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Name:
Wrist Fusion With Proximal Row Carpectomy
Description:
Wrist Fusion With Proximal Row Carpectomy
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https://cadmoremediastorage.blob.core.windows.net/2e62be04-1cf8-4cdd-b92c-4a9a62f3bdd4/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H35M49S
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https://cadmoreoriginalmedia.blob.core.windows.net/2e62be04-1cf8-4cdd-b92c-4a9a62f3bdd4/Wrist Fusion with proximal row carpectomy.mp4?sv=2019-02-02&sr=c&sig=olREBhjgjY%2B%2FkaLT6%2BNxeDitsRmpynRnxW%2F9zL0nubo%3D&st=2024-11-24T02%3A01%3A32Z&se=2024-11-24T04%3A06%3A32Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
BIJAYENDRA SINGH: Hello, everyone. This is a video on a patient who underwent wrist fusion with distal radio-ulnar reconstruction. She's a 60-year-old lady who sustained this very innocuous looking distal radius fracture which on the first views looked pretty simple and was managed conservatively.
BIJAYENDRA SINGH: The initial x-ray, although it was interrupted, showed the fracture to be pretty simple and was managed non operatively. The image is done after the first week showed some shortening, but given the patient was thought to have low demands, it was carried on to the managed non operatively at 5 weeks when the plaster was taken off was found to have significant shortening.
BIJAYENDRA SINGH: But on balance it was decided to see how she went on and was referred for hand therapy. Ultimately at six months she was having lots of trouble, as you can see, this functional disadvantage. And these are the radiographs. And hence, it was decided to proceed with fusion, which was deemed as the only realistic option.
BIJAYENDRA SINGH: You can see that functionally that this the wrist is a disadvantage because of the radial deviation and she has a significant madelung type of deformity. Patient is supine with a tourniquet. Mark the incision placed over the middle of the radius. Along the Lister's Tubercle if you can feel it. And the middle finger metacarpal as you can see because of the deformity mark the incision curve and hopefully once the wrist is straightened, it should straighten out.
BIJAYENDRA SINGH: The skin is incised and then thick flaps are raised. I often will do some undermining of the skin.
BIJAYENDRA SINGH: as vascularity is not a problem and it allows retraction. Adequate hemostasis is carried out as one goes into the wrist joint. I usually put sutures through the edges of the skin margin and stitch it to the neighboring edge of the wrist on both radial and ulnar side and this allows a good and stable retraction rather than having to rely on either the assistant or a self retainer, which often tends to fall off halfway through the important step.
BIJAYENDRA SINGH: So there's normally two on each side, one at the proximal edge and one at the distal edge of the skin incision. Of course, if you need to extend the incision, then you may need to apply another stich. Similar thing is done on the ulnar side of the wrist as well.
BIJAYENDRA SINGH: This not only provides the retraction, but also hemostasis. After this, do further isolation of the extensive entoclaculum. Then make a small incision in the extensor retinaculum of the third, fourth compartment.
BIJAYENDRA SINGH: level using a knife, I make a full thickness incision and then the scissors extended for approximately and distally. It's no big deal if you end up in the third compartment it just means that the extensor pollicis longus tendon would have to be dealt with either by exteriorizing or we're suturing it back into its groove.
BIJAYENDRA SINGH: You can see I'm carefully elevating the retinaculum on both the sides. Well, then put stay stitch on both these sides of the extensor retinaculum which is suture bracket at the end and it also helps with the retraction.
BIJAYENDRA SINGH: This is held under a clip and one on the other side.
BIJAYENDRA SINGH: After this, I'm going to go and dissect between the third and the fourth compartment, there you go, this is the extensor pollicis longus. So I can see and it is quite closed by, so I will probably release the EPL tendon sheath take it out of it's compartment.
BIJAYENDRA SINGH: Decided to take the EPL along with a bit of Lister's Tubercle and
BIJAYENDRA SINGH: Keep it in the sheath in the distal part so that hopefully I won't have to exteriorize the whole tendon. This osteotomy also helps for it to to reattach to the distal radius when the wound is closed. And equally allows easy placement of the plate on the back of the distal radius as this needs to be reshaped to allow fitting of the plate.
BIJAYENDRA SINGH: Once that is done, I incise the capsule, sharp dissection, in the middle. The traditional teaching is to go along the extrinsic ligament, sorry intrinsic ligament path. But I found this works pretty well for more any of the operations or procedures on the wrist. Certainly in this case, where there is not going to be much role of the ligaments
BIJAYENDRA SINGH: And making a straight incision keeps it simple without any problems and the exposure. Key is to dissect along on the carpal bones. The distal radius as well as the metacarpal. The middle metacarpal. Fairly soon, the sub-periosteum dissection is done. And again, I'll put a stay stitch on both the sides of the capsule as this allows for the retraction.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: I continue with the capsular release all around the wrist to expose the radio carpal and the mid-carpal joints. Sometimes you have to lift off the wrist capsule from the distal radius to provide adequate exposure, and this can be repaired back once the wound is closed.
BIJAYENDRA SINGH: The dorsal capsule is then released and all the ligaments in between the carpal bones is also removed and excised so that you can actually dislocate the wrist joint. You can see here the lunate and the scaphoid been opened up nicely. Then choose a nibbler or sometimes I will use an osteotome to break this into slightly smaller but large chunks.
BIJAYENDRA SINGH: which I then use as bone grafts. The distal most part of the scaphoid is a bit difficult to remove and I tend to leave the distal part out. So I remove the [lunate, the triquetrum] and about three quarters of the scaphoid.
BIJAYENDRA SINGH: So here I'm trying to see if I can just nibble this scaphoid but looks too big. And hence I'm going to use a osteotome to make the initial mark leaving the distal pole of the scaphoid in situ. Then remove the rest of the scaphoid easily. And so now I can see the capitate
BIJAYENDRA SINGH: as well as the remainder of the scaphoid and the articular surface of this. Now prep of the distal radius is also necessary to sit the plate on because of the curvature and the dorsal from - the plate wouldn't fit. But without this prep I use a saw to remove about a three or 4 millimeter thick
BIJAYENDRA SINGH: almost like a bone plate. which again, can be used as a bone graft. Make sure there is no stress rises, although I haven't seen a problem with that. Now is the time to prepare the bone surfaces.
BIJAYENDRA SINGH: You perform the fusion. So I'm opening up the joint between the capitate and the hamate as well as the carpo - metacarpal joints. Now to prepare...
BIJAYENDRA SINGH: Once I'm happy, I use a high speed burr to decorticate the remainder of the cartilage on the head of the capitate in between the capitate and hamate. The distal radius articular surface as well as the carpal metacarpal joints sometimes putting flat retractor like a
BIJAYENDRA SINGH: McDonald or indeed thin osteotome also helps to open up the joints, just the thin, small joints between the carpals and the intercarpal joint.
BIJAYENDRA SINGH: So I've prepped the carpal bones then I pay attention in this case to the distal ulna, which needs stabilization and reception. So from the joint side, I do a subperiosteal dissection of the distal ulna. As this is an older age group patient and the demand is low I'm going to do a resection and then stabilize this. So once I've done a subperiosteal elevation I'll use a saw blade to resect.
BIJAYENDRA SINGH: There's still about 1.5 to 2 centimeters of the ulna so that it sits below the distal end of the radius and not causing any abutment type of picture. And again, this distal end of the ulna comes in handy as a bone graft.
BIJAYENDRA SINGH: Once I'm happy with the prep, then I start to prepare the bone grafts from the removed carpals. Key is to remove the cartilage and then using a bone cutter and make slices rather than completely crushed, as you saw there. The bone cutter is used to have blocks, flat blocks, which fit nicely in between the carpal metacarpal and the carpal joints.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Once I've got enough graft, I would do a trial with the plates that I want to use just to check the positioning of the plate and then I like to do any more soft tissue releases as here I probably will need to release that level around the extensor tendon and also see what the position of my wrist is going to be.
BIJAYENDRA SINGH: So I'm happy I start to put bigger chunks in the radio carpal joint. And the thin flat ones between the inter carpal and Carpo metacarpal joints. Make sure I apply enough bone grafts.
BIJAYENDRA SINGH: Occasionally may need to use a bone punch to tamp any uneven uh, bone graft. So the plates, it's nice and flush.
BIJAYENDRA SINGH: Once I'm happy with the bone graft apply a plate. And the initial fixation in the distal fragment, distal most screws. But before you start putting any of this group, make sure that the alignment is checked. And we check again it like I'm doing here otherwise you could end up with a deformity in the forearm or a plate, which is off the bone.
BIJAYENDRA SINGH: We double check to make sure the alignment is good and once I'm happy with that then I put the second and the third screws in the distal fragment. I'm putting the proximal most in the distal row so that once that is fixed, the plate is less likely to sway.
BIJAYENDRA SINGH: Although the book technique describes going to 1 , 2, 3 from the distal end.
BIJAYENDRA SINGH: I then put the rest of these screws in the metacarpal side of the plate, generally anywhere between 3 and possibly four screws is what I used. Once I fixed this in the metacarpal, I align the wrist and position of the plate over the radius making sure that I get the appropriate angle as well as the alignment in
BIJAYENDRA SINGH: the coronal and sagittal plane. On this plate and the system is the possibility of achieving some compression at the fusion site so that the screw is put in the oval hole at the proximal most edge. And then
BIJAYENDRA SINGH: the screw is inserted on the proximal edge of the base of the plate and then compression device is used, as you can see here. To achieve some compression at the fusion site. Now, the key thing to remember is not to overdo it, this can put the wrist in either a radial or another deviation. Once that is done, then the remainder of the screws are inserted in the proximal fragment.
BIJAYENDRA SINGH: If required, a locking screw can be used in this situation. Just checking the rotations are intact. If required, I put a screw to the capitate to provide more robust fixation.
BIJAYENDRA SINGH: Once this last screw is in, then I go around and stabilize the distal ulna and check to see which side is the best I've decided and I'll probably go from the joint surface. So expose the distal ulna then I make a drill for about two centimeters from the tip, just uni cortical and angle it distally which will allow me to feed the tendon through.
BIJAYENDRA SINGH: Then I use an awl or a forceps incision here to open the medullary canal followed by currettes. You use the same currette to open up that dorsal cortex which should allow us to thread the tendon. So I'm happy with the enlargement then I will harvest part of the ECU tendon. It's generally fairly safe at this level, but
BIJAYENDRA SINGH: please remember the ulnar nerve is not far away from this dissection so be mindful and take care. The ECU tendon is now coming into view. Dissect it more in the proximal side as that's where I'm going to harvest, I leave it attached.
BIJAYENDRA SINGH: It's insertion on the little finger I take about 50% of the ECU, leaving the rest in place to provide balance against the flexor carpi ulnaris tendon. And I cut it at usually at the muscular tendonis junction.
BIJAYENDRA SINGH: So I tried to get about 5 centimeters from the edge of the distal ulna so that would allow and give me enough length to double up on itself. Be careful and make sure that the holes of the intramedullary canal and the dorsal cortex is large enough to pull that tendon.
BIJAYENDRA SINGH: We use a Hewson retriever. You could use a tendon retriever as well But I find this is the simplest way to do it. And once I've got the remainder of the edge, I suture it on itself using a non-absorbable suture.
BIJAYENDRA SINGH: I repair this tendon on itself, its important to remember is to bevel the edges of the distal ulna so that there are no sharp edges left to pose a attritional damage to the ECU tendon.
BIJAYENDRA SINGH: Once I've done that, I generally always use one CC of demeneralized bone matrix putty to put around the bone graft, which acts as a binding agent and also promotes osteo conduction. Following this, I close it in layers after taking some intraoperative images, initially the capsule.
BIJAYENDRA SINGH: The same stay sutures You could use the stay sutures or sometimes I use a non absorbable suture to close the capsule, followed by closure of the extensor retinaculum taking care, that tendons aren't tethered in either of the repairs.
BIJAYENDRA SINGH: Once I close the fat there, I often will delete the tourniquet and I use a 3-0 undyed subcuticular sutures to close the skin, followed by a compression dressing on and below elbow back slab post-op rehab. Patient comes back to outpatients in two weeks, at which time the sutures are removed and the patient is placed in a splint.
BIJAYENDRA SINGH: The patient also starts wrist rotation, the movement and function of use under the care of the hand therapist. These are the post-op radiographs at six months showing good order alignment, the ulnar stabilized and there is a good degree of fusion that has occurred at this wrist. Thank you very much for watching.
BIJAYENDRA SINGH: For more content and videos, please visit the YouTube channel. Thank you.
Segment:0 .
BIJAYENDRA SINGH: Hello, everyone. This is a video on a patient who underwent wrist fusion with distal radio-ulnar reconstruction. She's a 60-year-old lady who sustained this very innocuous looking distal radius fracture which on the first views looked pretty simple and was managed conservatively.
BIJAYENDRA SINGH: The initial x-ray, although it was interrupted, showed the fracture to be pretty simple and was managed non operatively. The image is done after the first week showed some shortening, but given the patient was thought to have low demands, it was carried on to the managed non operatively at 5 weeks when the plaster was taken off was found to have significant shortening.
BIJAYENDRA SINGH: But on balance it was decided to see how she went on and was referred for hand therapy. Ultimately at six months she was having lots of trouble, as you can see, this functional disadvantage. And these are the radiographs. And hence, it was decided to proceed with fusion, which was deemed as the only realistic option.
BIJAYENDRA SINGH: You can see that functionally that this the wrist is a disadvantage because of the radial deviation and she has a significant madelung type of deformity. Patient is supine with a tourniquet. Mark the incision placed over the middle of the radius. Along the Lister's Tubercle if you can feel it. And the middle finger metacarpal as you can see because of the deformity mark the incision curve and hopefully once the wrist is straightened, it should straighten out.
BIJAYENDRA SINGH: The skin is incised and then thick flaps are raised. I often will do some undermining of the skin.
BIJAYENDRA SINGH: as vascularity is not a problem and it allows retraction. Adequate hemostasis is carried out as one goes into the wrist joint. I usually put sutures through the edges of the skin margin and stitch it to the neighboring edge of the wrist on both radial and ulnar side and this allows a good and stable retraction rather than having to rely on either the assistant or a self retainer, which often tends to fall off halfway through the important step.
BIJAYENDRA SINGH: So there's normally two on each side, one at the proximal edge and one at the distal edge of the skin incision. Of course, if you need to extend the incision, then you may need to apply another stich. Similar thing is done on the ulnar side of the wrist as well.
BIJAYENDRA SINGH: This not only provides the retraction, but also hemostasis. After this, do further isolation of the extensive entoclaculum. Then make a small incision in the extensor retinaculum of the third, fourth compartment.
BIJAYENDRA SINGH: level using a knife, I make a full thickness incision and then the scissors extended for approximately and distally. It's no big deal if you end up in the third compartment it just means that the extensor pollicis longus tendon would have to be dealt with either by exteriorizing or we're suturing it back into its groove.
BIJAYENDRA SINGH: You can see I'm carefully elevating the retinaculum on both the sides. Well, then put stay stitch on both these sides of the extensor retinaculum which is suture bracket at the end and it also helps with the retraction.
BIJAYENDRA SINGH: This is held under a clip and one on the other side.
BIJAYENDRA SINGH: After this, I'm going to go and dissect between the third and the fourth compartment, there you go, this is the extensor pollicis longus. So I can see and it is quite closed by, so I will probably release the EPL tendon sheath take it out of it's compartment.
BIJAYENDRA SINGH: Decided to take the EPL along with a bit of Lister's Tubercle and
BIJAYENDRA SINGH: Keep it in the sheath in the distal part so that hopefully I won't have to exteriorize the whole tendon. This osteotomy also helps for it to to reattach to the distal radius when the wound is closed. And equally allows easy placement of the plate on the back of the distal radius as this needs to be reshaped to allow fitting of the plate.
BIJAYENDRA SINGH: Once that is done, I incise the capsule, sharp dissection, in the middle. The traditional teaching is to go along the extrinsic ligament, sorry intrinsic ligament path. But I found this works pretty well for more any of the operations or procedures on the wrist. Certainly in this case, where there is not going to be much role of the ligaments
BIJAYENDRA SINGH: And making a straight incision keeps it simple without any problems and the exposure. Key is to dissect along on the carpal bones. The distal radius as well as the metacarpal. The middle metacarpal. Fairly soon, the sub-periosteum dissection is done. And again, I'll put a stay stitch on both the sides of the capsule as this allows for the retraction.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: I continue with the capsular release all around the wrist to expose the radio carpal and the mid-carpal joints. Sometimes you have to lift off the wrist capsule from the distal radius to provide adequate exposure, and this can be repaired back once the wound is closed.
BIJAYENDRA SINGH: The dorsal capsule is then released and all the ligaments in between the carpal bones is also removed and excised so that you can actually dislocate the wrist joint. You can see here the lunate and the scaphoid been opened up nicely. Then choose a nibbler or sometimes I will use an osteotome to break this into slightly smaller but large chunks.
BIJAYENDRA SINGH: which I then use as bone grafts. The distal most part of the scaphoid is a bit difficult to remove and I tend to leave the distal part out. So I remove the [lunate, the triquetrum] and about three quarters of the scaphoid.
BIJAYENDRA SINGH: So here I'm trying to see if I can just nibble this scaphoid but looks too big. And hence I'm going to use a osteotome to make the initial mark leaving the distal pole of the scaphoid in situ. Then remove the rest of the scaphoid easily. And so now I can see the capitate
BIJAYENDRA SINGH: as well as the remainder of the scaphoid and the articular surface of this. Now prep of the distal radius is also necessary to sit the plate on because of the curvature and the dorsal from - the plate wouldn't fit. But without this prep I use a saw to remove about a three or 4 millimeter thick
BIJAYENDRA SINGH: almost like a bone plate. which again, can be used as a bone graft. Make sure there is no stress rises, although I haven't seen a problem with that. Now is the time to prepare the bone surfaces.
BIJAYENDRA SINGH: You perform the fusion. So I'm opening up the joint between the capitate and the hamate as well as the carpo - metacarpal joints. Now to prepare...
BIJAYENDRA SINGH: Once I'm happy, I use a high speed burr to decorticate the remainder of the cartilage on the head of the capitate in between the capitate and hamate. The distal radius articular surface as well as the carpal metacarpal joints sometimes putting flat retractor like a
BIJAYENDRA SINGH: McDonald or indeed thin osteotome also helps to open up the joints, just the thin, small joints between the carpals and the intercarpal joint.
BIJAYENDRA SINGH: So I've prepped the carpal bones then I pay attention in this case to the distal ulna, which needs stabilization and reception. So from the joint side, I do a subperiosteal dissection of the distal ulna. As this is an older age group patient and the demand is low I'm going to do a resection and then stabilize this. So once I've done a subperiosteal elevation I'll use a saw blade to resect.
BIJAYENDRA SINGH: There's still about 1.5 to 2 centimeters of the ulna so that it sits below the distal end of the radius and not causing any abutment type of picture. And again, this distal end of the ulna comes in handy as a bone graft.
BIJAYENDRA SINGH: Once I'm happy with the prep, then I start to prepare the bone grafts from the removed carpals. Key is to remove the cartilage and then using a bone cutter and make slices rather than completely crushed, as you saw there. The bone cutter is used to have blocks, flat blocks, which fit nicely in between the carpal metacarpal and the carpal joints.
BIJAYENDRA SINGH:
BIJAYENDRA SINGH: Once I've got enough graft, I would do a trial with the plates that I want to use just to check the positioning of the plate and then I like to do any more soft tissue releases as here I probably will need to release that level around the extensor tendon and also see what the position of my wrist is going to be.
BIJAYENDRA SINGH: So I'm happy I start to put bigger chunks in the radio carpal joint. And the thin flat ones between the inter carpal and Carpo metacarpal joints. Make sure I apply enough bone grafts.
BIJAYENDRA SINGH: Occasionally may need to use a bone punch to tamp any uneven uh, bone graft. So the plates, it's nice and flush.
BIJAYENDRA SINGH: Once I'm happy with the bone graft apply a plate. And the initial fixation in the distal fragment, distal most screws. But before you start putting any of this group, make sure that the alignment is checked. And we check again it like I'm doing here otherwise you could end up with a deformity in the forearm or a plate, which is off the bone.
BIJAYENDRA SINGH: We double check to make sure the alignment is good and once I'm happy with that then I put the second and the third screws in the distal fragment. I'm putting the proximal most in the distal row so that once that is fixed, the plate is less likely to sway.
BIJAYENDRA SINGH: Although the book technique describes going to 1 , 2, 3 from the distal end.
BIJAYENDRA SINGH: I then put the rest of these screws in the metacarpal side of the plate, generally anywhere between 3 and possibly four screws is what I used. Once I fixed this in the metacarpal, I align the wrist and position of the plate over the radius making sure that I get the appropriate angle as well as the alignment in
BIJAYENDRA SINGH: the coronal and sagittal plane. On this plate and the system is the possibility of achieving some compression at the fusion site so that the screw is put in the oval hole at the proximal most edge. And then
BIJAYENDRA SINGH: the screw is inserted on the proximal edge of the base of the plate and then compression device is used, as you can see here. To achieve some compression at the fusion site. Now, the key thing to remember is not to overdo it, this can put the wrist in either a radial or another deviation. Once that is done, then the remainder of the screws are inserted in the proximal fragment.
BIJAYENDRA SINGH: If required, a locking screw can be used in this situation. Just checking the rotations are intact. If required, I put a screw to the capitate to provide more robust fixation.
BIJAYENDRA SINGH: Once this last screw is in, then I go around and stabilize the distal ulna and check to see which side is the best I've decided and I'll probably go from the joint surface. So expose the distal ulna then I make a drill for about two centimeters from the tip, just uni cortical and angle it distally which will allow me to feed the tendon through.
BIJAYENDRA SINGH: Then I use an awl or a forceps incision here to open the medullary canal followed by currettes. You use the same currette to open up that dorsal cortex which should allow us to thread the tendon. So I'm happy with the enlargement then I will harvest part of the ECU tendon. It's generally fairly safe at this level, but
BIJAYENDRA SINGH: please remember the ulnar nerve is not far away from this dissection so be mindful and take care. The ECU tendon is now coming into view. Dissect it more in the proximal side as that's where I'm going to harvest, I leave it attached.
BIJAYENDRA SINGH: It's insertion on the little finger I take about 50% of the ECU, leaving the rest in place to provide balance against the flexor carpi ulnaris tendon. And I cut it at usually at the muscular tendonis junction.
BIJAYENDRA SINGH: So I tried to get about 5 centimeters from the edge of the distal ulna so that would allow and give me enough length to double up on itself. Be careful and make sure that the holes of the intramedullary canal and the dorsal cortex is large enough to pull that tendon.
BIJAYENDRA SINGH: We use a Hewson retriever. You could use a tendon retriever as well But I find this is the simplest way to do it. And once I've got the remainder of the edge, I suture it on itself using a non-absorbable suture.
BIJAYENDRA SINGH: I repair this tendon on itself, its important to remember is to bevel the edges of the distal ulna so that there are no sharp edges left to pose a attritional damage to the ECU tendon.
BIJAYENDRA SINGH: Once I've done that, I generally always use one CC of demeneralized bone matrix putty to put around the bone graft, which acts as a binding agent and also promotes osteo conduction. Following this, I close it in layers after taking some intraoperative images, initially the capsule.
BIJAYENDRA SINGH: The same stay sutures You could use the stay sutures or sometimes I use a non absorbable suture to close the capsule, followed by closure of the extensor retinaculum taking care, that tendons aren't tethered in either of the repairs.
BIJAYENDRA SINGH: Once I close the fat there, I often will delete the tourniquet and I use a 3-0 undyed subcuticular sutures to close the skin, followed by a compression dressing on and below elbow back slab post-op rehab. Patient comes back to outpatients in two weeks, at which time the sutures are removed and the patient is placed in a splint.
BIJAYENDRA SINGH: The patient also starts wrist rotation, the movement and function of use under the care of the hand therapist. These are the post-op radiographs at six months showing good order alignment, the ulnar stabilized and there is a good degree of fusion that has occurred at this wrist. Thank you very much for watching.
BIJAYENDRA SINGH: For more content and videos, please visit the YouTube channel. Thank you.
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