Name:
Proximal Hamate to Scaphoid Nonunion Reconstruction
Description:
Proximal Hamate to Scaphoid Nonunion Reconstruction
Thumbnail URL:
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Duration:
T00H09M55S
Embed URL:
https://stream.cadmore.media/player/957104fa-d279-4c9e-b442-a0321c9c4aff
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/957104fa-d279-4c9e-b442-a0321c9c4aff/v-005573.mp4?sv=2019-02-02&sr=c&sig=%2BoX5XR2yTTbWM9CWbV6iBGAvTLPS7pgHYvIpK5DA6Ck%3D&st=2024-11-21T17%3A23%3A52Z&se=2024-11-21T19%3A28%3A52Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
DAVID TUCKMAN: This is Dr. Tuckman. I'm going to be presenting a proximal pole scaphoid reconstruction using a handmade osteoarticular autograft. Patient is a right hand dominant 27-year-old male who presented after a repair of a proximal pole scaphoid non-union with distal radius bone grafting. X-rays and CT show persistent nonunion despite a very good repair.
DAVID TUCKMAN: If we look at our treatment options, revision repair is an option but given the size of proximal pole success would be unlikely. Salvage such as a PRC or four corner fusion as well are options but given the patient's age, this is not ideal. And if we get into reconstruction, medial femoral condyle, vascularized osteochondral graft is an option as well, but does have some downsides.
DAVID TUCKMAN: There is a second incision with potential donor site morbidity. You do have to do a microvascular anastomosis. There's really nothing to fix the scapholunate ligament to as well. A rib osteochondral graft is an option, but taking rib is not something most hand surgeons are really very comfortable with. There's a very interesting technique that came out of the Mayo using a handmade osteoarticular graft to reconstruct the proximal pole of the scaphoid
DAVID TUCKMAN: and it has a number of advantages. A, it's just a single incision. There's no vascular anastomosis, and you do have the ability to repair the scapholunate ligament. I want to thank Dr. Kakar for giving me really great tips and tricks for this case. The distance from the base of the hook of the hamate to the tip of the hamate was measured in order to ensure appropriate length of the graft can be harvested.
DAVID TUCKMAN: Procedure is performed under regional and general anesthesia. The prior dorsal incision was incorporated. The dissection was then taken down through the subcutaneous tissues. The retinaculum over the carpus is identified. The extensor pollicis longus is then dissected from the retinaculum, along with the tendons of the fourth dorsal extensor compartment.
DAVID TUCKMAN: A ligament sparing capsulotomy is then performed. The capsulotomy is taken slightly ulnar and distal in order to get adequate exposure of the hamate. Transverse capsulotomy is made in line with the radius just distal to the radiocarpal joint, leaving a small cuff of tissue for later repair. The distal radioulnar joint is identified and the incision is taken distally and ulnarly in line with the fibers of the dorsal radiocarpal ligament.
DAVID TUCKMAN: Transverse capsulotomy is then made just distal to the dorsal intercarpal ligament and the capsulotomy is elevated from ulnar to radial. Care is taken to preserve the scapholunate ligament. This will be needed later for the reconstruction. The capsulotomy is elevated to just pass the nonunion site. Scapholunate joint is identified and the scapholunate ligament is elevated off of the proximal pole of the scaphoid.
DAVID TUCKMAN: The screw is identified and then removed. Proximal pole of the scaphoid is then removed using a ronjour. Scaphoid is examined, there's an osteophyte on the dorsal aspect of the scaphoid that was debrided.
DAVID TUCKMAN: A ruler is trimmed and the defect is measured. Hamate is then exposed. Retractors placed between the fourth and fifth dorsal extensor compartments. The capsule between the triquetrum and hamate is divided with a 67 beaver blade. Care is taken not to plunge with the blade. The deep branch of the ulnar nerve is in the vicinity. Freer is in place between the capitate and the hamate.
DAVID TUCKMAN: The beaver blade is used to divide the capsule, taking care not to injure the articular cartilage or plunge with the blade. Ink is then placed on a 15 blade scalpel. Osteotomy location is marked on the hamate, in this case 10 millimeter. Osteotomy is then performed with a thin sagittal saw with saline irrigation going up to but not through the volar cortex.
DAVID TUCKMAN: Freer elevator is then used to crack the volar cortex. Capsular division is then completed and the graft is gently removed. The graft is inspected. It will be rotated 180 degrees and the scapholunate ligament will be sewn to the volar capsular attachments.
DAVID TUCKMAN: The scaphoid is then trimmed using a sagittal saw in order to get a flat surface for appropriate apposition of the graft. The scaphoid was then inspected, more debridement was required to get down to bleeding cancellous bone. The scaphoid was again inspected.
DAVID TUCKMAN: There was bleeding cancellous bone. The cortex needed to be trimmed in order to get its flattest surface as possible. Freer was placed between the scaphoid and the capitate in order to protect the capitate, a flat recipient site can be appreciated. The graft was then inserted into the defect.
DAVID TUCKMAN: Intraoperative fluoroscopy demonstrated a excellent size match and cortical opposition. There was a gap due to debridement of the cancellous bone. We have two options. The first is to make another cut with the sagittal saw to get a flat surface or fill the gap with bone graft. In this case, I do not have enough graft length to take more scaphoid, so I elected for bone grafting.
DAVID TUCKMAN: Just erased bone graft was harvested through the third dorsal extensor compartment. Scaphoid was impact with bone graft. It is very important to place bone graft in layers and try and compress the bone graft as much as possible to get as dense a graft as you can. The graft was then inserted and reduction was confirmed.
DAVID TUCKMAN: The wrist was slightly flexed and a guide pin for a headless compression screw was inserted. Fluoroscopy confirms graft placement and distal radius bone graft compaction. I would be careful about using a de-rotational k-wire due to the risk of fracturing the graft while inserting the screw. I do use a standard drill and if your set has an opening drill which will decrease insertion torque and decrease your chance of splitting the graft.
DAVID TUCKMAN: 2.2mm headless compression screws then inserted. The scapholunate ligament and the ligament attached to the graft is then approximated and secured with a 4-0 non-absorbable suture. The reconstruction is then inspected
DAVID TUCKMAN: along with the articular reduction. The capsulotomy is closed with 3-9 vicryl sutures. Final fluoroscopic images show placement of the graft and the screw as well as reduction of the scapholunate interval. Though I did not use a k-wire in this case, placement of a scaphoid capitate or capitate lunate wire is an option.
DAVID TUCKMAN: Patient is placed in a short arm splint at week one. Change their short arm cast with a bone stimulator. At 8 weeks post op, CAT scan showed healing and patient was changed to a wrist brace. At three months post op, patient began occupational therapy with range of motion exercises. This is a CAT scan at two months post op shows healing of the graft as well as screw placement and x-rays at three months shows maintenance of the reduction.
DAVID TUCKMAN: Thank you for watching this video. I encourage you to leave comments and let me know what you think.
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