mm burr may be substituted as the space between the metacarpal base and distal trapezium enlarges. After the bony resection is complete, the thumb may be K-wired in a pronated and abducted position (Fig. 25.5A–I). If there is lateral subluxation of the metacarpal base, thermal shrinkage of the AOL can be performed at this time. The thumb is immobilized in abduction by cast or splint for 4 weeks for all of these procedures. The use of a temporary TM K-wire is largely up to the surgeon’s preference, and is removed at 4 weeks. Presently, I no longer use K-wire immobilization or thermal shrinkage. The patient is placed in a removable splint postoperatively followed by gentle range of motion exercises at 2 weeks and strengthening at 4 to 6 weeks. The patients are generally pain-free by 3 months. In the rare case of failure, the procedure can be salvaged with an open arthroplasty (Fig. 25.6A–I).

CHAPTER 25  |  Arthroscopic Treatment of Trapeziometacarpal Osteoarthritis  247

D-2

Osteophyte

1-R

Stress view

A

B

Left

C

Mild recurrence of osteophyte

Note resection of osteophyte 1-U portal

Trapezium

D

G

E

Stress view at 2 1/2 years

H

F

At 2 1/2 years

I

FIGURE 25.5 (A) A 55-year-old male with left trapeziometacarpal (TM) osteoarthritis

(OA). Note the large medial osteophyte arising from the trapezium. (B) Stress radiograph. (C) Arthroscopic TM arthroplasty. Scope in the D-2 portal and burr in the 1-R portal. (D) View from the D-2 portal with the burr in the 1-R portal. (E) Radiograph after partial trapeziectomy. (F) Radiograph 2½ years postoperatively. (G) Stress view demonstrating stability of TM joint. (H) Clinical appearance. (I) Normal motion.

Outcomes Menon reported his results on performing a partial arthroscopic resection of the trapezium and an interposition arthroplasty in 31 patients (33 hands).11 The mean age was 59 years (range, 48–81 yr) with an average follow-up of 37.6 months (range, 24–48 mo). Gortex was used in 19 patients and autogenous tendon or allograft in 14 patients. Complete

pain relief was obtained in 25 patients/hands (75.7%). Three patients had mild pain (4 hands) and 4 patients had persistent pain that required conversion to an open trapeziectomy and ligament reconstruction. All patients maintained their preoperative motion. Pinch strength improved from 6 psi. preoperatively to 11.1 psi. postoperatively. Because of osteolysis in 3 patients/4 hands, the use of Gortex as an interpositional substance was not recommended.

248  SECTION VI  |  Small Joint Arthroscopy MTC

** Tm

A

B

C

Tm

D

E

F

* *

G

H

I

FIGURE 25.6 Failed Arthroscopic Resection Arthroplasty.  (A) A 46-year-old female with painful right trapeziometacarpal (TM) joint 2 years following pinning of a fracture of the trapezium. (B) View from the 1-R portal demonstrating a loss of cartilage on the distal trapezium (TM). MTC, Metacarpal base. (C) Note the synovitis. (D) Resection of the trapezium. (E) Postoperative radiograph of a partial trapeziectomy. (F) Radiograph at 6 months postoperatively with patient complaining of persistent painful subluxation despite a negative grind test. (G) Arthroscopic view of the distal trapezium showing central area of fibrous ingrowth (arrow) surrounded by bare bone (asterisk). (H) View of the distal trapezium after resection, demonstrating the modes central area of fibrous ingrowth (arrow) surrounded by bare bone (asterisk). (I) Trapeziectomy and ligament suspension arthroplasty. Furia published his experience with arthroscopic debridement and synovectomy of the TM joint in 23 patients with Eaton stage I and stage II OA compared with a control group of 21 patients treated with nonoperative measures.23 The pretreatment mean pain ratings on the visual analog scale (VAS) were 7.7 and 7.5, and the DASH scores were 55.6 and 54.4. At the 1-year follow-up, the mean VAS were 2.7 and 7.3 and the DASH scores were 26 and 53.1. The mean pinch strength for the surgical and control groups was 6.2 1/- 1.3 kg and 4.9 1/- 1.1 kg.

Hofmeister et al. reviewed the long-term results in 18 patients following an arthroscopic hemitrapeziectomy, thermal capsular shrinkage, and temporary K-wire fixation.24 At an average follow-up of 7.6 years, they noted a subjective improvement in pain, pinch activities, strength, and range of motion in all patients. No patients required further surgery on their thumb. No patients had a first CMC grind or laxity by examination. The total thumb range of motion decreased by 20%, but all patients could oppose to the fifth finger. Grip strength remained

CHAPTER 25  |  Arthroscopic Treatment of Trapeziometacarpal Osteoarthritis  249

unchanged, key pinch improved from 8 to 11 pounds, and tip pinch improved from 4 to 5 pounds. Radiographs showed a metacarpal subsidence of 1.8 mm (range, 0–4 mm). Four complications were noted: two cases of dorsal radial nerve neuritis, one rupture of the flexor pollicis longus (FPL), and one prolonged hematoma. Edwards and Ramsey reported similar findings.25 They prospectively evaluated 23 patients with stage III OA at a minimum follow-up of 4 years, who were treated with pan arthroscopic hemitrapeziectomy and thermal capsular shrinkage, without interposition, plus K-wire fixation for 3 to 4 weeks. At 3 months postoperatively, the average DASH score improved from 61 to 10 and pain scores decreased from 8.3 to 1.5. Grip and key pinch strength improved 6.8 kg and 1.9 kg, respectively, and wrist and finger motion were unchanged. Proximal migration of the first metacarpal averaged 3 mm and translation decreased from 30% to 10%. These findings remained unchanged at 4 years or more. Pegoli et al. performed an arthroscopic hemitrapeziectomy and tendon interposition using the palmaris longus tendon in 16 patients with Eaton stage I and II disease.26 At 12 months postoperatively, there were 6 excellent, 6 good, 3 fair, and 1 poor result using the Modified Mayo Wrist Score (MMWS). Adams and Steinmann treated 17 patients with an arthroscopic debridement and interposition arthroplasty for stage II and III disease, using a folded acellular dermal matrix allograft.27 The average age was 61.7 (range, 47–86 yr) and the follow-up averaged 17 months (range, 6–39 mo). Eighty-eight percent of the patients reported no pain, or only occasional pain, during activities with an average pain score of 1.125 out of 10. The average grip strength was 18.3 postoperatively versus 22.6 kg preoperatively, and the average pinch strength was 4.0 kg versus 4.8 kg. Only two patients had limited range of motion, as assessed by the palm flat test and the ability to oppose the thumb to the fifth metacarpal head. None of the patients required revision surgery and there were no instances of graft reaction.

References 1. Chaisson CE, Zhang Y, McAlindon TE, et al. Radiographic hand osteoarthritis: incidence, patterns, and influence of preexisting disease in a population based sample. J Rheumatol. 1997;24:1337-1343. 2. Wilder FV, Barrett JP, Farina EJ. Joint-specific prevalence of osteoarthritis of the hand. Osteoarthritis Cartilage. 2006;14:953-957. 3. Xu L, Strauch RJ, Ateshian GA, et al. Topography of the osteoarthritic thumb carpometacarpal joint and its variations with regard to gender, age, site, and osteoarthritic stage. J Hand Surg Am. 1998;23:454-464. 4. Cooney WP 3rd, Chao EY. Biomechanical analysis of static forces in the thumb during hand function. J Bone Joint Surg Am. 1977;59:27-36. 5. Imaeda T, An KN, Cooney WP 3rd, et al. Anatomy of trapeziometacarpal ligaments. J Hand Surg Am. 1993;18:226-231. 6. Bettinger PC, Linscheid RL, Berger RA, et al. An anatomic study of the stabilizing ligaments of the trapezium and trapeziometacarpal joint. J Hand Surg Am. 1999;24:786-798.

7. Colman M, Mass DP, Draganich LF. Effects of the deep anterior oblique and dorsoradial ligaments on trapeziometacarpal joint stability. J Hand Surg Am. 2007;32:310-317. 8. Bettinger PC, Smutz WP, Linscheid RL, et al. Material properties of the trapezial and trapeziometacarpal ligaments. J Hand Surg Am. 2000;25:1085-1095. 9. Edmunds JO. Current concepts of the anatomy of the thumb trapeziometacarpal joint. J Hand Surg Am. 2011;36:170-182. 10. Menon J. Arthroscopic management of trapeziometacarpal joint arthritis of the thumb. Arthroscopy. 1996;12:581-587. 11. Menon J. Arthroscopic evaluation of the first carpometacarpal joint. J Hand Surg Am. 1998;23:757. 12. Berger RA. A technique for arthroscopic evaluation of the first carpometacarpal joint. J Hand Surg Am. 1997;22:10771080. 13. Orellana MA, Chow JC. Arthroscopic visualization of the thumb carpometacarpal joint: introduction and evaluation of a new radial portal. Arthroscopy. 2003;19:583-591. 14. Walsh DM, Howe TE, Johnson MI, et al. Transcutaneous electrical nerve stimulation for acute pain. Cochrane Database Syst Rev. 2009:CD006142. 15. Slutsky DJ. The use of a dorsal-distal portal in trapeziometacarpal arthroscopy. Arthroscopy. 2007;23:1244, e1-4. 16. Ropars M, Fontaine I, Morandi X, et al. Preserving the superficial branch of the radial nerve during carpometacarpal and metacarpophalangeal joint arthroscopy: an anatomical study. Surg Radiol Anat. 2010;32:271-276. 17. Eaton RG, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg Am. 1973;55:1655-1666. 18. Badia A. Trapeziometacarpal arthroscopy: a classification and treatment algorithm. Hand Clin. 2006;22:153-163. 19. Cobb T, Sterbank P, Lemke J. Arthroscopic resection arthroplasty for treatment of combined carpometacarpal and scaphotrapeziotrapezoid (pantrapezial) arthritis. J Hand Surg Am. 2011;36:413-419. 20. Poulter RJ, Davis TR. Management of hyperextension of the metacarpophalangeal joint in association with trapeziometacarpal joint osteoarthritis. J Hand Surg Eur Vol. 2011;36: 280-284. 21. Badia A, Riano F, Young LC. Bilateral arthroscopic tendon interposition arthroplasty of the thumb carpometacarpal joint in a patient with Ehlers-Danlos syndrome: a case report. J Hand Surg Am. 2005;30:673-676. 22. Landstrom JT. Radial portal tendon harvest and interposition in arthroscopic treatment of thumb basilar joint osteoarthritis. J Hand Surg Am. 2008;33:442-445. 23. Furia JP. Arthroscopic debridement and synovectomy for treating basal joint arthritis. Arthroscopy. 2010;26:34-40. 24. Hofmeister EP, Leak RS, Culp RW, et al. Arthroscopic hemitrapeziectomy for first carpometacarpal arthritis: results at 7-year follow-up. Hand (N.Y.). 2008;4:24-8. 25. Edwards SG, Ramsey PN. Prospective outcomes of stage III thumb carpometacarpal arthritis treated with arthroscopic hemitrapeziectomy and thermal capsular modification without interposition. J Hand Surg Am. 2010;35:566-571. 26. Pegoli L, Parolo C, Ogawa T, et al. Arthroscopic evaluation and treatment by tendon interpositional arthroplasty of first carpometacarpal joint arthritis. Hand Surg. 2007;12:35-39. 27. Adams JE, Merten SM, Steinmann SP. Arthroscopic interposition arthroplasty of the first carpometacarpal joint. J Hand Surg Eur Vol. 2007;32:268-274.

CHAPTER

26

Arthroscopic Treatment of Scaphotrapeziotrapezoidal Osteoarthritis Relevant Anatomy and Pathomechanics Isolated scaphotrapeziotrapezoidal (STT) osteoarthritis (OA) involves the distal scaphoid, trapezium, and trapezoid. The true incidence is uncertain because many patients with radiographic changes remain asymptomatic, but it is a common finding with advancing age. Bhatia et al. noted degenerative changes involving the STT joint in 61 out of 73 cadaver hands (average age, 84 yr).1 Moritomo et al. found similar STT changes in 64 out of 165 cadaver wrists (average age, 76 yr).2 In Watson’s series it affected 26% of patients who presented with painful degenerative arthritis involving the wrist.3 It has been reported to be a frequent finding in the presence of chondrocalcinosis.4 Although it may present as a primary form of arthritis, there is some evidence that STT OA is linked with carpal instability nondissociative (CIND) pattern. Ferris et al.5 surveyed the radiographs of 697 wrists in patients over 50 years old and found the combination of a dorsal intercalated segmental instability (DISI) deformity and STT OA in 16 wrists. Viegas et al.6 found a significant correlation between a membranous tear of the scapholunate interosseous ligament (SLIL) and the presence of cartilage erosion in the STT joint. Tay et al.7 also found that DISI was linked with STT OA in 26 patients. Distal scaphoid excision for the treatment of STT arthritis is an appealing treatment alternative to fusion because STT motion is retained and it does not carry the risk of nonunion or radial styloid impingement that can occur after a fusion. The procedure is not without consequences, 250

however. The proximal carpal row acts as an intercalated segment between the distal row and the radius and can be envisioned as a multilevel linkage that has the tendency to collapse in a Z-shaped manner. The distal row joint reactive forces are transmitted through the trapezium, which imparts a flexion moment to the long lever arm of the distal scaphoid. This is balanced by an equal and opposite extension moment, which is transmitted through the hamate to the triquetrum. Garcia-Elias and Lluch have likened the situation to a spring with a medial and lateral prong extending distally in divergent directions.8 Others have compared this to a twisted wash rag in which one end is twisted into flexion (the scaphoid) and the other end is twisted into extension (the triquetrum) with the lunate in between. In either event, if the distal scaphoid lever arm is shortened, the ulnar column takes control of the proximal row, causing the triquetrum to rotate into extension (taking the lunate with it) until a new equilibrium is reached. This produces a CIND pattern with a DISI deformity (CIND-DISI). In addition, the loads are shifted toward the capitolunate (CL) joint.8 The scaphoid bridges the proximal and distal rows of the carpus and articulates with the distal radius, the lunate, capitate, trapezium, and trapezoid. Moritomo et al. found an interfacet ridge dividing the distal scaphoid into a dorsoulnar and radiopalmar facet in 140 out of 165 cadaver wrists (Fig. 26.1). Wrists with scaphoids that have a wide dorsoulnar facet were more likely to have STT OA. The ulnar facet of the distal scaphoid was the most common location for degenerative changes as was the radial and central aspect of the trapezoid facet, more so than the trapezium.2 They also noted that the scaphoid axial plane is oriented in

CHAPTER 26  |  Arthroscopic Treatment of Scaphotrapeziotrapezoidal Osteoarthritis  251

M

Td Tm C

S L

FIGURE 26.1 Skeletal Anatomy.  Dorsal view of a dry bone

model of the left hand is used to illustrate the dorsoulnar facet (gray), which articulates with the trapezoid (Td) and the radiopalmar facet (green), which articulates with the trapezium (Tm). C, Capitate; L, lunate; M, thumb metacarpal; S, scaphoid.

An inclination of 70 degrees or more perpendicular relative to the third metacarpal axis had a significant correlation with the presence of degenerative changes in the STT joint. These same authors identified three distinct ligaments around the STT joint (Fig. 26.3A).2 The scaphotrapezial (ST) ligament is a V-shaped ligament composed of a radial and ulnar limb that originate from the radiopalmar aspect of the scaphoid tuberosity and attach to the trapezium and the trapezial ridge, respectively, and work as a collateral ligament in STT motion. The scaphocapitate (SC) ligament is a short ligament that originates from the palmar aspect of the scaphoid at the ulnar aspect of the border between the trapezoid facet and the capitate facet of the scaphoid and inserts on the palmar waist of the capitate. The capitate-trapezium (C-Tm) ligament originates from the radiopalmar aspect of the trapezium and inserts directly onto the volar waist of the capitate without any attachment to the trapezoid. The C-Tm presumably acts as a labrum, which deepens the socket of the STT joint and serves to

approximately 45 degrees of supination from the anteroposterior (AP) (a.k.a., coronal) plane of the wrist. The trapeziumtrapezoid (TT) inclination represents the degree of bone coverage by the facets of the trapezium and the trapezoid over the distal pole of the scaphoid, which is defined as an angle between a line drawn over the distal scaphoid with a line drawn along the axis of the third metacarpal. It ranged from 55 to 90 degrees (ave., 68 deg) (Fig. 26.2).

ST

Td

Tm

C

C-Tm

SC

S

T

L

A

Tm

Td

C

T S

70°

L

B FIGURE 26.3 Scaphotrapeziotrapezoidal Ligaments. 

FIGURE 26.2 Trapezium-Trapezoid Inclination.  The trapezium-trapezoid (TT) inclination represents the degree of coverage by the TT over the distal pole of the scaphoid, which is defined as an angle between a line drawn over the distal scaphoid with a line drawn along the axis of the third metacarpal.

(A) Dry bones model with a schematic representation of the scaphotrapezial (ST) ligament, the scaphocapitate (SC) ligament, and the capitate-trapezium (C-Tm) ligament. C, Capitate; L, lunate; M, thumb metacarpal; S, scaphoid; Td, trapezoid; Tm, trapezium. (B) The C-Tm ligament (purple), viewed from the proximal aspect, originates from the radiopalmar aspect of the trapezium and inserts directly onto the volar waist of the capitate without any attachment to the trapezoid.

252  SECTION VI  |  Small Joint Arthroscopy prevent palmar subluxation of the distal pole of the scaphoid (Fig. 26.3B). The authors observed that underdevelopment of the C-Tm ligament was associated with a higher incidence of degenerative changes, which may be due to higher shear forces in the STT joint.2,9 Garcia-Elias et al. noted that removal of the C-Tm ligament also weakened the stability of the carpal arch.10

Diagnosis Because STT and trapeziometacarpal (TM) arthritis often coexist (Fig. 26.4), patients frequently present with complaints of basilar thumb pain. In isolated STT arthritis, pain is often localized as more medial, within the thenar eminence, and is noted as a deep aching pain not necessarily associated with thumb motion. Palpation of the STT joint, which is located at the junction of the extensor pollicis longus (EPL) and extensor carpi radialis brevis (ECRB), may elicit pain. The Watson test may be painful but the carpometacarpal (CMC) grind test is negative. Gerald Blatt, M.D. introduced the shake test (personal communication) wherein the examiner grasps the patient’s wrist and then shakes the wrist up and down in a rapid fashion. This reproduces the pain. ST joint stress testing can also be performed by moving the wrist from full ulnar deviation to full radial deviation and back, to provoke pain at the STT joint.11 A diagnostic local anesthetic injection of the STT joint under fluoroscopy may help to localize the site of pain generation.

The definitive diagnosis is usually made radiographically. The STT joint is best seen by maintaining the hand in a half-pronated position and obtaining a pronated oblique view, or by fully supinating the forearm and obtaining an AP view.11 A lateral view should be performed to measure the SL and radiolunate angles, to rule out a preexisting DISI deformity. Radiographic and visual evaluations of the STT joint do not necessarily correlate with each other.12 Asymptomatic STT OA is common despite radiographic findings.

Treatment Nonoperative treatment consists of a thumb spica splint, NSAIDs, and activity modification. Activity modification consists of avoiding forceful pinch and using adaptive equipment such as jar-top openers. Splinting can consist of either a long or short thumb spica splint, or both. Corticosteroid injections have not been studied specifically for STT arthritis but may provide temporary relief. Surgical treatment is indicated after a failure of response to conservative measures. STT fusion is one method of treatment, though the recognized complications include nonunion, radial styloid impingement, and radioscaphoid OA. Distal scaphoid resection for STT OA is not a new concept, having been proposed more than three decades ago.9 In 1999, GarciaElias et al. reported encouraging results at the midterm follow-up in a series of patients who underwent this procedure.13 A disconcerting finding, however, was the development of a DISI in over half of the patients, which highlighted the integral role of the palmar ST ligaments in maintaining carpal stability. An arthroscopic distal scaphoid resection or a resection of the proximal trapezium have been proposed as less invasive techniques that have the potential of preserving these ligaments, which may reduce the risk of a DISI deformity, although there are no long-term studies as yet to substantiate this.

Indications An arthroscopic distal scaphoid excision or resection of the proximal trapezium with or without an interposition arthroplasty are indicated in the symptomatic patient with isolated STT osteoarthritis who has failed an adequate trial of splinting, NSAIDs, and activity modification. The procedures can be performed either as an open or arthroscopic procedure according to surgeon preference.

Contraindications FIGURE 26.4 AP radiograph revealing marked narrowing at

the trapeziometacarpal (TM) and scaphotrapezial (ST) joints (arrows).

Because of the increased midcarpal loads following a distal scaphoid resection, the procedure is not indicated when there is a preexisting CL arthritis or if there is a DISI deformity due to the risk of an increased painful subluxation of the capitate.14 Consequently, it should also be used with

CHAPTER 26  |  Arthroscopic Treatment of Scaphotrapeziotrapezoidal Osteoarthritis  253

caution when the radiolunate angle is greater than 15 degrees or in the presence of a dynamic scapholunate (SL) instability, which can be worsened by disruption of the ST ligaments.

portal protects the radial artery in the snuffbox from injury. A radial portal for STT arthroscopy, known as the scaphotrapeziotrapezoidal-radial (STT-R) portal, was described by Caro et al.16 This portal is radial to the abductor pollicis longus (APL) tendon at the level of the STT joint. Cadaver dissections demonstrated that maintaining a position palmar and radial to the APL tendon at the STT joint level avoids the radial artery by a mean of 8.8 mm (range, 6–10 mm). Branches of the superficial radial nerve (SRN) virtually surround the arthroscopic field, hence blunt dissection of the capsule and knowledge of the regional anatomy are essential. Ashwood et al. used a portal that was radial to the EPL tendon along with the MCR portal for arthroscopic debridement of isolated STT OA.17 They recommended a 1.5-cm skin incision to enable safe blunt dissection. Baré et al. described the scaphotrapeziotrapezoidal-palmar (STT-P) portal based on a dissection of 10 cadaver arms.8 They identified a safe portal of entry that was midway between

Surgical Technique The STT joint can be accessed through a number of portals. The midcarpal radial (MCR) portal is found 1 cm distal to the 3,4 portal in line with the index metacarpal. The STT joint lies radially and can be seen by rotating the   scope dorsally (Video 26-1). Bowers and Whipple described the scaphotrapeziotrapezoidal-ulnar (STT-U) portal, which is located in line with the midshaft axis of the index metacarpal, just ulnar to the EPL and radial to the insertion of the ECRB tendon into the base of the index metacarpal, at the level of the STT joint (Fig. 26.5A–E).15 Entry into this portal is facilitated by traction on the index finger. Leaving the EPL to the radial side of the STT

MTC

1-R Trapezium

STT-R Scaphoid A

B

STT-R Scope MCR Burr C

D FIGURE 26.5 Scaphotrapeziotrapezoidal Portals.  (A) Clinical photo of relative position

of the scaphotrapeziotrapezoidal-radial (STT-R) to the 1-R trapeziometacarpal (TM) portal. (B) Radiographic localization of the STT joint with a 22-gauge needle, with a hook probe in the TM joint. MTC, Metacarpal base. (C) Clinical view of the scope in the STT-R portal with the burr in the midcarpal radial (MCR) portal. (D) AP view of the scope and burr in the STT joint. Continued

254  SECTION VI  |  Small Joint Arthroscopy Proximal trapezium

Distal scaphoid

*** Distal scaphoid E

F FIGURE 26.5, cont'd (E) View of the distal scaphoid revealing the marked loss of cartilage with exposed subchondral bone (asterisk). (F) Arthroscopic view following distal scaphoid excision.

the radial styloid and the base of the first metacarpal, 3 mm ulnar to the APL tendon, and 6 mm radial to the scaphoid tubercle. The trocar is inserted into the STT joint aiming toward the base of the fifth metacarpal while holding the thumb in extension and adduction. This portal lies 7.6 mm (range, 5–11 mm) from the radial artery, 6.5 mm (range, 4–11 mm) from the superficial branch of the radial artery, and 11.6 mm (range, 3–20 mm) from the closest radial sensory nerve branch. The patient is positioned supine under general anaesthesia with the arm abducted under tourniquet control. The thumb is suspended by finger traps with 5 pounds of countertraction. I prefer to use a 2.7-mm 30-degree angled scope along with a camera attachment, although a 1.9-mm scope may be substituted until after the space has been partially decompressed. A 3-mm hook probe is needed for palpation. If there is clinical suspicion of a coexisting SL

instability, a standard wrist arthroscopy is performed and any SL ligament pathology is addressed. It is common to enter the TM joint by mistake; hence patience and gentle persistence are requisite. Intraoperative fluoroscopy is employed to assess the adequacy of bone resection and for locating the portals as needed. The STT-U portal is localized by finding the STT joint with a 22-gauge needle just ulnar to the EPL tendon, in line with the index metacarpal. Two milliliters of saline is injected followed by a small skin incision. Similar to other procedures, I often perform much of the diagnostic procedure dry, without irrigation fluid. Tenotomy scissors are used to spread the soft tissues and pierce the capsule, and then a cannula and blunt trocar are inserted, followed by the arthroscope. An identical procedure is used to establish the STT-P portal, which is identified roughly 3 mm ulnar to the APL tendon and 6 mm radial to the scaphoid tubercle (Fig. 26.6A–B). Portal placement is

STT-P

STT-U

STT-R

A

B FIGURE 26.6 (A) View of the scope in the scaphotrapeziotrapezoidal-ulnar (STT-U) portal. (B) Relative position of the scaphotrapeziotrapezoidal-palmar (STT-P) and scaphotrapeziotrapezoidal-radial (STT-R) portals.

CHAPTER 26  |  Arthroscopic Treatment of Scaphotrapeziotrapezoidal Osteoarthritis  255

aided by advancing the scope through the STT-U portal across the joint until it lights up the capsular interval. The angle between the 2 portals is 130 degrees, which improves triangulation. Both portals are interchangeable for viewing and for instrumentation. The joint is debrided using a combination of a fullradius resector and a thermal probe. Once any residual articular cartilage has been removed, a 2.9-mm burr is applied to the distal scaphoid in a to-and-fro manner (Fig. 26.7A–F). The bony resection is limited to 3 to 4 mm in an attempt to preserve the insertion of the ST ligaments and to lessen the risk of a symptomatic DISI deformity. The diameter of the burr and fluoroscopy provide a gauge as to the amount of bony resection. Alternatively, in situations where the distal scaphoid cartilage is well preserved and most of the articular loss is seen at the proximal trapezium and trapezoid, a resection of the proximal trapezium and

  trapezoid can be performed (Fig. 26.8A–C) (Video 26-2). This is performed in similar fashion. When there is co­ existing TM OA, a double arthroscopic resection can be performed (Fig. 26.9A–B).

Interposition Substances Tendon autograft is a popular interposition substance following an open distal scaphoid resection, using either palmaris longus, a strip of flexor carpi radialis (FCR), or the APL. The tendon is often sutured into a ball to create a bulky anchovy. A folded tendon can also be introduced arthroscopically as described by Tham.19 Alternatively, a pyrocarbon spacer (STPI, Bioprofile-Tornier, Grenoble, France) may be interposed, which was designed to prevent dorsal midcarpal instability. Care must be taken to ensure an adequate resection medially to decrease the risk of

T

S

A

B

C

* *

S

D

E

F

FIGURE 26.7 (A) Preoperative radiograph demonstrating marked scaphotrapeziotrape-

zoidal (STT) OA. (B) View from the scaphotrapeziotrapezoidal-ulnar (STT-U) portal with a resector in the scaphotrapeziotrapezoidal-palmar (STT-P) portal. Note the marked loss of cartilage with exposed subchondral bone on the trapezium (T) and the distal scaphoid (S). (C) Radiograph appearance. (D) A 2.9-mm burr is used to resect the distal scaphoid (S). (E) Completed resection with exposure of cancellous bone. (F) Radiograph showing the decompression of the STT joint.

256  SECTION VI  |  Small Joint Arthroscopy

Tm

*

* Td

S

TM and STTA OA

A

A

Preoperative x-ray

TM

B

STT

B

Postop

FIGURE 26.9 Combined Trapeziometacarpal and Scaphotrapeziotrapezoidal Arthroscopic Resection.  (A) Preop-

C FIGURE 26.8 (A) View of the scaphotrapeziotrapezoidal (STT) joint showing relative preservation of the cartilage on the distal scaphoid (S) but marked cartilage loss on the proximal trapezium (Tm) and trapezoid (Td) except for a small rim adjacent to the joint space (asterisk). (B) Burr is used to resect the proximal trapezium. (C) Completed resection with exposed bleeding cancellous bone.

implant dislocation. A strong capsular repair is also necessary to prevent migration of the implant or soft tissue spacer. Graftjacket (Wright Medical, Arlington, TN) is a popular implant, which is an acellular dermal matrix allograft   (Video 26-3). Because of the prolonged inflammatory response in some patients, I no longer use any interposition

erative radiograph demonstrating medial trapeziometacarpal (TM) OA and advanced scaphotrapeziotrapezoidal (STT) OA. (B) Postoperative radiograph following distal scaphoid resection and TM resection.

substances nor temporary K-wire fixation. A thumb spica splint is applied for comfort for 2 to 4 weeks followed by progressive thumb mobilization. Dynamic splinting is instituted at 8 weeks if full opposition has not been regained, followed by light strengthening exercises. Gripping exercises, especially with the wrist in flexion, are avoided for 3 months. Contact sports are avoided for 6 months following surgery to diminish the risk of a dorsal midcarpal instability.

Complications An inadequate excision of the distal scaphoid articular surface can lead to residual ST impingement and persistent pain.9 For this reason, many authors recommend excision of

CHAPTER 26  |  Arthroscopic Treatment of Scaphotrapeziotrapezoidal Osteoarthritis  257

one-fourth of the distal scaphoid. Radial artery injury in the snuffbox is a risk as is trauma to the SRN branches, which can result in a symptomatic neuroma formation. The development of a dorsal midcarpal instability may lead to persistent wrist pain due to painful dorsal subluxation of the capitate (Fig. 26.10A–F).13 This is particularly frequent among patients whose STT OA has been caused by a chronic inflammatory process, such as chondrocalcinosis or rheumatoid

A

arthritis, in whom the carpus was already malaligned before excision of the distal scaphoid.4 Another possible complication, in cases where a pyrocarbon implant has been used as spacer, is a dislocation of the implant.20,21 The most usual direction of the subluxation is toward the anteromedial corner of the joint, where it is likely to impinge against the FCR tendon, or toward the anterolateral aspect of the scaphoid where it will irritate the SRN branches and may cause pain.

B

E 80°

C

D

F

FIGURE 26.10 Arthroscopic Distal Scaphoid Resection with Dorsal Intercalated Segmental Instability.  (A) Preoperative AP radiograph revealing marked narrowing of

the scaphotrapeziotrapezoidal (STT) joint. (B) Preoperative lateral radiograph demonstrating a normal radiolunate angle and no dorsal intercalated segmental instability (DISI) deformity. (C) Postoperative radiograph following a distal scaphoid (S) resection. (D) A 1-year follow-up radiograph after an arthroscopic resection demonstrates preservation of the arthroplasty space between the trapezium and the distal scaphoid, but a slightly widened scapholunate (SL) gap. (E) A lateral radiograph demonstrates a dorsally tilted lunate with a DISI posture. Despite the radiographic findings, the patient was minimally symptomatic. (F) Line drawing of the scaphoid and lunate illustrating an increased SL angle of 80 degrees.

258  SECTION VI  |  Small Joint Arthroscopy

Open Partial Trapeziectomy

Outcomes Good results can occur in the midterm (Fig. 26.11A–B). There is, however, a paucity of published studies following an open or arthroscopic distal scaphoid resection for STT OA. The papers mostly consist of small patient series of nonrandomized level IV retrospective case series with short follow-up.

Open Resection Garcia-Elias et al. reported encouraging outcomes with this procedure in 21 patients, at an average follow-up time of 29 months (range, 12–61 mo). In 12 wrists, interposition of either tendon or capsule was performed. At the final follow-up, 13 patients were pain-free, and 8 had occasional mild discomfort. The mean flexion-extension arc was 119 degrees and minimally changed compared with the other side. The grip and pinch strengths improved by an average of 26% and 40%, respectively. It is notable that there was a significant reduction in the wrist flexion-extension arc in those patients who had undergone a soft-tissue interposition compared with those in whom the defect was left unfilled. A DISI pattern was seen radiographically in 12 out of 21 wrists, but at the final follow-up, none of these wrists showed further joint deterioration due to the residual malalignment. The congruency of the radiolunate and radioscaphoid joints, however, did not appear to be disrupted because the entire proximal row extended. The authors surmised that congruency and not alignment appeared to be the leading factor for patients to achieve an acceptable functional result.

A

5 yrs

Noland et al. reviewed 13 patients who underwent an open partial resection of the proximal trapezium for STT OA. The length of follow-up averaged 9 years (range, 5–13 yr). The average age at follow-up was 69 years. At follow-up, no patient had pain at the STT joint with direct palpation or stress testing. They classified the STT OA into three radiographic stages: minimally narrow, stage 1; definitely narrow, stage 2; joint effaced, stage 3. Postoperative radiographs of the ST joint demonstrated a mean score of 1 (range, 0–3). Mean pinch strength was 5 kg on the operated hand and 5 kg on the nonoperated hand. Scores on the pain scale averaged 6 (range, 0–100). The average DASH score was 11. Of 13 patients, 12 were very satisfied or extremely satisfied, and 1 was not satisfied. There was no symptomatic progression of arthritis at the STT joint after partial trapeziectomy.

Arthroscopic Partial Trapeziectomy Cobb reviewed 39 patients (30 females, 9 males) who underwent an arthroscopic resection arthroplasty (ARA) of the STT joint over a 3-year period.22 The average age was 63 (range, 46–79 yr). The preoperative length of symptoms averaged 195 weeks. The follow-up time averaged 444 days. No patients required formal therapy postoperatively. The average time of postoperative immobilization was less than 3 weeks. Palmar abduction did not change, averaging 44 degrees (range, 30–60 deg) at 1 year. The patients progressively improved over time with most improvement seen between 3 to 6 months. At 1 year, the average DASH score was 14, Pain 1 on the VAS scale, key pinch was 14 kgf, and grip strength was 52 kgf. He concluded that

B

5 yrs

FIGURE 26.11 (A, B) Radiographs at a 5-year follow-up with maintenance of the arthroplasty space and good pain relief with absence of a dorsal intercalated segmental instability (DISI) deformity or midcarpal OA.

CHAPTER 26  |  Arthroscopic Treatment of Scaphotrapeziotrapezoidal Osteoarthritis  259

an arthroscopic STT arthroplasty provided satisfactory relief of pain and return of strength and function. Cobb et al.23 also evaluated 34 patients at 1 year postoperatively who underwent an ARA for combined TM and STT OA. There were 27 women and 7 men with an average age of 63 years (range, 46–79 yr). All patients had a simultaneous ARA of both the CMC and STT joints. A 2- to 3-mm section of bone was resected from the proximal and distal aspect of both the CMC and STT joints. Graftjacket (Wright Medical, Arlington, TN) was used as an interposition material at both the CMC and STT joints in 23 cases, but the results were not separated out. The average time of postoperative immobilization was less than 3 weeks (range, 2–6 wk). The DASH scores averaged 46 before surgery, and averaged 19 (range, 1–50) at follow-up. The mean improvement in key pinch was 1.3 kg. The mean improvement in grip was 4.3 kg. The average preoperative pain score was 7 on the VAS scale (range, 5–10). Pain improved to an average of 1 (range, 0–6) at 1 year with 12 patients reporting no pain. Four patients had additional surgery with 2 patients revised to an open procedure elsewhere. Cobb revisited the results for 41 patients (ages 45–83 yr) from the previous two studies at a mean follow-up of 6.5 years (range, 4–10 yr).24 The results appeared to hold up over time. The mean decrease in pain from preoperative to postoperative was 5.46 points (SD 5 1.5), the mean improvement in pinch force was 1.36 kg (SD 5 1.9), and the mean improvement in grip strength was 2.66 kg (SD 5 9.3). There were 2 failures. Atzei reported his results with this technique in 12 cases (1 bilateral).25 There were 2 males and 9 female, with an average age of 62 years (range, 32–73 yr).The technique was performed using the MCR and STT portals. After an extensive synovectomy and osteophyte resection, a 3- to 4-mm resection was performed using a burr to expose the subchondral bone and preserve the ligamentous attachments around the STT joint (Fig. 26.12A–G). No intraoperative complications were recorded. Resection of the palmar aspect of the trapezium allowed visualization of the FCR tendon sheath. The FCR was debrided for partial laceration in 3 cases, and resected, due to massive laceration, in 2 cases. After a mean follow-up of 2.7 years, all patients reported a functional improvement of their hand. The thumb range of motion was 96% of the contralateral side. The mean pain visual analog scale (VAS) score was 3 (occasional pain in 3 cases). Grip and pinch strength were 85% and 90% of the contralateral side. The Modified Mayo Wrist Score (MMWS) was excellent in 10 patients (incl. bilateral) and fair in 1 patient. The DISI posture increased in 9 patients, though less than 10 degrees, and was not related to any clinical impairment. The quick DASH and PRWE scores were 27.8% and 5%, respectively. Transient irritation of the dorsal sensory branch of the radial nerve was observed in 2 cases.

Arthroscopic Debridement Ashwood and Bain reported their results with arthroscopic debridement of synovitis, chondral flaps, and rim osteophytes

of the STT joint, with minimal or no bone resection in 10 consecutive patients. Good or excellent subjective results were achieved in 9 out of 10 patients at an average of 36 months (range, 12–65 mo).17 All of the patients showed a reduction in VAS pain scores, which improved from a mean of 86 to 14. The mean Green and O’Brien wrist scores improved from 63 to 91. Tham et al. performed an arthroscopic resection of the distal scaphoid and tendon interposition for isolated STT OA in 7 patients (ave. age, 58 yr).19 At a mean follow-up of 13.3 months (range, 7–21 mo), 5 patients described no pain or mild pain during intermittent activity (preoperative average VAS: 7.4; postoperative average VAS: 0.2). There was no change in wrist motion and the mean grip strength increased from 12 kg to 26 kg and key pinch strength improved from 4 kg to 7.6 kg. There were 2 failures due to persistent pain due to an inadequate resection of the distal scaphoid. Radiographically, there were no cases of worsening of the radiolunate angle.

Pyrocarbon Implants Most of the data on the use of pyrocarbon spacers comes from Europe because they are not FDA-approved in North America. Pequignot et al. inserted a discoid pyrocarbon implant (STPI; Bioprofile-Tornier, Grenoble, France) after an open distal scaphoid excision in 15 patients (mean age, 65 yr) for the treatment of STT OA. At a mean follow-up of 4 years (range, 1–8 yr), the VAS pain score improved from an average of 8.5 to 2. There was a minimal loss of radial deviation (,10 deg) and extension (,15 deg). Grip strength was similar to the contralateral side, and there was a slight decrease in pinch strength (0.8 kg). There were no implant dislocations and no instances of a DISI deformity.26 Similarly favorable results were reported in 2 other small series of 10 patients each with short-term follow-ups of 2 to 35 months, following an open approach or combined open/arthroscopic approach.20 Da Rin and Mathoulin performed arthroscopic resections of 2 to 3 mm of the distal pole of the scaphoid for isolated STT OA in 26 women. Thirteen patients had an open insertion of a pyrolytic carbon STT spacer (avg. age, 62 yr) and 13 had no interposition (avg. age, 58 yr). The longest follow-up was 4 years. The Green and O’Brien score improved from an average of 50 preoperatively to 90 postoperatively in patients without the spacer, and pinch increased from 5 to 15 kg., which compared favorably with the spacer.23 In summary, a distal scaphoid resection with or without an interposition substance, or proximal trapezium and trapezoid resection are viable alternatives to a fusion for the treatment of STT OA, provided that rigid selection criteria are adhered to. Unanswered questions remain, however, as to the long-term outcomes following interposition of synthetic substances and the ultimate fate of patients who develop a DISI posture.

260  SECTION VI  |  Small Joint Arthroscopy

Tm

Td

A

Tm

S

C

Td

E

Td

STT-U

B

STT-R

STT-R

D

STT-R

STT-U

F

Tm

6 mths

G

FIGURE 26.12 (A) Arthroscopic view from the scaphotrapeziotrapezoidal-ulnar (STT-U) portal of the STT joint with a complete loss of cartilage on the trapezium (Tm), Trapezoid (Td), and distal scaphoid (S). (B) A 3.0-mm burr is used to resect subchondral bone. (C) A 4.0-mm burr is substituted to speed up the resection. (D, E) Completed resection as seen from the scaphotrapeziotrapezoidal-radial (STT-R) and STT-U portals. (F, G) STT arthroplasty space (arrow) at 6 months. Note the dorsal intercalated segmental instability (DISI) posture.

6 mths

CHAPTER 26  |  Arthroscopic Treatment of Scaphotrapeziotrapezoidal Osteoarthritis  261

References 1. Bhatia A, Pisoh T, Touam C, et al. Incidence and distribution of scaphotrapezotrapezoidal arthritis in 73 fresh cadaveric wrists. Ann Chir Main Memb Super. 1996;15:220-225. 2. Moritomo H, Viegas SF, Nakamura K, et al. The scaphotrapezio-trapezoidal joint. Part 1: An anatomic and radiographic study. J Hand Surg Am. 2000;25:899-910. 3. Watson HK, Ryu J. Evolution of arthritis of the wrist. Clin Orthop Relat Res. 1986:57-67. 4. Saffar P. Chondrocalcinosis of the wrist. J Hand Surg Br. 2004;29:486-493. 5. Ferris BD, Dunnett W, Lavelle JR. An association between scapho-trapezio-trapezoid osteoarthritis and static dorsal intercalated segment instability. J Hand Surg. 1994;19: 338-339. 6. Viegas SF, Patterson RM, Hokanson JA, et al. Wrist anatomy: incidence, distribution, and correlation of anatomic variations, tears, and arthrosis. J Hand Surg. 1993;18:463-475. 7. Tay SC, Moran SL, Shin AY, et al. The clinical implications of scaphotrapezium-trapezoidal arthritis with associated carpal instability. J Hand Surg. 2007;32:47-54. 8. Garcia-Elias M, Lluch A. Partial excision of scaphoid: is it ever indicated? Hand Clin. 2001;17:687-695. 9. Crosby EB, Linscheid RL, Dobyns JH. Scaphotrapezial trapezoidal arthrosis. J Hand Surg Am. 1978;3:223-234. 10. Garcia-Elias M, An KN, Cooney WP, et al. Transverse stability of the carpus. An analytical study. J Orthop Res. 1989;7: 738-743. 11. Noland SS, Saber S, Endress R, et al. The scaphotrapezial joint after partial trapeziectomy for trapeziometacarpal joint arthritis: long-term follow-up. J Hand Surg. 2012;37:1125-1129. 12. North ER, Eaton RG. Degenerative joint disease of the trapezium: a comparative radiographic and anatomic study. J Hand Surg. 1983;8:160-166. 13. Garcia-Elias M, Lluch AL, Farreres A, et al. Resection of the distal scaphoid for scaphotrapeziotrapezoid osteoarthritis. J Hand Surg Br. 1999;24:448-452. 14. Malerich MM, Clifford J, Eaton B, et al. Distal scaphoid resection arthroplasty for the treatment of degenerative arthritis

secondary to scaphoid nonunion. J Hand Surg Am. 1999;24: 1196-1205. 15. Bowers WH WT. Arthroscopic anatomy of the wrist. In: McGinty J, ed. Operative Arthroscopy. New York: Raven Press; 1991:613-623. 16. Carro LP, Golano P, Farinas O, et al. The radial portal for scaphotrapeziotrapezoid arthroscopy. Arthroscopy. 2003;19: 547-553. 17. Ashwood N, Bain GI, Fogg Q. Results of arthroscopic debridement for isolated scaphotrapeziotrapezoid arthritis. J Hand Surg Am. 2003;28:729-732. 18. Bare J, Graham AJ, Tham SK. Scaphotrapezial joint arthroscopy: a palmar portal. J Hand Surg Am. 2003;28:605-609. 19. Tham S. Arthroscopic resection of distal scaphoid and tendon interposition for isolated scaphotrapezial trapezoid arthritis. In: Slutsky DJ SJI, ed. The Scaphoid. New York, NY: Thieme, Inc; 2010. 20. Low AK, Edmunds IA. Isolated scaphotrapeziotrapezoid osteoarthritis: preliminary results of treatment using a pyrocarbon implant. Hand Surg. 2007;12:73-77. 21. Pegoli L, Zorli IP, Pivato G, et al. Scaphotrapeziotrapezoid joint arthritis: a pilot study of treatment with the scaphoid trapezium pyrocarbon implant. J Hand Surg Br. 2006;31:569-573. 22. Cobb TK. Arthroscopic STT arthroplasty: level 4 evidence. J of Hand Surg. 2009;34:42-43. 23. Cobb T, Sterbank P, Lemke J. Arthroscopic resection arthroplasty for treatment of combined carpometacarpal and scaphotrapeziotrapezoid (pantrapezial) arthritis. J Hand Surg. 2011;36:413-419. 24. Cobb AG. Differences in outcomes following arthroscopic resection arthroplasty (ARA) for isolated TM OA vs simultaneous ARA of TM and STT joints. Seattle, WA: International Wrist Investigators Workshop; 2015. 25. Atzei A. Arthroscopic proximal trapezio-trapezoid resection for STT osteoarthritis. Seattle, WA: International Wrist Investigators Workshop; 2015. 26. Pequignot JP, D’Asnieres de Veigy L, Allieu Y. Arthroplasty for scaphotrapeziotrapezoidal arthrosis using a pyrolytic carbon implant. Preliminary results. Chir Main. 2005;24:148-152.

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Index 1,2 portal, 7t 3,4 portal, 7t, 10 4-corner fusion and scaphoidectomy, 207–208 4,5 portal, 7t, 10 6 radial (6R) portal, 7t, 10–11 6 ulnar (6U) portal, 7t, 10–11

A

Abductor pollicis longus (APL), 242f Acute ulnar collateral ligament of injury of thumb, 221 Acutrak screw, 113 ALP. See Arthroscopic ligament plication (ALP) Anterior oblique ligament (AOL), 20–22, 226, 241 AO classification, 123 AO delta frame external fixator, 126 AOL. See Anterior oblique ligament (AOL) APL. See Abductor pollicis longus (APL) APRC. See Arthroscopic proximal row carpectomy (APRC) ARA. See Arthroscopic resection arthroscopy (ARA) ARASL. See Arthroscopic reduction association of the scaphoid-lunate (ARASL) Arcuate ligament, 12f, 96f Arthritis and degenerative disorders. See also Osteoarthritis (OA) chondral defects, 169–170 hamate arthrosis, 167–169 inflammatory arthritis, 165–171 Kienböck disease, 172–182 partial scaphoidectomy, 196–203 partial wrist fusion, 204–212 proximal row carpectomy (PRC), 213–218 radial styloidectomy, 189–195 septic arthritis, 170–171 synovectomy, 165–167, 166–167f synovial biopsy, 165 wrist capsulotomy, 159–164 wrist ganglionectomy, 183–188 Arthrofibrosis, 160, 161f Arthroscopic-assisted 4-corner fusion and scaphoidectomy, 207–208 Arthroscopic-assisted capitolunate fusion and scaphoidectomy, 205–207 Arthroscopic-assisted fixation (distal radius), 132–136 Arthroscopic-assisted lunate core decompression, 181 Arthroscopic-assisted radioscapholunate fusion, 210–211 Arthroscopic-assisted reattachment of deep radioulnar ligament, 45 Arthroscopic-assisted scaphocapitate (SC) fusion, 208–210, 209–210f Arthroscopic-assisted transarticular K-wire fixation, 71–72 Arthroscopic-assisted ulnar styloid excision technique, 58

Arthroscopic bone grafting, 113–115, 181-182. See also Bone graft Arthroscopic capsular shrinkage, 99–100 Arthroscopic debridement SL instability, 68–69 STT OA, 259 TM OA, 245 Arthroscopic distal scaphoid excision, 199 Arthroscopic distal scaphoid resection, 257f Arthroscopic dorsal capsuloligamentous repair, 72–73 Arthroscopic ligament plication (ALP), 85–86, 101 Arthroscopic partial scaphoidectomy anatomy and pathomechanics, 196–198 complications, 202 diagnosis, 198–199 indications/contraindications for surgical treatment, 199, 200 nonoperative treatment, 199 outcomes, 202 surgical technique, 200–202 Arthroscopic partial trapeziectomy, 258–259 Arthroscopic partial wrist fusion 4-corner fusion and scaphoidectomy, 207– 208 capitolunate fusion and scaphoidectomy, 205– 207 instrumentation and methodology, 204–205 outcomes, 211 radioscapholunate (RSL) fusion, 210–211 scaphocapitate (SC) fusion, 208–210, 209– 210f Arthroscopic portals. See Wrist arthroscopy portals Arthroscopic proximal row carpectomy (APRC) biomechanics and kinematics, 213 diagnosis, 213 indications/contraindications for arthroscopic PRC, 175, 214 Kienböck disease, 179–181, 180f outcomes, 215–216 surgical technique, 214–215 Arthroscopic radial styloidectomy chronic scapholunate dissociation, 192–193f diagnosis, 190–191 dorsal lip scaphoid nonunion, 190, 193–194f dorsal-type scaphoid nonunion, 189–190 equipment, 191 indications/contraindications for treatment, 191 outcomes, 194 pathophysiology, 189–190 SLAC arthritis, 189 SNAC arthritis, 189 styloid pattern of impingement, 190, 190f surgical technique, 192–194 volar-type scaphoid nonunion, 190 Arthroscopic reduction association of the scaphoid-lunate (ARASL), 74, 75f

Arthroscopic resection arthroscopy (ARA), 258–259 Arthroscopic scaphocapitate (SC) fusion with lunate excision, 178–179, 178–179f Arthroscopic synovectomy, 165–167, 166–167f Arthroscopic synovial biopsy, 165 Arthroscopic trapeziectomy with interposition, 245–246 Arthroscopic trapeziectomy without tendon interposition, 246 Arthroscopic wafer resection, 51–55 alternative procedures, 53–55 contraindications, 53 indications, 52–53 outcomes, 55 surgical technique, 53 Arthroscopic wrist capsulotomy complications, 164 distal radioulnar joint (DRUJ) capsulotomy, 162–163 dorsal capsulotomy, 161–162, 162f equipment, 161 indications/contraindications to wrist arthroscopy, 160 midcarpal joint capsulotomy, 162 outcomes, 164 pathomechanics, 160 physical examination, 160 postoperative management, 163–164 radiocarpal joint capsulotomy, 161–162 surgical technique, 161–163 volar capsulotomy, 161, 162f wrist arthrofibrosis, 161f Arthroscopic wrist ganglionectomy anatomy and etiology, 183–184 diagnosis, 184 indications/contraindications to arthroscopic resection, 184 nonoperative treatment, 184 outcomes, 187–188 surgical technique, 184–187 Arthrosis of proximal pole of hamate, 167–169, 170f Articular cartilage damage, 169 Augmented external fixation, 126–128 Avascular necrosis (AVN), 104, 172 AVN. See Avascular necrosis (AVN)

B

Barton fracture, 129f Beak ligament, 226. See also Anterior oblique ligament (AOL) Bennett fracture, 226. See also First metacarpal base fracture Bent guide wire, 108f, 115–116 Blatt, Gerald, 252 Bone graft distal radius fracture (DRF), 131 Kienböck disease, 181–182 percutaneous bone graft harvesting, 113f scaphoid fractures and nonunions, 113–115

263

264  Index Bone substitutes. See Bone graft “Book-opening” motion, 197–198 Bridging external fixation, 124–125

C

C-Tm ligament. See Capitate-trapezium (C-Tm) ligament Calcium pyrophosphate dihydrate crystal deposition disease (CPPD), 165, 166f Capitate fracture, 145, 146f Capitate shortening, 173, 174f Capitate-trapezium (C-Tm) ligament, 251–252, 251f Capitohamate interosseous ligament (CHIL) tear, 92–93t Capitolunate (CL) fusion, 205–207 Capitolunate stress test, 98, 98f Carpal fracture. See Wrist and carpal fractures Carpal instability nondissociative (CIND) pattern, 250 Carpal ligament injury arthroscopic capsular shrinkage, 99–100 arthroscopic ligament plication (ALP), 85–86 dorsal capsuloligamentous repair, 72–73 dorsal radiocarpal ligament (DRCL) tears, 87–94 lunotriquetral (LT) injuries, 79–86 midcarpal instability (MCI), 95–102 scapholunate (SL) instability, 63–78 thermal shrinkage, 69–70 transarticular K-wire fixation, 71–72 Carpal tunnel syndrome, 242–244 Carpometacarpal (CMC) grind test, 252 Carpometacarpal (CMC) joint, 234 CHIL tear. See Capitohamate interosseous ligament (CHIL) tear Chinese finger traps, 245 Chondral defects, 169–170 Chondrocalcinosis, 250 Chronic scaphoid nonunion, 191 Chronic scapholunate (SL) dissociation, 192–193f, 196–197, 206f, 214f CIND. See Carpal instability nondissociative (CIND) pattern CIND-DISI, 250 CL fusion. See Capitolunate (CL) fusion Closed reduction, 123 CMC grind test. See Carpometacarpal (CMC) grind test CMC joint. See Carpometacarpal (CMC) joint Colles fracture, 123 Combined trapeziometacarpal and scaphotrapeziotrapezoidal arthroscopic resection, 256f Comminuted displaced volar Barton fracture, 129f Comminuted scaphoid fracture, 109f, 113f Concomitant soft tissue injuries, 118 Coronal fractures of scaphoid, 117 Corrective osteotomy, 140–142 Cortical ring sign, 150–151

D

D-2 portal. See Distal-dorsal (D-2) portal dAOL. See Deep anterior oblique ligament (dAOL) DCBUN. See Dorsal cutaneous branch of ulnar nerve (DCBUN) Deep anterior oblique ligament (dAOL), 20–22, 226, 227f, 241 Deep radioulnar ligament (RUL), 37–38 Degenerative disorders. See Arthritis and degenerative disorders Del Piñal, Francisco, 15 Diathermy probe, 245 Diathermy unit, 245 DIC ligament. See Dorsal intercarpal (DIC) ligament DIML. See Dorsal intermetacarpal ligament (DIML)

Direct foveal portal, 45f Discoid pyrocarbon implant, 259 DISI deformity. See Dorsal intercalated segmental instability (DISI) deformity Distal-dorsal (D-2) portal, 18, 19f, 20 Distal oblique bundle (DOB), 37–38 Distal pole scaphoid fracture, 107 Distal radioulnar joint (DRUJ), 38f Distal radioulnar joint (DRUJ) arthroscopy, 44–45 Distal radioulnar joint (DRUJ) capsulotomy, 162–163 Distal radioulnar joint (DRUJ) instability, 41f, 42f Distal radius fracture (DRF) A-type fracture, 123 anatomy, 121 AO classification, 123 arthroscopic-assisted fixation, 132–136 augmented external fixation, 126–128 B-type fracture, 123 bone graft and bone substitutes, 131 bridging external fixation, 124–125 C-type fracture, 123 classification, 122–123 closed reduction, 123 comminuted displaced volar Barton fracture, 129f complications, 125–126 diagnosis, 122 distraction plating, 131–132 dorsal plating, 128 external fixation, 123–124 fixator loosening, 125–126 four-part fracture, 135–136 Frykman classification, 122–123 indications/contraindications for surgery, 132 joint bridging fixation, 128 ligamentotaxis, 123–124 Mayo classification, 122–123 mechanism of injury, 121–122 Melone classification, 122–123 nonbridging external fixation, 126–128 outcomes, 136–137 pin site complications, 125–126 plate fixation, 128–131 radial styloid fracture, 132–134 reduction techniques, 130–131 surgical technique, 125 three-column concept, 123 three-part fracture, 134 volar plating, 128–130 Distal radius malunion, 96t Distal scaphoid excision, 250 Distal scaphoid resection, 252, 259 Distal scaphoidectomy, 210 Distraction plating, 131–132 DMCI. See Dorsal midcarpal instability (DMCI) DOB. See Distal oblique bundle (DOB) Dorsal arthroscopic ligament plication (ALP), 101 Dorsal capsular reefing, 101 Dorsal capsuloligamentous repair, 72–73 Dorsal capsulotomy, 161–162, 162f Dorsal cutaneous branch of ulnar nerve (DCBUN), 4, 121 Dorsal distal radial ulnar joint (DRUJ) portal, 5f, 7t, 14–15, 40f, 45 Dorsal distal radial ulnar joint (DRUJ) portal anatomy, 5f Dorsal intercalated segmental instability (DISI) deformity arthroscopic distal scaphoid resection, 257f arthroscopic partial scaphoidectomy, 196–197 arthroscopic radial styloidectomy, 189 capitolunate fusion, 205

Dorsal intercalated segmental instability (DISI) deformity (Continued) CIND-DISI, 250 DRCL tears, 87 open resection, 258 perilunate injuries, 154–157 scaphoid fractures and nonunions, 105 scapholunate instability, 64 STT OA, 252 Dorsal intercarpal (DIC) ligament, 87 Dorsal intermetacarpal ligament (DIML), 18 Dorsal lip scaphoid nonunion, 190, 193–194f, 198f Dorsal midcarpal instability (DMCI), 95-96. See also Midcarpal instability (MCI) Dorsal midcarpal portal, 4 Dorsal plating, 128 Dorsal portal anatomy, 3f Dorsal radiocarpal ligament (DRCL), 87, 89f Dorsal radiocarpal ligament (DRCL) tears anatomy and biomechanics, 87–88 diagnosis, 88 DISI deformity, 87 indications/contraindications for arthroscopy, 88–89 nonsurgical treatment, 88 normal DRCL, 89f outcomes, 91, 92–93t surgical technique, 89–90 Dorsal radiocarpal portal, 3–4 Dorsal radioulnar ligament (DRUL), 26 Dorsal radioulnar portal, 4 Dorsal-type scaphoid nonunion, 189–190, 197 Dorsal wrist ganglion (DWG), 183, 184. See also Arthroscopic wrist ganglionectomy Dorsoradial ligament (DRL), 20–22, 241 Dorsoulnar facet, 251f Dorsoulnar triangular fibrocartilage complex (TFCC) tear, 30f DRCL. See Dorsal radiocarpal ligament (DRCL) DRL. See Dorsoradial ligament (DRL) DRUJ. See Distal radioulnar joint (DRUJ) DRUJ arthroscopy. See Distal radioulnar joint (DRUJ) arthroscopy DRUJ capsulotomy. See Distal radioulnar joint (DRUJ) capsulotomy DRUJ instability. See Distal radioulnar joint (DRUJ) instability DRUL. See Dorsal radioulnar ligament (DRUL) Dry technique of del Piñal, 132 DWG. See Dorsal wrist ganglion (DWG) Dynamic scapholunate (SL) instability, 65f

E

ECU subluxation. See Extensor carpi ulnaris (ECU) subluxation ECU synergy test. See Extensor carpi ulnaris (ECU) synergy test ECU tendonitis. See Extensor carpi ulnaris (ECU) tendonitis EPB. See Extensor pollicis brevis (EPB) EPL. See Extensor pollicis longus (EPL) Extensor carpi ulnaris (ECU) subluxation, 27–28 Extensor carpi ulnaris (ECU) synergy test, 51 Extensor carpi ulnaris (ECU) tendonitis, 51 Extensor pollicis brevis (EPB), 242f Extensor pollicis longus (EPL), 121, 242f External fixation, 123–124 Extrinsic midcarpal instability (MCI), 95, 96t

F

Failed arthroscopic resection arthroscopy, 248f FCR. See Flexor carpi radialis (FCR) FCR tendinitis. See Flexor carpi radialis (FCR) tendinitis

Index  265 Fifth carpometacarpal (CMC) fracture dislocations anatomy and pathomechanics, 234–235 complications, 237 equipment and implants, 235 imaging, 235 intermetacarpal ligament anatomy, 234 outcomes, 237–239 postoperative management, 236–237 surgical technique, 235–236 Fine synovial rongeur, 215, 216f Finger metacarpophalangeal (MCP) joints, 220–221 First metacarpal base fracture dAOL, 226, 227f diagnosis, 227 Gedda classification of Bennett fractures, 227 ligament anatomy and biomechanics, 226–227 nonoperative treatment, 227–228 outcomes, 229–232 Rolando fracture, 228, 233f sAOL, 226, 227f surgical technique, 228 T-condylar fracture, 228, 232f volar ulnar fragment, 226, 227f Fixator loosening, 125–126 Flexor carpi radialis (FCR), 241 Flexor carpi radialis (FCR) tendinitis, 242–244 Forced wrist extension, 184 4-corner fusion and scaphoidectomy, 207–208 Four-part fracture, 135–136 Foveal tears anatomy and biomechanics, 37–38 distal radioulnar joint arthroscopy, 44–45 hook test, 41, 43f press test, 38–40, 41f reattachment of deep radioulnar ligament, 45 suture repair techniques, 45–48 TFCC anatomy, 37–38 Fracture. See Wrist and carpal fractures Fracture of the triquetrum, 145 Freer elevator arthroscopic wrist capsulotomy, 161 Bennett fracture, 228 distal radius fracture (DRF), 128, 132–134 fifth CMC fracture, 236f MCP joint arthroscopy, 222–224 perilunate injuries, 151–152, 152f T-condylar fracture, 232f Frykman classification, 122–123

G

Ganglion cyst, 190–191 Gedda classification of Bennett fractures, 227 Geissler classification of intercarpal ligaments, 2 Geissler grade I injuries, 67, 68f Geissler grade II injuries, 67 Geissler grade III injuries, 67, 68f Geissler grade IV injuries, 67, 68f Goddard’s technique, 152–153 Graftjacket, 256 Greater arc perilunate injuries, 145, 146f

H

HALT (hamate arthrosis lunate ligament tear), 167–168 Hamate arthrosis, 167–169, 170f Hamate bone, 96f Herbert-Whipple screw, 154–157 Hook test, 41, 43f Horizontal triangular fibrocartilage complex (TFCC) tear, 32f Hyaluronic acid injections, 244–245

I

Inflammatory arthritis. See also Arthritis and degenerative disorders arthrosis of proximal pole of hamate, 167–169, 170f chondral defects, 169–170 CPPD and scapholunate (SL) dissociation, 165, 166f hamate arthrosis, 167–169, 170f MCP joint arthroscopy, 221 pathophysiology, 165 septic arthritis, 170–171 synovectomy, 165–167, 166–167f synovial biopsy, 165 Intercarpal ligament, 96f Intermetacarpal ligament anatomy, 234 Interposition substances, 255–256 Intraarticular distal radius fracture, 136-137. See also Distal radius fracture (DRF) Intraarticular malunions of distal radius biomechanics and natural history, 139 corrective osteotomy, 140–142 diagnosis, 140 indications/contraindications for surgery, 140 malunited lunate facet fracture, 143f osteoarthritis (OA), 139 outcomes, 141–142 surgical technique, 140–141 Intrinsic midcarpal instability (MCI), 95, 96t Irreducible dorsal metacarpophalangeal (MCP) dislocation, 223–224f Irreducible transscaphoid dorsal perilunate dislocation, 152f Isolated partial LTIL tear, 79–80 Isolated scaphotrapeziotrapezoidal (STT) osteoarthritis (OA), 250. See also Scaphotrapeziotrapezoidal (STT) osteoarthritis (OA)

J

Joint bridging fixation, 128

K

K-wire fixation, transarticular, 71–72 K-wire targeting, 109f Kienböck disease, 88, 172–182 anatomy and etiology, 172 arthroscopic bone grafting, 181–182 arthroscopic lunate core decompression, 181 arthroscopic proximal row carpectomy (APRC), 179–181, 180f arthroscopic scaphocapitate (SC) fusion with lunate excision, 178–179, 178–179f arthroscopic survey, 175–176 arthroscopic treatment, 175 avascular necrosis (AVN), 172 capitate shortening, 173, 174f diagnosis, 173 Lichtman classification, 173 open treatment, 173–175 outcomes, 181–182 radial shortening, 173, 174f scaphocapitate (SC) fusion, 175, 176f stage I, 173, 173f stage II, 173, 174f, 175f stage IIIA, 173 stage IIIB, 175, 176f surgical technique, 175–181 ulnar-minus variance, 173, 174f ulnar-positive variance, 173, 174f wrist denervation, 175, 177f

L

LABCN. See Lateral antebrachial cutaneous nerve (LABCN)

Lateral antebrachial cutaneous nerve (LABCN), 121 Lesser arc perilunate injuries, 145 Lichtman classification, 173 Lichtman test, 168–169 Ligamentotaxis, 123–124 Linscheid maneuver, 205 Lister tubercle, 121 Locking plate technology, 128 Long radiolunate ligament, 96f Longitudinal split tear of ulnotriquetral (UT) ligament, 33–35 Loose body removal, 221 LTIL. See Lunotriquetral interosseous ligament (LTIL) LTIL tear, 27-28. See also Lunotriquetral (LT) injuries Lunate avascular necrosis (AVN), 172 Lunate bone, 96f Lunate facet fracture, 143f Lunate fossa, 121 Lunate fracture, 149f Lunotriquetral (LT) injuries anatomy and biomechanics, 79–80 arthroscopic ligament plication (ALP), 85–86 diagnosis, 80–81 indications/contraindications for arthroscopy, 81 outcomes, 82–85 surgical technique, 81–82 VISI deformity, 80–81, 81f, 85 Lunotriquetral interosseous ligament (LTIL), 79 Lunotriquetral interosseous ligament (LTIL) tear, 27-28. See also Lunotriquetral (LT) injuries

M

Madelung’s deformity, 50–51 Malunited lunate facet fracture, 143f Mayo classification, 122–123 MCP joint dislocation. See Metacarpophalangeal (MCP) joint dislocation MCP joint fracture, Metacarpophalangeal (MCP) joint fracture MCP joint. See Metacarpophalangeal (MCP) joint MCP joint synovitis. See Metacarpophalangeal (MCP) joint synovitis Median nerve compression test, 242–244 Melone classification, 122–123 Metacarpophalangeal (MCP) arthroscopy anatomy and methodology, 220 complications, 224 indications/contraindications, 221, 222 inflammatory arthritis, 221 irreducible dorsal MCP dislocation, 223–224f loose body removal, 222f MCP joint dislocation, 221 MCP joint fracture, 221 MCP joint synovitis, 221f outcomes, 224–225 physical examination and imaging, 221 posttraumatic volar plate adhesions, 221 Salter III fracture, 221–222f surgical technique, 222–224 ulnar collateral ligament of injury of thumb, 221 Metacarpophalangeal (MCP) joint, 220. See also Metacarpophalangeal (MCP) arthroscopy Metacarpophalangeal (MCP) joint dislocation, 221 Metacarpophalangeal (MCP) joint fracture, 221 Metacarpophalangeal (MCP) joint synovitis, 221f Methylmethacrylate cement, 131 Midcarpal arthritis, 154–157 Midcarpal instability (MCI) anatomy and biomechanics, 95–96 arthroscopic capsular shrinkage, 99–100

266  Index Midcarpal instability (Continued) capitolunate stress test, 98, 98f classification, 96t clinical findings, 96 diagnosis, 96–98 DMCI, 95–96 dorsal arthroscopic ligament plication (ALP), 101 imaging, 96–98 indications/contraindications for arthroscopy, 99 intrinsic/extrinsic MCI, 95, 96t nonsurgical treatment, 98 outcomes, 100–101 PMCI, 95, 97f surgical treatment, 99–100 three-point fixation with dynamic splint, 98f VISI deformity, 98, 98f Midcarpal joint capsulotomy, 162 Midcarpal portal, 15 Midcarpal radial portal, 7t Miniarthroscopy (MA) of metacarpophalangeal (MCP) joints, 224–225 Mobile-type scaphoid nonunion, 190 Modified radial portal, 17

N

Nonbridging external fixation, 126–128 Norian SRS, 131

O

OA. See Osteoarthritis (OA) OATS. See Osteoarticular transfer system (OATS) Open arthroscopic irrigation and debridement, 170 Open partial trapeziectomy, 258 Open radial styloidectomy, 194 Open resection, 258 Osteoarthritis (OA), 139. See also Arthritis and degenerative disorders scaphotrapeziotrapezoidal, 250–262 trapeziometacarpal, 240–249 Osteoarticular transfer system (OATS), 169–170 Osteochondral grafting, 169–170 Osteotomy, 140–142 Outside-in osteotomy, 140

P

Palm press test. See Press test Palmar midcarpal instability (PMCI), 95, 97f. See also Midcarpal instability (MCI) Palmar radioulnar ligament (PRUL), 26, 38f Partial scaphoidectomy. See Arthroscopic partial scaphoidectomy Partial wrist fusion. See Arthroscopic partial wrist fusion Percutaneous bone graft harvesting, 113f Percutaneous reduction of transscaphoid dorsal perilunate dislocation, 152–153f Perilunate dislocations, 145 Perilunate injuries anatomy and biomechanics, 145–146 capitate fracture, 145, 146f cortical ring sign, 150 diagnosis, 150–151 fracture of the triquetrum, 145 Goddard’s technique, 152–153 greater arc injuries, 145, 146f irreducible transscaphoid dorsal perilunate dislocation, 152f lesser arc injuries, 145 outcomes, 154–157 percutaneous reduction of transscaphoid dorsal perilunate dislocation, 152–153f perilunate dislocations, 145 PLIND injury, 145–146, 148–149f, 155f, 157

Perilunate injuries (Continued) pure perilunate injury, 145 reduced transradial styloid dorsal perilunate dislocation, 156f SC syndrome, 145, 151 surgical treatment, 151–153 tear of volar capsule, 151f transradial styloid perilunate fracture dislocations, 153 transscaphoid fracture/dislocation, 145, 146f, 152–153 transtriquetral dorsal perilunate fracture dislocation, 146–147f undiagnosed perilunate fracture dislocation, 150f Peripheral triangular fibrocartilage complex (TFCC) tear, 27f, 30f Phalen test, 242–244 Pin site complications, 125–126 Pisiform bone, 96f Pisotriquetral orifice (PTO), 11f, 34f Plate fixation, 128–131 PLIND injury, 145–146, 148–149f, 155f, 157 PMCI. See Palmar midcarpal instability (PMCI) POL. See Posterior oblique ligament (POL) Portals arthroscopy. See Wrist arthroscopy portals STT joint. See Scaphotrapeziotrapezoidal (STT) portals TM joint. See Trapeziometacarpal (TM) joint portals Posterior oblique ligament (POL), 20–22, 241 Posttraumatic volar plate adhesions, 221 Predynamic instability, 65–66 Premature wrist loading, 196 Press test foveal tears, 38–40, 41f TFCC tears, 27–28, 28f Proximal distal radioulnar joint (PDRUJ) portal, 5f, 14 Proximal pole scaphoid fracture, 104–105, 107 Proximal row carpectomy (PRC), 213. See also Arthroscopic proximal row carpectomy (APRC) PRUL. See Palmar radioulnar ligament (PRUL) PTO. See Pisotriquetral orifice (PTO) Pure perilunate injury, 145 Push-up position, 184 Pyrocarbon implants, 259 Pyrocarbon spacer, 255–256 Pyrolytic carbon STT spacer, 259

R

Radial artery, 242f Radial sensory nerve, 3 Radial shortening, 173, 174f Radial styloid fracture, 132–134 Radial styloid impingement, 191 Radial styloidectomy. See Arthroscopic radial styloidectomy Radial triangular fibrocartilage complex (TFCC) tear, 28f, 31f, 32f Radiocarpal dislocation, 191 Radiocarpal joint capsulotomy, 161–162 Radiolunate angle, 197–198f Radiopalmar facet, 251f Radioscaphocapitate (RSC), 64 Radioscaphocapitate (RSC) ligament, 96f, 151 Radioscaphoid arthritis, 191 Radioscapholunate (RSL) fusion, 210–211 Radioulnar ligament (RUL), 37–38, 38f Radius, 96f, 121 RASL. See Reduction association of the scaphoid-lunate (RASL) Reattachment of deep radioulnar ligament, 45 Reduced transradial styloid dorsal perilunate dislocation, 156f

Reduction association of the scaphoid-lunate (RASL), 74 Reduction techniques, 130-131. See also Closed reduction Removal of loose bodies, 221 Rolando fracture, 228, 233f Rongeur, 215, 216f RSC. See Radioscaphocapitate (RSC) RSC ligament. See Radioscaphocapitate (RSC) ligament RSL fusion. See Radioscapholunate (RSL) fusion RUL. See Radioulnar ligament (RUL)

S

Salter III fracture, 221–222f sAOL. See Superficial anterior oblique ligament (sAOL) SC fusion. See Scaphocapitate (SC) fusion SC syndrome. See Scaphocapitate (SC) syndrome Scaphocapitate (SC) fusion, 175, 176f, 208–210, 209–210f Scaphocapitate (SC) ligament, 96f, 251–252, 251f Scaphocapitate (SC) syndrome, 145, 151 Scaphoid bone, 96f, 104, 250–251 Scaphoid fossa, 121 Scaphoid fractures and nonunions anatomy and biomechanics, 104–105 arthroscopic bone grafting, 113–115 arthroscopic setup, 107f arthroscopy for evaluation purposes, 118 bent guide wire, 108f, 115–116 comminuted scaphoid fracture, 109f, 113f complications, 115–116 concomitant soft tissue injuries, 118 coronal fractures of scaphoid, 117 diagnosis, 105–106 DISI deformity, 105 displacement of the fracture, 105 distal pole scaphoid fracture, 107 dorsal approach to surgery, 107–110 dry bone model demonstration, 108f factors predisposing toward nonunion, 105 hybrid approach to surgery, 113 indications/contraindications of surgical treatment, 107 K-wire targeting, 109f nonoperative treatment, 106–107 oblique insertion of screw, 115–116 outcomes, 118 overly long screw, 108f percutaneous bone graft harvesting, 113f proximal pole fracture, 104–105, 107 scaphoid waist fractures, 118 scaphoid waist nonunion, 115f screw being too short, 108f screw inserted too horizontally, 108f segmental scaphoid fracture, 112f surgical technique, 107–116 undisplaced scaphoid fracture involving proximal one third, 111f volar approach to surgery, 110–113 Scaphoid nonunion, 191. See also Arthroscopic partial scaphoidectomy; Arthroscopic radial styloidectomy Scaphoid nonunion advanced collapse (SNAC) arthritis, 189, 196–197 Scaphoid shift test, 190–191 Scaphoid waist fractures, 118 Scaphoid waist nonunion, 115f Scapholunate advanced collapse (SLAC) arthritis, 64, 189 Scapholunate (SL) dissociation, 166f. See also Chronic scapholunate (SL) dissociation

Index  267 Scapholunate (SL) instability anatomy and biomechanics, 64–65 ARASL, 74, 75f arthroscopic debridement, 68–69 classification of ligament instability, 67–68 diagnosis, 65 diagnostic arthroscopy, 66–68 dorsal capsuloligamentous repair, 72–73 dynamic SL instability, 65f Geissler grade I injuries, 67, 68f Geissler grade II injuries, 67 Geissler grade III injuries, 67, 68f Geissler grade IV injuries, 67, 68f outcomes, 92–93t scapholunate pinning, 73f SL ligament tear, 68f SLIC screw, 76, 77f surgical technique, 74 thermal shrinkage, 69–70 transarticular K-wire fixation, 71–72 treatment, 65–66 Scapholunate interosseous ligament (SLIL), 64 Scapholunate interosseous ligament (SLIL) tear, 189. See also Scapholunate (SL) instability Scapholunate (SL) ligament, 12f Scapholunate (SL) ligament tear, 68f Scapholunate (SL) pinning, 73f Scaphotrapezial (ST) ligament, 251–252, 251f Scaphotrapeziotrapezoidal (STT) fusion, 191, 252 Scaphotrapeziotrapezoidal (STT) joint, 256f Scaphotrapeziotrapezoidal (STT) ligaments, 251–252, 251f Scaphotrapeziotrapezoidal (STT) osteoarthritis (OA) anatomy and pathomechanics, 250–252 arthroscopic debridement, 259 arthroscopic distal scaphoid resection, 257f arthroscopic partial trapeziectomy, 258–259 combined trapeziometacarpal and scaphotrapeziotrapezoidal arthroscopic resection, 256f complications, 256–257 diagnosis, 252 indications/contraindications for surgical treatment, 252–253 interposition substances, 255–256 nonoperative treatment, 252 open partial trapeziectomy, 258 open resection, 258 outcomes, 258–259 pyrocarbon implants, 259 skeletal anatomy, 251f STT fusion, 252 STT joint, 256f STT ligaments, 251–252, 251f STT portals, 253–254f surgical technique, 253–255 trapezium-trapezoid (TT) inclination, 250–251, 251f Scaphotrapeziotrapezoidal (STT) portals, 253-254f. See also Portals methodology, 22–23, 24f palmar (STT-P), 20, 22–23, 200, 200f radial (STT-R), 18, 200, 200f surface landmarks, 242f ulnar (STT-U), 12, 18, 22–23, 200, 200f Scaphotrapeziotrapezoidal-palmar (STT-P) portal, 20, 22–23, 200, 200f Scaphotrapeziotrapezoidal-radial (STT-R) portal, 18, 200, 200f Scaphotrapeziotrapezoidal-ulnar (STT-U) portal, 12, 18, 22–23, 200, 200f Secondary radial styloid impingement, 191 Segmental scaphoid fracture, 112f Septic arthritis, 170–171 Shake test, 252 Short radiolunate ligament (SRL), 96f

SL instability. See Scapholunate (SL) instability SL ligament. See Scapholunate (SL) ligament SL ligament tear. See Scapholunate (SL) ligament tear SL pinning. See Scapholunate (SL) pinning SLAC arthritis. See Scapholunate advanced collapse (SLAC) arthritis SLIC screw, 76, 77f SLIL. See Scapholunate interosseous ligament (SLIL) SLIL tear. See Scapholunate interosseous ligament (SLIL) tear Small joint arthroscopy Bennett fracture, 226–233 fifth CMC fracture dislocations, 234–239 first metacarpal base fracture, 226–233 MCP joint arthroscopy, 219–225 scaphotrapeziotrapezoidal osteoarthritis, 250–262 trapeziometacarpal osteoarthritis, 240–249 SNAC arthritis. See Scaphoid nonunion advanced collapse (SNAC) arthritis Soft tissue injuries, 118 ST ligament. See Scaphotrapezial (ST) ligament Stable-type scaphoid nonunion, 190 STT fusion. See Scaphotrapeziotrapezoidal (STT) fusion STT joint. See Scaphotrapeziotrapezoidal (STT) joint STT ligaments. See Scaphotrapeziotrapezoidal (STT) ligaments STT OA. See Scaphotrapeziotrapezoidal (STT) osteoarthritis (OA) STT portals. See Scaphotrapeziotrapezoidal (STT) portals STT-P portal. See Scaphotrapeziotrapezoidalpalmar (STT-P) portal STT-R portal. See Scaphotrapeziotrapezoidalradial (STT-R) portal STT-U portal. See Scaphotrapeziotrapezoidalulnar (STT-U) portal Styloid pattern of impingement, 190, 190f, 197 Superficial anterior oblique ligament (sAOL), 20–22, 226, 227f, 240–241 Superficial radial nerve (SRN), 4, 4f, 17–18, 121 Synovectomy, 165–167, 166–167f Synovial biopsy, 165

T

T-condylar fracture, 228, 232f Tear of volar capsule, 151f Tendon autograft, 255–256 Tenotomy scissors, 222–224, 254–255 TFCC. See Triangular fibrocartilage complex (TFCC) TFCC tears. See Triangular fibrocartilage tears Thenar muscle weakness, 242–244 Thenar portal, 17–18 Thermal shrinkage, 69–70 Three-column concept, 123 Three-part fracture, 134 Thumb spica splint, 256 Tinel sign, 242–244 TM grind test. See Trapeziometacarpal (TM) grind test TM joint portals. See Trapeziometacarpal (TM) joint portals TM OA. See Trapeziometacarpal (TM) osteoarthritis (OA) Trabecular bone, 104 Transarticular K-wire fixation, 71–72 Transcapitate perilunate fracture, 146f Transhamate perilunate fracture, 147–148f Transhamate styloid PLIND, 155f Transradial styloid perilunate fracture dislocations, 147–148f, 150f, 153, 154f Transradial styloid PLIND, 155f

Transscaphoid perilunate fracture dislocation, 145, 146f, 150f, 152–153, 154f Transtriquetral dorsal perilunate fracture dislocation, 146–147f Transulnar styloid dorsal perilunate dislocation, 147–148f, 154f Transulnar styloid PLIND, 155f Trapeziectomy and ligament suspension arthroscopy, 248f Trapeziectomy with interposition, 245–246 Trapeziectomy without tendon interposition, 246 Trapeziometacarpal (TM) grind test, 242–244 Trapeziometacarpal (TM) joint, 241. See also Trapeziometacarpal (TM) osteoarthritis (OA) Trapeziometacarpal (TM) joint portals, 241-242. See also Portals distal-dorsal (D-2) portal, 18, 19f, 20 methodology, 20–23 modified radial portal, 17 standard portals, 17 surface landmarks, 242f thenar portal, 17–18 Trapeziometacarpal (TM) osteoarthritis (OA) anterior oblique ligament (AOL), 241 arthroscopic debridement and capsular shrinkage, 245 biomechanics and anatomy, 240–242 dAOL, 241 diagnosis, 242–244 dorsoradial ligament (DRL), 241 failed arthroscopic resection arthroscopy, 248f indications/contraindications to arthroscopic treatment, 245 nonoperative treatment, 244–245 outcomes, 247–249 posterior oblique ligament (POL), 241 precautions, 245 sAOL, 240–241 surgical technique, 245–246 TM joint portals, 241–242, 242f trapeziectomy and ligament suspension arthroscopy, 248f trapeziectomy with interposition, 245–246 trapeziectomy without tendon interposition, 246 ulnar collateral ligament (UCL), 241 Trapezium bone, 96f Trapezium-trapezoid (TT) inclination, 250–251, 251f Trapezoid bone, 96f Triangular fibrocartilage complex (TFCC), 26, 37–38 Triangular fibrocartilage tears anatomy and biomechanics, 26 diagnosis and nonoperative treatment, 27–28 indication/contraindications for arthroscopy, 29 mechanism and classification, 26–27 outcomes, 33, 92–93t type 1A lesions, 26 type 1B lesions, 26, 29–30 type 1C lesions, 26, 31 type 1D lesions, 26, 31–32 Triquetrohamate portal, 4 Triquetrohamate-capitate ligament, 96f Triquetrum bone, 96f TT inclination. See Trapezium-trapezoid (TT) inclination

U

UCI syndrome. See Ulnocarpal impaction (UCI) syndrome UCL. See Ulnar collateral ligament (UCL) UCMA. See Undifferentiated chronic monoarthritis (UCMA) Ulna, 96f

268  Index Ulnar collateral ligament (UCL), 20–22, 222f, 241 Ulnar collateral ligament of injury of thumb, 221 Ulnar-minus variance, 173, 174f Ulnar-positive variance, 173, 174f Ulnar shortening osteotomy (USO), 26 Ulnar styloid excision technique, 58 Ulnar styloid impaction (USI) syndrome anatomy and etiology, 56–57 diagnosis, 57 outcomes, 58 treatment, 57 ulnar styloid excision technique, 58 Ulnar styloid nonunion, 58–60 Ulnar styloid triquetral impingement (USTI), 51 Ulnar translocation, 191 Ulnocapitate ligament, 37–38, 96f Ulnocarpal impaction (UCI) syndrome anatomy and biomechanics, 50 arthroscopic wafer resection, 51–55 diagnosis, 51 mechanism and classification, 50–51 Palmer’s classification, 50–51 Ulnocarpal joint arthroscopic wafer resection, 51–55 distal radioulnar joint arthroscopy, 44–45 foveal tears, 37–49 longitudinal split tear of UT ligament, 33–35 reattachment of deep radioulnar ligament, 45 TFCC tears, 26–33 ulnar styloid impaction syndrome, 56–58 ulnar styloid nonunion, 58–60 ulnocarpal impaction (UCI) syndrome, 50 Ulnolunate ligament, 11f, 96f Ulnotriquetral ligament, 37–38, 96f Undiagnosed perilunate fracture dislocation, 150f Undifferentiated chronic monoarthritis (UCMA), 167 Undisplaced scaphoid fracture involving proximal one third, 111f USI syndrome. See Ulnar styloid impaction (USI) syndrome

USO. See Ulnar shortening osteotomy (USO) USTI. See Ulnar styloid triquetral impingement (USTI)

V

VISI deformity. See Volar intercalated segment instability (VISI) deformity Volar Barton fracture, 129f Volar beak ligament, 20–22, 226, 241 Volar capsulotomy, 161, 162f Volar central portal, 6, 12–13, 14f Volar distal radial ulnar joint (DRUJ) portal, 6f, 7t, 44 Volar distal radial ulnar joint (DRUJ) portal anatomy, 6f Volar distal radioulnar portal, 5–6 Volar intercalated segment instability (VISI) deformity lunotriquetral injuries, 80–81, 81f, 85 midcarpal instability (MCI), 95 volar capsulotomy, 161 Volar ligaments, 96f Volar locking plates, 130, 134–135f Volar plating, 128–130 Volar portals, 4–6, 12–15 Volar radial midcarpal portal, 2, 5 Volar radial portal, 2, 4–5, 7t, 13f Volar shear type malunions, 140 Volar-type scaphoid nonunion, 190, 197, 197–198f Volar ulnar fragment, 226, 227f Volar ulnar portal, 2, 5, 12, 13f, 44 Volar wrist ganglion, 184. See also Arthroscopic wrist ganglionectomy

W

Watson test, 184, 191, 252 Wrist and carpal fractures arthroscopic bone grafting, 113–115 augmented external fixation, 126–128 Bennett fracture, 226–233 bone graft and bone substitutes, 113–115, 131 corrective osteotomy, 140–142 distal radius fracture (DRF), 121–138

Wrist and carpal fractures (Continued) distraction plating, 131–132 fifth CMC fracture dislocations, 234–239 first metacarpal base fracture, 226–233 four-part fracture, 135–136 intraarticular malunions of distal radius, 139–144 perilunate injuries, 145–158 plate fixation, 128–131 PLIND lesion, 145–146, 148–149f, 157 radial styloid fracture, 132–134 scaphoid fractures and nonunions, 103–120 three-part fracture, 134 Wrist arthrofibrosis, 161f Wrist arthroscopy portals. See also Portals 3,4 portal, 10 4,5 portal, 10 6R portal, 10–11 6U portal, 10–11 anatomy, 3–6 clinical and biomechanical studies, 6–8 complications, 8 contraindications, 3 dorsal midcarpal portal, 4 dorsal radiocarpal portal, 3–4 dorsal radioulnar portal, 4 equipment/implants, 8–9 field of view, 6, 7t indications, 2–3 methodology, 9–15 midcarpal portal, 15 STT-U portal, 12 triquetrohamate portal, 4 volar central portal, 6, 12–13, 14f volar distal radioulnar portal, 5–6 volar portals, 4–6, 12–15 volar radial midcarpal portal, 5 volar radial portal, 4–5, 13f volar ulnar portal, 5, 12, 13f Wrist capsulotomy. See Arthroscopic wrist capsulotomy Wrist contractures, 160 Wrist denervation, 175, 177f Wrist ganglionectomy. See also Arthroscopic wrist ganglionectomy