Wrist Arthroscopy Techniques (eBook)

Christophe Mathoulin (Autor)

eBook Download: EPUB

2019 | 2. Auflage
204 Seiten
Georg Thieme Verlag KG
9783132580589 (ISBN)

Infos

<p>In the past 5 years, wrist arthroscopy has become the third most common arthroscopic procedure, behind knee and shoulder. The method has evolved significantly over the past decade, providing a better understanding of disease mechanisms and applications. Authored by a renowned expert in the field of hand and wrist surgery, this second edition of <cite>Wrist Arthroscopy Techniques</cite> is a step-by-step, anatomically illustrated manual encompassing the latest concepts in the field, now greatly enhanced by 200 short videos, accompanying each illustration in the book.</p><p>Starting with an introduction about instrumentation and techniques, readers will gain insight into how an arthroscope enables precise visualization and analysis of the internal structural make-up of the wrist.</p><p>Each chapter provides a how-to, detailed procedural guide&mdash;from the point of incision to closure, accompanied by artfully drawn illustrations. The author shares clinical pearls and provides comprehensive explanations on treating specific conditions, including ligament tears and instability, complex fractures, dorsal and volar wrist ganglia, advanced arthritis, and fibrocartilage tears. Indications, risks, special precautions, and postoperative care are covered.</p><p><strong>Special Features:</strong><ul><li>200 brilliant videos provide complete coverage of all procedures</li><li>Meticulous explanation of anatomical structures</li><li>Multiple surgical approaches included, where applicable</li><li>Coverage of new minimally invasive arthroscopy</li><li>Use of pyrocarbon implants, and bone and tendon grafts for reconstruction</li><li>Analyses of postoperative range-of-motion, stability, and overall outcome</li></ul></p><p>Whether you are a seasoned surgeon or an advanced fellow, <cite>Wrist Arthroscopy Techniques</cite> is certain to be consulted frequently. An invaluable and comprehensive resource tool covering the state-of-the-art arthroscopic techniques, it is a must-have for a

Textauszug

2 Surgical Approaches

2.1 Introduction

Arthroscopic surgery avoids the joint exposure that results from extensive surgical approaches. Conventional wrist surgery incisions are known to cause fibrosis and stiffness. Arthroscopic approaches are thus as small as possible. This chapter describes the main arthroscopic approaches, knowing that other possibilities exist, depending on the surgeon, the amount of exposure required, and variations in anatomic configuration.

2.2 General Principles of Approaches

The incisions are horizontal, following the skin creases and left to granulate to achieve an aesthetically pleasing scar. A no. 15 blade is used; no. 11 blades are used for other joints such as the shoulder or the hip, but not for the wrist where noble structures, such as tendons, vessels, and nerves, lie just beneath the skin and risk being damaged (▶ Fig. 2.1).

The steps for establishing an approach or portal are always as follow:

• Finger palpation of the zone

• Placement of a needle in the exact location of the portal, taking into account bony anatomy and the required angle

• Short incisions of 1 to 2 mm using the no. 15 blade

• Breaching of the skin and the capsule using a blunt mosquito clip to push away any noble structures without injuring them (▶ Video 2.1)

The dorsal radiocarpal portals are named for the dorsal extensor compartments they are between, so that portal 3–4 lies between the 3rd and 4th compartments and portal 6R is radial to the 6th compartment, and so on.

2.3 Radiocarpal Portals

The radiocarpal portals are named according to their positions in relation to the dorsal extensor compartments (▶ Fig. 2.2).

2.3.1 3–4 Radiocarpal Portal

This portal is the real key to wrist exploration and the easiest one to locate. The first method of location uses the three circles technique: a circle is drawn over the tubercle of Lister, two identical circles of the same size are marked distally and the portal is located at the center of the third circle (▶ Video 2.2). In the second technique, the thumb is held vertically against the wrist so that the pulp feels the tubercle of Lister and the tip is at the distal end of the tubercle, the thumb is rolled toward the distal end of the wrist, second phalanx of the thumb (P2) passing from the vertical to the horizontal position, and the tip falls into the dip of the radial radiocarpal joint. The 3–4 portal is located just over the nail.

Fig. 2.1 Operative view of a 3–4 portal. The approach is a small horizontal skin incision allowing introduction of instruments and the scope.

Video 2.1 Video showing the sequence to establish an ulnar midcarpal portal (finger palpation, needle insertion, and introduction of the blunt clip followed by the arthroscope).

Once the position is marked, the needle is inserted, respecting the radial slope from dorsal to palmar and from lateral to medial (▶ Video 2.3). Once the needle is correctly placed, i.e., felt freely inside the joint, the portal is established as usual using a blunt mosquito forceps (▶ Video 2.4).

2.3.2 6R Radiocarpal Portal

This portal is easy to find once the 3–4 radiocarpal portal is established. The scope in portal 3–4 is directed ulnarward and when facing the triangular fibrocartilage complex (TFCC), the spot for the 6R portal is seen by transillumination. The correct position is verified using the needle in the joint (▶ Video 2.5).

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

2.3.3 4–5 Radiocapral Portal

This portal is less frequently used, as the previous two portals are sufficient for wrist exploration. However, it may be useful for certain techniques.

Video 2.2 Video showing the sequence for a 3–4 portal using the three circles technique.

Video 2.3 Video showing the sequence for a 3–4 portal using the flexed thumb technique.

Video 2.4 Video showing the introduction of a clip through the capsule, respecting the curve of the clip and the curve of the posterior rim of the radius: the clip rolls over the radial slope.

Video 2.5 Video showing the localization of the 6R portal: the scope is positioned in the 3–4 portal ulnarward and the needle is placed in the center of a circle of transillumination. The position of the needle is checked on the screen. The scope is held as a trigger, with the index applied against the skin to control the length of the scope introduced into the joint.

With the scope in the 3–4 portal, a needle is used to locate this portal situated between the 4th and 5th compartments, 1 cm lateral to the 6R portal.

2.3.4 6U Radiocarpal Portal

This portal was classically used for outflow. It is often associated with a direct foveal distal radioulnar portal for foveal reinsertion of the TFCC.

The 6U radiocarpal portal is ulnar to the extensor carpi ulnaris tendon (ECU) on the medial aspect of the wrist.

The scope in position 3–4 is pushed ulnarward and placed at the TFCC, facing the styloid recess. The intramuscular needle must emerge in the middle of the styloid recess.

This approach is risky due to the association with the dorsal sensory branch of the ulnar nerve. Extra care is needed to avoid injury to this sensory nerve.

2.3.5 1–2 Radiocarpal Portal

This portal is situated between the 1st and 2nd compartments above the radial styloid. The depression distal to the styloid is used to locate it, using the thumb and transillumination: the scope in 3–4 position is directed radially toward the styloid.

The needle is placed respecting the radial slope and checked intra-articularly (▶ Video 2.6). The approach may be horizontal for a styloidectomy, or an extended vertical approach may be used to place an implant and avoid injury to the cutaneous sensory branches of the radial nerve.

2.4 Midcarpal Portals

There are three classic midcarpal portals: the midcarpal ulnar (MCU) portal, the radial midcarpal (MCR) portal, and the scaphotrapeziotrapezoid (STT) portal (▶ Fig. 2.3).

Video 2.6 Video showing the sequence for the 1–2 radiocarpal portal, the scope is in 3–4, the camera toward the radial styloid, the needle is positioned at the center of a circle of transillumination with respect to the radial slope.

2.4.1 Midcarpal Ulnar Portal

The MCU is the simplest arthroscopic approach to the midcarpal joint. The midcarpal joint depression situated between the medial four wrist bones is easily palpable and is called the “crucifixion fossa.” An intramuscular injection needle helps locate the exact orientation of this portal. It should be placed following the slope of the first and second carpal rows, and directed from ulnar to radial (▶ Video 2.7).

2.4.2 Radial Midcarpal Portal

This portal is not very simple to locate. It is situated about 1 cm distal to the 3–4 radiocarpal portal. The space between the scaphoid and the head of capitate is very tight, and the curve of the two bones is prominent. Lesions of the cartilage are not uncommon, if this is used as the primary approach to the midcarpal joint.

After the MCU portal is established, it is easier to introduce the scope into the joint and direct it toward the dorsal aspect of the scaphoid just after the scapholunate joint to locate this portal by transillumination (▶ Video 2.8).

2.4.3 STT Midcarpal Portal

This portal is situated between flexor carpi radialis (FCR) laterally and extensor carpi radialis (ECR) medially at the STT joint just radial to the index extensors (▶ Fig. 2.4). Localization is not simple. Transillumination may be used, directing the scope toward the STT joint (▶ Video 2.9). For this, the arthroscope must be introduced through the 3–4 portal following the medial aspect of the scaphoid distally until the STT.

Fig. 2.3 Diagram showing the classic midcarpal portals: STT: Scaphotrapezotrapezoid portal, MCR: radial midcarpal portal between compartments 3 and 4, and MCU: midcarpal ulnar portal classically between compartments 4 and 5 but sometimes crossing compartment 4.

2.5 Distal Radioulnar Portals

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

2.5.1 Distal Radioulnar Portal

This portal is located below the TFCC precisely at the apex of an isoceles triangle the base of which is the line joining the 4–5 and the 6R portals. To find it, the scope is placed in 3–4 portal with the camera facing the TFCC. The needle must be inserted in the interval between the radius and the ulna and used to lift the center of the TFCC from below...

Produkt-Details

• Erscheint lt. Verlag: 22.5.2019
• Verlagsort: Stuttgart
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete ► Chirurgie
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete ► Orthopädie
• Schlagworte: arthroscopy • Arthroscopy video • articular injury • hand surgery • Orthopedics • orthopedic surgery • Wrist • Wrist surgery
• ISBN-13: 9783132580589 / 9783132580589