Name:
Scaphoid Excision and Four-Corner Fusion Using Nitinol Staples
Description:
Scaphoid Excision and Four-Corner Fusion Using Nitinol Staples
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Duration:
T00H13M15S
Embed URL:
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Upload Date:
2024-06-01T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
KALPIT SHAH: Hello, my name is Kal Shah, and in this video, we'll demonstrate our technique for scaphoid excision and four corner arthrodesis using staples. We'll begin with a case. The patient is a 52-year-old right hand dominant construction worker.
KALPIT SHAH: He presents to our office for a second opinion. The patient underwent a scapholunate ligament reconstruction about a year ago, which has unfortunately failed. He continues to have wrist pain, especially with activity and when his wrist is loaded in a extended position. On examination, he was tender over the scapholunate interval. He had a positive Watson shift test. He was otherwise neurovascularly intact.
KALPIT SHAH: His range of motion showed decreased extension and flexion on the affected side compared to the contralateral side. He also had decreased grip on that side compared to the contralateral side, and he had a relatively high QuickDASH score of 56. Three views of the right wrist were obtained. Shown here are the PA, oblique and lateral radiographs. There is a persistent diastasis at the scapholunate interval.
KALPIT SHAH: Cystic changes are noted in the scaphoid and the lunate, along with degenerative changes at the radial scaphoid and capitolunate joints. After extensive discussion with the patient, the patient elected to move forward with a scaphoid excision and four corner arthrodesis. A dorsal incision was taken centered over the wrist, just ulnar to Lister's tubercle.
KALPIT SHAH: Branches of the radial sensory nerve were identified and protected. When at the level of the extensor retinaculum, the third extensor compartment was divided and the EPL was transposed radially. The second and fourth extensor compartments were raised sub-periosteally. When at the level of the wrist joint, a ligament sparing capsulotomy was designed.
KALPIT SHAH: A ligament sparing capsulotomy is performed with a radial based flap. The wrist capsule is divided in line with the dorsal radial carpal ligament and the dorsal intercarpal ligament. All capsular attachments are then removed from the scaphoid extending distally all the way to the FTP joint.
KALPIT SHAH: The corkscrew is then placed into the scaphoid. After the corkscrew is fully seated into the scaphoid in McGlamry elevator is introduced distally at the STT joint and a scooping motion is used to remove the scaphoid on block.
KALPIT SHAH: Once the scaphoid is excised, a ronjeur is used to remove the articular cartilage and subchondral bone. The remaining cancellous portion is morsalized as bone graft for a later use. Next, the ronjeur is used to perform a radial stylodectomy. Care is taken to only remove roughly 4 to 5mm to the radial styloid as the radial scaffold capitate ligament attaches 4 to 5mm from the tip of the radial styloid.
KALPIT SHAH: The capitatp lunate and the triquetrohamate joint surfaces are prepared next for arthrodesis. We introduce a 1.6mm k-wire into the lunate to use it as a joystick. The wrist is then flexed down over a cowle bump to open up the capitilatolunate joint. We use a ronjeur to remove the cartilage and the subchondral bone off the convex surface of the capitate.
KALPIT SHAH: The articular cartilage of the convex surface of the hamate is removed similarly using the ronjeur.
KALPIT SHAH: For the convex surfaces of the triquetrum and the lunate, we use a 2 millimeter burr to remove the articular cartilage and the subchondral bone. Irrigation is used liberally in conjunction with suction to remove some of the articular debris and also to cool the bony surfaces.
KALPIT SHAH: After adequate articular preparation, the lunate is pinned to the radius using a 1.6mm k-wire in a slightly flexed position. The bone graft we prepared from the scaphoid previously is now placed into the capito lunate and the triquetrohamate joint. Once the bone graft has been placed across the capito lunate joint,
KALPIT SHAH: we're ready for our fusion. In the setting of a scapholunate injury, the lunate typically goes into extension. When preparing the capitolunate joint for fusion, we recommend removing the lunate out of extension and into slight flexion. The capitate should be left in neutral alignment. We feel that in this configuration, when the lunate returns to neutral alignment, the hand will be positioned in a slight extension which is more functional.
KALPIT SHAH: A measuring guide is then used to find an appropriate size suitable for the capitate lunate joint. Wires are then placed into the capitate and the lunate using the guide. These wires represent the future space where the staple ties will be. A mini C arm can be used to check position.
KALPIT SHAH: A cannulated drill is used over the wires by cortically. A narrow ronjeur is then used to create a trough between the two drill holes.
KALPIT SHAH: This will allow for the staple to sit below the articular surface of the lunate. This prevents the staple from impinging on the dorsal distal radius when the wrist is extended. The drill holes are then measured and an appropriately sized staple is placed across the capitolunate joint.
KALPIT SHAH: The staple across the triquetrohamate joint is placed in a similar fashion.
KALPIT SHAH: A mini c arm is used again to confirm appropriate placement of the hardware. The wound is irrigated thoroughly and the closure is begun. We reapproximate the fibers of the dorsal radiocarpal ligament as well as the dorsal intercarpal ligaments.
KALPIT SHAH: Next, the second and fourth dorsal compartments are reapproximated, leaving the EPL transposed radially. The skin is finally closed with monocryl suture and the patient is placed in a volar resting wrist splint.
KALPIT SHAH: The patients are kept at a post op splint for two weeks. They are then converted to a cast for two to four weeks based on their radiographic healing. They're then sent to hand therapy for removable wrist splint and range of motion exercises. The patient had an uncomplicated post-operative course.
KALPIT SHAH: Three views of the right wrist obtained at the six week point are shown here. The capitolunate, as well as the triquetrohamate joint, appear to have fused. There are no hardware complications noted on these images. On examination at the six month point, his incisions had healed and he had a normal motor and sensory exam.
KALPIT SHAH: His QuickDASH had improved from 56 preoperatively to 18 at the six month point. His range of motion continued to improve for extension and flexion, though not quite the same as the contralateral size. Similarly, his grip strength improved, though not quite the same as the contralateral side. Here's a review of some of the tips we've mentioned during our video.
KALPIT SHAH: First, we recommend using a combination of a corkscrew and a McGlamry elevator for expeditious scaphoid excision. When preparing the capitolunate and triquetrohamate joints for arthrodesis, we recommend using a ronjeur for the convex surfaces of the capitate and hamate and using a 2 or 3 millimeter burr for the concave surfaces of the lunate and the triquetrum. For a bone graft to help with the arthrodesis, we recommend using the excised scaphoid.
KALPIT SHAH: After removing the subchondral bone and the cartilage using a ronjeur leaving you with good cancellous bone. When preparing the capitolunate joint for fusion, we recommend removing the lunate out of extension and into a slightly flexed position. The capitate should be left in neutral alignment. We feel that in this configuration, when the lunate returns to neutral alignment, the hand will be positioned in a slightly extended position, which is more functional.
KALPIT SHAH: Finally create a trough across the capitolunate joint for the staple, such that the staple lies below the articular surface of the lunate. This will prevent impingement of the staple on the dorsal distal radius rim.
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