Cadmore media player playing video Scaphoid Nonunion Repair with an Intercalated Iliac Crest Bone Graft
Video Player
Accessibility
Using forms mode, you can utilize keyboard shortcuts to make usability more efficient.
Space bar will play and pause the video. Pressing escape will close all displays and pressing it again will jump to the end of the player.
You can press A to open the Keyboard Shortcut Dialog which also provides an audio description of the player and all of its features.
Language
1x
Play Speed
Adjust Volume
Transcript
Search
Result Count
of
Click to jump to result
Search
Re-center
Segments
Result Count
of
Click to jump to result
Search
Name:
Scaphoid Nonunion Repair with an Intercalated Iliac Crest Bone Graft
Description:
Scaphoid Nonunion Repair with an Intercalated Iliac Crest Bone Graft
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/ca7b9911-800b-4aa3-9c8a-8683207ef154/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H12M44S
Embed URL:
https://stream.cadmore.media/player/ca7b9911-800b-4aa3-9c8a-8683207ef154
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/ca7b9911-800b-4aa3-9c8a-8683207ef154/v-004911.mp4?sv=2019-02-02&sr=c&sig=al8PCKiVeafx48lF9D1nNASbQGk7QMOwKctCJGd%2FZeI%3D&st=2024-11-22T05%3A29%3A34Z&se=2024-11-22T07%3A34%3A34Z&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 scaphoid, non-union repair with an intercalated iliac crest bone graft. Patient is a 32-year-old male who presents approximately six months after a wrist injury. X-rays show a scaphoid non-union with a significant amount of bone loss.
DAVID TUCKMAN: There's an incidental finding of a lunotriquetral joint coalition, and interestingly, there is no evidence of a carpal collapse or a DISI. 3D CT highlights the amount of bone loss as well as the displacement. With this amount of bone loss, this is not amenable to a standard bone grafting. This does require an intercalated iliac crest
DAVID TUCKMAN: bone graft. The procedure is performed under regional and general anesthesia. The ink on the patient's forearm is blocking off a tattoo. Tattoos are not HIPAA compliant. The incision is made in line with the flexor carpi radialis tendon and then taken distally in line with the first ray. The flexor carpi radialis tendon is identified proximally.
DAVID TUCKMAN: Superficial branch of the radial artery is identified, cauterized and then divided. The dissection is taken distal through the thenar musculature and the roof of the flexor carpi radialis sheath is opened. The tendon is then retracted ulnar exposing the volar wrist capsule.
DAVID TUCKMAN: Capsulotomy is then performed in line with the tendon. The scaphoid tubercle is palpated. Disproportion of the capsulotomy can be taken a little bit radial. Dissection is taken straight down onto the scaphoid, tends to be easier to identify the scaphoid tubercle and then take the dissection proximal.
DAVID TUCKMAN: The dissection is continued through the volar capsule, this capsule needs to be preserved. This is the radial scaphoid capitate ligament that needs to be repaired at the end of the case. Care is taken not to injure the articular cartilage on the proximal portion of the scaphoid. Further dissection of the distal portion of the scaphoid is performed.
DAVID TUCKMAN: It is very important to expose the scaphoid capitate joint, we're going to need to be visually inspecting this during the course of the procedure. The retractor is then placed deep, exposing the nonunion site. The nonunion is then debrided using a ronjeur as well as curettes and very important to get down to healthy cancellous bleeding bone, both proximally and distally.
DAVID TUCKMAN: 0-6-2 k-wires are then placed proximal and distal to be used as joysticks. It is important to place these wires aimed towards the nonunion site, this keeps the wires out of your way when you're working. A freer elevator is then placed in the scaphoid capitate joint to avoid injury to the articular cartilage.
DAVID TUCKMAN: A saw is then used to flatten the surfaces, it is very important to get good apposition between the graft and the native scaphoid. If the bone is hard, you can use irrigation to decrease the temperature of the blade to prevent thermal necrosis. This portion of the scaphoid is trimmed as well.
DAVID TUCKMAN: A clamp is then placed in the nonunion site to give us a general idea of the size graft we're going to need. Fluoroscopy is then used to confirm appropriate carpal reduction, the joysticks can be used to aid this as well. A ruler is trimmed and then used to measure approximate graft length. Iliac crest bone graft is then harvested and incision is started approximately four centimeters lateral to the anterior superior iliac spine.
DAVID TUCKMAN: The dissection is taken down through the subcutaneous and fatty tissues down to the fascia. The iliac crest is palpated to ensure appropriate dissection. The plane is identified by following the abdominal musculature distal. This interval is then continued on to the iliac crest.
DAVID TUCKMAN: This dissection can be done with a bovie as well, though this does tend to be a pretty avascular plane. Self-retaining retractors are placed right on top of the crest. It is important to use the entirety of your incision so you're not operating in a hole. Bovie is used to begin the dissection of the iliac crest, it is important to not use the bovie when you're actually exposing the crest.
DAVID TUCKMAN: You don't want to cause any thermal necrosis of your graft. A periosteal elevator as well as a knife is used to expose the crest. It is important to expose both the inner and outer table. The fascial attachment to the outer table is divided. Next, your freer elevator is used to identify the inner table and the musculature is elevated off both the inner and outer table.
DAVID TUCKMAN: A Hohmann retractor can be used to aid exposure of the inner table distal to the crest. Dissection is taken approximately 1 to 1.5cm distal to the crest. Appropriate graft size is measured. It's important to take a little bit more graft than you think you need.
DAVID TUCKMAN: This will be trimmed significantly during the course of the shaping to get it to the appropriate size. The graft is then harvested using a sagittal saw and irrigation. It's important to make these cuts parallel to each other so you don't narrow the graft. A curved osteotome is then used to crack the outer table,
DAVID TUCKMAN: the graft is then levered, cracking the inner table. A Coker clamp is then used to remove the graft. The graft is inspected. Fascia is enclosed with interrupted figure of eight O vicryl sutures.
DAVID TUCKMAN: Tight facial closure will help prevent any hematoma or seroma formation. The graft is held with the bone tenaculum during any manipulation. The soft tissue is removed using a ronjour. It is important to get every drop of soft tissue off the graft. Length of the graft is then marked. I typically, at this point, leave the graph a little bit larger.
DAVID TUCKMAN: The size of the graft will be fine tuned many times, the first cut is made using irrigation to keep the temperature of the blade down. Width of the graft is then marked. I will typically extend these markings down the side of the graft to ensure that the cut is perfect. Graft is then cut again using irrigation. Graft placement is attempted.
DAVID TUCKMAN: Clearly at this point, the graft is too large. This will take multiple attempts of going back and forth, slowly trimming the graft and making it smaller to make sure that the graft fits appropriately. Placement of the graft is then attempted again, this can be aided with the use of a bone tamp. Graft is then trimmed some more and replaced. At this point, the fit seems a little bit more appropriate. Appropriate apposition with the native scaphoid is confirmed.
DAVID TUCKMAN: The dorsal portion of the graft is rounded to better fit the dorsal anatomy of the scaphoid. The graft is then placed in the scaphoid. The position is fine tuned with a bone tamp. Scaphoid. capitate joint is inspected to confirm that the graft is not articulating on the capitate. On inspection,
DAVID TUCKMAN: there is a mismatch between the scaphoid and the graft. We can either bone graft it with cancellous bone or a cortical wedge. If you have enough graft length, I think better is to trim the graft to make sure that the graft seats appropriately. These blades can sometimes wobble. You can put your finger on the flat part of the blade until the blade starts cutting into the bone.
DAVID TUCKMAN: Graft was seated and inspected, there was no evidence of mismatch. Fluoroscopy demonstrates appropriate length of the scaphoid as well as a good capitolunate angle. On closer inspection of the graft position, there is overlap radially. It's very important to not have any overlap, either radial or ulnar. The graft is repositioned using a freer as well as a bone tamp.
DAVID TUCKMAN: Fluoroscopy shows much better position, there is a slight gap distal, which will be compressed using the compression screws. Scaphotrapezial joint is entered. The volar portion of the trapezium is debrided using a ronjour. This is in order to get a more dorsal starting hole for screws.
DAVID TUCKMAN: Appropriate starting hole was confirmed, the wire was then passed in the proximal portion of scaphoid. A second k-wire was passed for a second screw. We do know biomechanically two smaller screws are stronger than a single, larger screw. Appropriate position was confirmed on multiple views. Screw sizes were measured,
DAVID TUCKMAN: drill was used to aid passage of the screw across the graft. This is a 2.2mm headless compression screw that is 4 millimeters shorter than measured. Second screw was inserted. Final images show good position of the hardware, good apposition of the graft with the native scaphoid and a good carpal alignment. Inspection shows the graft is stable as well as there is no overlap with the radial scaphoid joint or the scaphoid capitate joint.
DAVID TUCKMAN: The capsule is closed with interrupted 3-0 vicryl sutures. A good capsular closure is very important in order to restore the function of the radial scaphoid capitate ligament. The thenar muscles are repaired as well. Patient is placed in a short arm
DAVID TUCKMAN: splint post-operatively. At week one will be changed to a short arm cast. At six weeks, we change to a short arm splint until fracture union, patient may return to full activity when the fracture unites. If there's any question about union, it can be evaluated with CT. X-rays at week one demonstrate good position in the graft and good carpal reduction.
DAVID TUCKMAN: Thank you for watching this video. I would encourage you to leave comments and let me know what you think.
Segment:0 .
DAVID TUCKMAN: This is Dr. Tuckman. I'm going to be presenting a scaphoid, non-union repair with an intercalated iliac crest bone graft. Patient is a 32-year-old male who presents approximately six months after a wrist injury. X-rays show a scaphoid non-union with a significant amount of bone loss.
DAVID TUCKMAN: There's an incidental finding of a lunotriquetral joint coalition, and interestingly, there is no evidence of a carpal collapse or a DISI. 3D CT highlights the amount of bone loss as well as the displacement. With this amount of bone loss, this is not amenable to a standard bone grafting. This does require an intercalated iliac crest
DAVID TUCKMAN: bone graft. The procedure is performed under regional and general anesthesia. The ink on the patient's forearm is blocking off a tattoo. Tattoos are not HIPAA compliant. The incision is made in line with the flexor carpi radialis tendon and then taken distally in line with the first ray. The flexor carpi radialis tendon is identified proximally.
DAVID TUCKMAN: Superficial branch of the radial artery is identified, cauterized and then divided. The dissection is taken distal through the thenar musculature and the roof of the flexor carpi radialis sheath is opened. The tendon is then retracted ulnar exposing the volar wrist capsule.
DAVID TUCKMAN: Capsulotomy is then performed in line with the tendon. The scaphoid tubercle is palpated. Disproportion of the capsulotomy can be taken a little bit radial. Dissection is taken straight down onto the scaphoid, tends to be easier to identify the scaphoid tubercle and then take the dissection proximal.
DAVID TUCKMAN: The dissection is continued through the volar capsule, this capsule needs to be preserved. This is the radial scaphoid capitate ligament that needs to be repaired at the end of the case. Care is taken not to injure the articular cartilage on the proximal portion of the scaphoid. Further dissection of the distal portion of the scaphoid is performed.
DAVID TUCKMAN: It is very important to expose the scaphoid capitate joint, we're going to need to be visually inspecting this during the course of the procedure. The retractor is then placed deep, exposing the nonunion site. The nonunion is then debrided using a ronjeur as well as curettes and very important to get down to healthy cancellous bleeding bone, both proximally and distally.
DAVID TUCKMAN: 0-6-2 k-wires are then placed proximal and distal to be used as joysticks. It is important to place these wires aimed towards the nonunion site, this keeps the wires out of your way when you're working. A freer elevator is then placed in the scaphoid capitate joint to avoid injury to the articular cartilage.
DAVID TUCKMAN: A saw is then used to flatten the surfaces, it is very important to get good apposition between the graft and the native scaphoid. If the bone is hard, you can use irrigation to decrease the temperature of the blade to prevent thermal necrosis. This portion of the scaphoid is trimmed as well.
DAVID TUCKMAN: A clamp is then placed in the nonunion site to give us a general idea of the size graft we're going to need. Fluoroscopy is then used to confirm appropriate carpal reduction, the joysticks can be used to aid this as well. A ruler is trimmed and then used to measure approximate graft length. Iliac crest bone graft is then harvested and incision is started approximately four centimeters lateral to the anterior superior iliac spine.
DAVID TUCKMAN: The dissection is taken down through the subcutaneous and fatty tissues down to the fascia. The iliac crest is palpated to ensure appropriate dissection. The plane is identified by following the abdominal musculature distal. This interval is then continued on to the iliac crest.
DAVID TUCKMAN: This dissection can be done with a bovie as well, though this does tend to be a pretty avascular plane. Self-retaining retractors are placed right on top of the crest. It is important to use the entirety of your incision so you're not operating in a hole. Bovie is used to begin the dissection of the iliac crest, it is important to not use the bovie when you're actually exposing the crest.
DAVID TUCKMAN: You don't want to cause any thermal necrosis of your graft. A periosteal elevator as well as a knife is used to expose the crest. It is important to expose both the inner and outer table. The fascial attachment to the outer table is divided. Next, your freer elevator is used to identify the inner table and the musculature is elevated off both the inner and outer table.
DAVID TUCKMAN: A Hohmann retractor can be used to aid exposure of the inner table distal to the crest. Dissection is taken approximately 1 to 1.5cm distal to the crest. Appropriate graft size is measured. It's important to take a little bit more graft than you think you need.
DAVID TUCKMAN: This will be trimmed significantly during the course of the shaping to get it to the appropriate size. The graft is then harvested using a sagittal saw and irrigation. It's important to make these cuts parallel to each other so you don't narrow the graft. A curved osteotome is then used to crack the outer table,
DAVID TUCKMAN: the graft is then levered, cracking the inner table. A Coker clamp is then used to remove the graft. The graft is inspected. Fascia is enclosed with interrupted figure of eight O vicryl sutures.
DAVID TUCKMAN: Tight facial closure will help prevent any hematoma or seroma formation. The graft is held with the bone tenaculum during any manipulation. The soft tissue is removed using a ronjour. It is important to get every drop of soft tissue off the graft. Length of the graft is then marked. I typically, at this point, leave the graph a little bit larger.
DAVID TUCKMAN: The size of the graft will be fine tuned many times, the first cut is made using irrigation to keep the temperature of the blade down. Width of the graft is then marked. I will typically extend these markings down the side of the graft to ensure that the cut is perfect. Graft is then cut again using irrigation. Graft placement is attempted.
DAVID TUCKMAN: Clearly at this point, the graft is too large. This will take multiple attempts of going back and forth, slowly trimming the graft and making it smaller to make sure that the graft fits appropriately. Placement of the graft is then attempted again, this can be aided with the use of a bone tamp. Graft is then trimmed some more and replaced. At this point, the fit seems a little bit more appropriate. Appropriate apposition with the native scaphoid is confirmed.
DAVID TUCKMAN: The dorsal portion of the graft is rounded to better fit the dorsal anatomy of the scaphoid. The graft is then placed in the scaphoid. The position is fine tuned with a bone tamp. Scaphoid. capitate joint is inspected to confirm that the graft is not articulating on the capitate. On inspection,
DAVID TUCKMAN: there is a mismatch between the scaphoid and the graft. We can either bone graft it with cancellous bone or a cortical wedge. If you have enough graft length, I think better is to trim the graft to make sure that the graft seats appropriately. These blades can sometimes wobble. You can put your finger on the flat part of the blade until the blade starts cutting into the bone.
DAVID TUCKMAN: Graft was seated and inspected, there was no evidence of mismatch. Fluoroscopy demonstrates appropriate length of the scaphoid as well as a good capitolunate angle. On closer inspection of the graft position, there is overlap radially. It's very important to not have any overlap, either radial or ulnar. The graft is repositioned using a freer as well as a bone tamp.
DAVID TUCKMAN: Fluoroscopy shows much better position, there is a slight gap distal, which will be compressed using the compression screws. Scaphotrapezial joint is entered. The volar portion of the trapezium is debrided using a ronjour. This is in order to get a more dorsal starting hole for screws.
DAVID TUCKMAN: Appropriate starting hole was confirmed, the wire was then passed in the proximal portion of scaphoid. A second k-wire was passed for a second screw. We do know biomechanically two smaller screws are stronger than a single, larger screw. Appropriate position was confirmed on multiple views. Screw sizes were measured,
DAVID TUCKMAN: drill was used to aid passage of the screw across the graft. This is a 2.2mm headless compression screw that is 4 millimeters shorter than measured. Second screw was inserted. Final images show good position of the hardware, good apposition of the graft with the native scaphoid and a good carpal alignment. Inspection shows the graft is stable as well as there is no overlap with the radial scaphoid joint or the scaphoid capitate joint.
DAVID TUCKMAN: The capsule is closed with interrupted 3-0 vicryl sutures. A good capsular closure is very important in order to restore the function of the radial scaphoid capitate ligament. The thenar muscles are repaired as well. Patient is placed in a short arm
DAVID TUCKMAN: splint post-operatively. At week one will be changed to a short arm cast. At six weeks, we change to a short arm splint until fracture union, patient may return to full activity when the fracture unites. If there's any question about union, it can be evaluated with CT. X-rays at week one demonstrate good position in the graft and good carpal reduction.
DAVID TUCKMAN: Thank you for watching this video. I would encourage you to leave comments and let me know what you think.
Form Title Download
Transcript
Form Title Bookmark
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Share
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Form Title Accessibility and Keyboard Shortcuts
The cadmore media player is a professional video and audio player experience designed to deliver media as well as relevant transcript, segmentation, and metadata. On the screen is a traditional html video player with buttons such as play, pause, forward, captioning, language and play speed selection and more. Adjacent to the video player are generally tabs, one of which shows a scrolling transcript of the video and the other shows any segmentation of the media, sometimes referred to as chapters. At the top of the video is a menu bar containing an Explore button and Tools button. The Explore button allows you to dig deeper into the video by opening up an explore dialog which contains tabs for a visual navigation of the video using thumbnails, an about tab which contains rich metadata about the media, a segments tab which contains further information about the video, and a related tab which contains links to other media related to this media. The tools button opens a menu with options for sharing the media on social media, creating bookmarking links, creating embed codes for your website, generating citations, and more.
Keyboard Shortcuts
Keyboard shortcuts only work while you are in forms mode. By entering forms mode, you will be able to quickly access portions of the media player with single key commands.
Spacebar: Play/Pause Toggle
I: Info Menu,
O: Tools Menu
T: Transcript Tab,
S: Segments Tab
F: Forward 15,
R: Rewind 15
L: Languages,
P: Playspeed
M: Mute Toggle,
V: Volume Bar
N: Video Only Toggle,
B: Full Screen Toggle
C: Captions Toggle
Escape: Closes dialogs and menus / Exits Player
Z: Next Transcript Chapter
X: Previous Transcript Chapter
Q: Next Transcript Paragraph
W: Previous Transcript Paragraph
Entire Media
Segment(s)
Custom Clip
Start At:
End At:
Embed Size
-
You Size - Responsive
-
We Size - Responsive
-
Picture Overlay Popup
-
400 x 225
-
512 x 288
-
400 x 700
-
768 x 1024
-
1024 x 512
-
1280 x 608
Form Title Cite
No citation provided.
Info
Segments
Related
Thumbnails
Exit Clip Mode
You have requested to see a portion of the video outside of the clip.
Click OK to switch to the full video or click if you would like to stay inside the clip. You can always go back to the clip with Tools and Clip Mode