Name:
A Guide To Performing Wrist Arthroscopy
Description:
A Guide To Performing Wrist Arthroscopy
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T00H14M23S
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Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SANJEEV KAKAR: Hello, my name is Sanj Kakar and it's a privilege to go through this surgical video on diagnostic wrist arthroscopy. These are my disclosures. So in terms of the anatomy, we should think of the wrist as comprising of two rows of bones,
SANJEEV KAKAR: four bones in each. One can see that one has the proximal carpal row as well as the distal carpal row. The proximal carpal row comprises of the scaphoid, the lunate and triquetrum and most palmarly, the pisiform and the distal carpal row comprises of the hamate, capitate, trapezoid and trapezium. You will see that the bones are bound by thick ligaments in terms of the distal row comprising of the capitellum hamate ligament, which you don't really appreciate through the midcarpal arthroscopy.
SANJEEV KAKAR: The capitate trapezoid ligament as well as the trapezoid, trapezium ligament. In terms of the proximal carpal row, the most important here are the scapholunate ligament and the lunotriquetral ligament, which can be seen from both the radiocarpal joint and the midcarpal joint. In terms of my basic setup, patients are either having regional anesthesia or wide awake anesthesia with 1% lidocaine with 1 in 100,000 epinephrine in the skin and capsule.
SANJEEV KAKAR: In terms of traction, no more than 10 to 12 pounds of traction and I do put a tourniquet, especially if I'm doing wrist arthroscopy, in a dry manner. In terms of doing this dry, this is popularized by Paco Del Parnell [?] using an automatic washout technique, which I'll explain during this video. Alternatively, you can use saline irrigation, and I tend to do this. If I do do this using gravity inflation as opposed to using a pump.
SANJEEV KAKAR: So in terms of the anatomy, these were slides that were provided by Dick Berger. One can appreciate in terms of the portals, one has the 3-4 radiocarpal portal and the portals are named based on their relationship to the extensor tendon, so this is between the third and fourth extensor compartment tendons, and this is the main working portal for the radiocarpal joint.
SANJEEV KAKAR: The 4-5 portal is between the fourth and fifth extensor compartment tendons. You then have the 6-U portal and I've asterisked here the dorsal sensory branch of the ulnar nerve. It's very close to these portasl, so if I am making this portal and doing work through this, I will make an incision, dissect down and identify the dorsal sensory branch of the ulnar nerve and retract this out of harm's way.
SANJEEV KAKAR: Traditionally, I'll use the other working portal as the 6R portal, which is just radial to the ECU tendon. In addition, one has the 1-2 portal, and this actually technically is closer to being between the second and third extensor compartment tendons, and here one needs to be careful of the radial artery as well as the dorsal sensory branch of the radial nerve. In terms of the midcarpal portals, the main working portals are the radial midcarpal portal, which is about one-two centimeters distal to the 3-4 portal in line with the radial border of the long finger and the ulnar midcarpal portal, which is distal to the four-five radial carpal portal.
SANJEEV KAKAR: So this is a case example of a patient with a six month history of left wrist pain who was tender over the scapholunate ligament and had a positive Watson shift test. The MRI was equivocal, but you can see from the X-rays overall the carpus doesn't look too bad. So here what we're doing is the patient is in traction, we're making a small incision just skin only at the 3-4 portal, I spread down with the tenotomy scissors working between the third and fourth extensor compartment tendons, and then I pop straight into the joint. Here,
SANJEEV KAKAR: there was no need to insufflate the joint, we're doing this under dry arthroscopy. Now, I'm placing the cannula into the joint and it pops straight in and you can see it's a very deliberate method and you can see we're into the joint and now I'm introducing the arthroscope. And I did mention to you about the automatic washout technique. When you first start doing this, there may be some debris occluding your view
SANJEEV KAKAR: and so what we're doing here, we have a 2 millimeter shaver in the 6-R portal and we have a 10 CC syringe and essentially you're creating a closed circuit whereby the arthroscopic irrigation system is washing out the joint. Now I'm taking the arthroscope and you can see I'm in the 3-4 portal and my fingers are very close to the skin and this way, it gives you fine details in terms of your motion,
SANJEEV KAKAR: and I'm going from the radial tuberosity the ulnar side of the wrist. Now I want to show what the radiocarpal joint looks like through the dorsal portals. So here we're seeing, this is a normal wrist, and once we've come in here, the radius scaphoid for capitate and long radial lunate ligament. Now, as you come ulnar, you'll see the ligament of Testut, which is this vascular sheath with the membranous portion of the scapholunate ligament,
SANJEEV KAKAR: and if you drop your hand, you're now going up to the dorsal scapholunate. Here you can see we come to the ulnar side. There's some wear of the lunate, there's the lunate, and as we go to the ulnar side of the wrist, now we drop onto the TFCC. So you can see the TFCC here and this is the pre-styloid recess, which is a normal finding in the wrist and above you, you have the triquetrum.
SANJEEV KAKAR: There you can see the LT ligament between the lunate and the triquetrum. Now, I've brought in a probe and we're doing the trampoline sign and you can see that there's a loss of turgor of that TFCC and this is a hook test where I've come underneath the TFCC lifting this up. You can see the trampoline, you can see how floppy the TFCC is, indicating that this may have a potential tear.
SANJEEV KAKAR: Here we're also describing the suction test, so now you put the shaver on and you can see just by turning it on, how it lifts the TFCC up and this is a useful test for me either if there's a foveal detachment of the TFCC or sometimes the TFCC will have peripherally scarred down and when you get inside the joint, it looks normal but doing the suction test and the trampoline sign will give you a clue that the natural tension of the TFCC has been lost.
SANJEEV KAKAR: Now, here we are in this patient, you can see when the radiocarpal portal, we've gone from the scaphoid facet to the lunate facet, there's the lunate and we follow past the inter-sulcus ridge and you can see the hand working across, lifting up the arthroscope and now we're at the TFCC region. You can see this patient has some synovitis in the ulnar gutter.
SANJEEV KAKAR: This is where we would see a UT split tear, but this patient is asymptomatic. Now I'm taking the probe and I'm doing the trampoline sign, just putting down, pushing down on the TFCC, making sure that this feels normal. I also now want to share with you about radiocarpal joint evaluation through the volar portals, which was described by David Slutsky. So you'll see this is a different patient,
SANJEEV KAKAR: I've marked out the FCR on the right and so what I've done is made an incision, dissected out the FCR, I cheated ulnarly and then I put a needle through between the radius scaphoid capitate and long radial lunate ligament. And then you put the trocar in here, you can see the camera is in the dorsal 3-4 portal and now the camera has been switched around and you can see that there's a probe coming in from the dorsal side.
SANJEEV KAKAR: Next, I'd like to show you the volar ulnar portals and so I'll make a larger incision in here because I want to dissect out the ulnar neurovascular bundle. So after I've made a skin incision, I'll be working between the ulnar aspect of the flexor tendons, which are on the right and the FCU and the ulnar neurovascular bundles are on the left. So these are now retracted out of harm's way and the actual self retainer is placed and a needle will be placed just radial to the ulnar carpal ligaments.
SANJEEV KAKAR: And so here now you can see that the camera is being put in through the volar ulnar portal, a shaver or a probe. You can see here a shaver is coming from the dorsal side, there's a dorsal TFCC tear, which we're debriding. In this patient, we're doing wet arthroscopy, so we're using thermal shrinkage to basically spot weld any tissues and you must do it in a pulsed manner as opposed to continuous
SANJEEV KAKAR: and here we're doing the volar LT and you can see here how it looks from the dorsal and volar side. An easier way to do this is through the switching stick technique, so when we're making the volar radial portal, what we'll do is we'll have the arthroscope in either the 4-5 or the 6R portal on the dorsal side, and a switching stick comes in through the 3-4 radiocarpal portal.
SANJEEV KAKAR: You then pass this switching stick between the radius scaphoid capitate and long radial lunate ligament through the capsule and then make your volar FCR approach. So what you'll see in this cadaver, I've basically put the camera in the 4-5 and I've put the switching stick between the radius scaphoid capitate and long radial lunate ligament. You can see what it looks like here and for demonstration purposes, you can see how it indents on the volar side,
SANJEEV KAKAR: I would recommend that you just go through the capsule, identify the FCR and then retract the FCR to the ulnar side. The radial artery is radial and then you can push this through and then you put your trocar over this. In making the volar ulnar portal using a switching stick technique, here you'll paste the arthroscope in the dorsal 3-4 radiocarpal portal, put the switching stick in either the 4-5 or the 6R radiocarpal portal and then place the switching stick radial to the ulnocarpal ligaments,
SANJEEV KAKAR: you'll then make a volar approach and then pass the switching stick through the capsule between the flexor tendons on the radial side of the fingers and the FCU and the ulnar neurovascular bundle on the ulnar side. So if we look at what this looks like, you'll see here in the cadaver, you've got the camera in the 3-4 portal, the switching stick coming in, you've got radial to the ulnar carpal ligaments.
SANJEEV KAKAR: I've made my volar incision and then you can place a trocar through. Moving on now, back to the midcarpal joint evaluation from the dorsal side, here you'll see I've made an incision over the ulnar midcarpal portal, I've spread down and I've put the trocar in. Always make the ulnar midcarpal portal first, especially when you're thinking about a scapholunate ligament injury because the joint space is much smaller on the radial midcarpal portal because the scaphoid tends to want to go into flexion.
SANJEEV KAKAR: Now here you can see that the camera is in the ulnar midcarpal portal, I have a needle in the dorsal radial midcarpal portal. A small transverse skin incision is made and once I've made the skin incision, I'll then take my tenotomy scissors as earlier to spread down, spreading between the extensor tendons and as such, I'll pop into the joint space. And this is a relatively straightforward
SANJEEV KAKAR: and simple technique and you can see there I've popped straight in. Now this is the automatic wash out.
SANJEEV KAKAR: You can see I have the camera in my left hand with the 10 CC syringe and you can see I have the shaver in my right hand using the suction and you can see how the plunger depresses and this irrigates the joint and this is a very useful technique, for example, to clean debris in the joint or when you're doing, for example, an arthroscopic distal radius fracture to irrigate hematoma out of the joint. Here in this patient, you will see this is a different patient,
SANJEEV KAKAR: you'll see, there's the scaphoid on the left and you will see the capitate on the right. And so we'll go up to the scaphoid, gives you an unparalleled view of the scaphoid. We drop back down, now you'll see the lunate in the center screen, the lunotriquetral joint triquetrum. Next you're going in towards the ulnar side of the ulnar carpal joint and you'll see the capitate and the hamate.
SANJEEV KAKAR: There's a smooth transition between the capitate and the hamate. Now I'm taking a probe and you'll see how I'm probing between the scaphoid and the lunate. You can see there's a step off between the scaphoid and the lunate, and I'm feeling dorsally, checking out the integrity of the scapholunate ligament, the membranous portion, and then making the probe all the way to the volar side to check the volar scapholunate ligament.
SANJEEV KAKAR: Here I'm doing the lunotriquetral joint, so here the camera is in the radial midcarpal portal and the probe is coming from the ulnar midcarpal portal, probing the integrity between this lunate and triquetrum. Back to the patient in hand, here we're doing the ulnar midcarpal arthroscopy and what I'm seeing here is the lack of the quality of this dorsal scapholunate ligament, how I can reduce the carpus and also the nature of the cartilage.
SANJEEV KAKAR: And now I'm driving volarly and you can see that this patient actually has a volar and a dorsal scapholunate ligament incompetency. Here I dropped my hand, so we're looking at the STT joint and now as I raise my hand, we're going all the way along the scaphoid and then we're back into the midcarpal joint
SANJEEV KAKAR: and so this is a nice trick to look at the STT joint or, for example, a scaphoid fracture. Here's another look at the scaphoid and the capitate and as I push the camera, you can see the trapezoid and the trapezium and this will give you a view of the STT joint. So in terms of my post-operative plan, in terms of the dressings, I put Steri strips on the wounds and place the patient in a sterile bandage. In terms of the pathology being treated, that really determines the actual post-operative protocols,
SANJEEV KAKAR: so, for example, if a patient has a TFCC repair, then they'll go in above elbow splint for two weeks and then go into a Munster cast. So really, the post-operative plan varies depending on the pathology that you're treating. I hope you've enjoyed this video, which tries to outline basic diagnostic dorsal and volar arthroscopic examination of the wrist. Please, if you have any questions or concerns, do not hesitate to contact me.
SANJEEV KAKAR: Thank you for the privilege of your time.