Tips 'n Tricks for wrist arthroscopy: installation, portals and exploration

Wrist arthroscopy allows a thorough exploration of the radiocarpal and midcarpal joints simply by carrying out small portals. This video shows how to achieve them and what can be seen in the wrist. The purpose of this video is to understand the principle of wrist arthroscopy and how to perform the portals in the least invasive way. We can draw tendon-bone elements on the skin in order to create anatomical landmarks. Before using the knife, using a single needle is essential to identify the exact position of portals. We always start the exploration of the wrist with the radiocarpal joint, and the 3-4 portal. To find it, there are several simple ways. Once the scope is entered in the radiocarpal joint, it is possible only by this portal to explore all the articulation from radial styloid to ulnar styloid. Instrumental 6R portal will be performed. The midcarpal joint is narrower than the radiocarpal joint. We start with the ulnar midcarpal portal, the easiest to find, then an instrumental radiocarpal portal will be used. Placing the scope in a radial midcarpal position allows to explore the scapho-trapezoid-trapezium joint distally as well as the dorsal surface of the capitate bone.

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Tips   'n   Tricks   for   wrist   arthroscopy:   installation,   portals   and   exploration

Authors
C Mathoulin, P Liverneaux
Abstract
Wrist arthroscopy allows a thorough exploration of the radiocarpal and midcarpal joints simply by carrying out small portals. This video shows how to achieve them and what can be seen in the wrist.
The purpose of this video is to understand the principle of wrist arthroscopy and how to perform the portals in the least invasive way. We can draw tendon-bone elements on the skin in order to create anatomical landmarks. Before using the knife, using a single needle is essential to identify the exact position of portals. We always start the exploration of the wrist with the radiocarpal joint, and the 3-4 portal. To find it, there are several simple ways. Once the scope is entered in the radiocarpal joint, it is possible only by this portal to explore all the articulation from radial styloid to ulnar styloid. Instrumental 6R portal will be performed. The midcarpal joint is narrower than the radiocarpal joint. We start with the ulnar midcarpal portal, the easiest to find, then an instrumental radiocarpal portal will be used. Placing the scope in a radial midcarpal position allows to explore the scapho-trapezoid-trapezium joint distally as well as the dorsal surface of the capitate bone.
Classification
tips and tricks
Keywords
Tips 'n Tricks, wrist arthroscopy, installation, portals and exploration
Media type
Duration
20'00''
Publication
2010-03
Popular
Favorites
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Audio
en fr
Subtitles
en
E-publication
WeBSurg.com, Mar 2010;10(03).
URL: http://www.websurg.com/doi-vd01en2935.htm

Tips   'n   Tricks   for   wrist   arthroscopy:   installation,   portals   and   exploration

3. Radiocarpal joint 03'00''
Now, how can you enter the wrist? The first joint to be found is the radiocarpal joint using a “three-four” portal. Indeed, there are the extensors’ compartments, the first one with the long abductor and the short extensor, the second one, the third one, the forth one, the fifth one, and so on. Consequently, the “three-four” portal is situated between the extensor communis of digits and the long extensor of the thumb. In order to identify this “three-four” portal, as this patient is very thin, which makes it easy to visualize, your thumb is laid in such a way that the tip of the thumb is at the end of the Lister’s tubercle in a vertical position. Then, your thumb is flexed and you can very well feel the soft area between the first row and the radius, and when this maneuver is made, by putting your needle just above, you will enter the wrist. As can be seen here is essential: this is the distance between the Lister’s tubercle and the place of the “three-four” portal. Another technique that unfortunately causes drawing damage only is to draw the system of the 3 circles. That is you draw a circle around the Lister’s tubercle, and then a second circle above, a third circle, and then the access is precisely in the centre of the third circle. But personally, I prefer this technique that is the most simple. Indeed, if you have found the “three-four” portal, you have found everything for the radiocarpal joint. Don’t forget one thing: the radius has two oblique angles, one dorso-frontal and another radio-ulnar. In other words, when the needle is entered, attention must be paid not to cause any damage at the level of these two oblique angles, and you can see that the needle is bent forward and towards the ulnar side. This is the first approach. Now I need the scalpel. The access routes, the skin folds have a major advantage at wrist level: they are horizontal. Therefore, do not open vertically, otherwise you will cause visible scars. Always open using small horizontal incisions. Take a look at the size of the access route I now use: it is extremely small. Now let’s use our second help: place the Mosquito forceps in the palm and close the fingers over it; the index finger is placed on the dorsal part in order to guide. The motion can be well understood. The blunt tip is used to retract the noble elements without causing any injury and we will go around the posterior margin of the radius using the curved side of the distal portion of the Mosquito forceps to go across the capsule and perform a very small hole. This motion is very simple, but one essential thing is to never force. If this is uneasy, you can use your needle again and try to see if you are in the correct place. When you are sure to be in the correct place, never forget to use the two friends of the arthroscopic surgeon, the needle and the Mosquito forceps, in order to avoid causing any damage. The “three-four” approach has been found. It is perfect; no damage has been caused. We are between the common extensors and the long extensor of the thumb. Naturally, the traction system that we used is one among many others. The objective is to have the hand as free as possible to be able to turn it. Similarly, with the system we are using among many others, what is most important is always to enter with a blunt-tipped drain. We will now proceed with the radial styloid and the ulnar styloid. There are two ways of doing arthroscopy, using water and/or using a dry environment. In the treatment of radius bone fractures, it is preferable to use a “dry” technique, which is without any water in order to avoid liquid passing through bone fragments. When an electrothermal Vape is used to perform shrinkage, water must be used to avoid burns. Here we will use both techniques. As you can see, I do not force. I use the same position as earlier. It can be put in and out easily without tension. This is removed. We hold the camera and we arrange the whites.
4. Exploration of the radiocarpal joint and 6R portal 08'10''
Using the camera, we enter inside. This is a dry technique. As soon as we enter, the first thing to see is the depression. This is a strictly regular case. There is no water. This is the scapholunate ligament. It is interesting to see that we have the scaphoid bone here, here is the scapholunate ligament, here the lunate, and absolutely no difference can be observed. Here we are at the level of the radial styloid. Obviously, there are some bubbles; so we clean and to do so, some water is added. The volar ligaments are well visible here, with the radial styloid here. Traction is insufficient here. This patient has a regular wrist here. Here the radio-scapho-capitate ligaments and long radio-ulnar ligaments, the ligament of Testut (or the radio-scapho-lunate ligament) that is a small expansion. The lunate ligament is followed. The medial portion is reached with the lunotriquetral ligament here. We can see that there is a bit of synovitis in the dorsal part of this wrist and the triangular ligament can be found again here. We have this “three-four” portal and we must identify the internal route in order to work as in a triangle. There are two access routes: one called the “four-five” portal situated between the 4th and the 5th compartment, that is between the common extensor and the proper extensor of the fifth finger. This approach has a defect in that it is a little bit too medial. Personally I like very much the “6 R” portal, that is on the radial side in relation to compartment 6 where the extensor carpi ulnaris can be found and which is situated approximately here. To find it, it is quite easy: we go within and look around; the triangular ligament can be well seen here; you look out by trans-illumination and you can see the tip of the styloid perfectly; the light is seen here and when light is seen somewhere, we enter!!! Therefore we enter. Let’s use our first friend, the needle and let’s enter here. This works very well. Facing the triangular ligament here, we have identified the “6 R” access route, and with the scalpel, the needle is withdrawn and similarly, a very small incision is performed big enough to pass the instruments. I never close the scars, there are no stitches. The scars are thin and are within the skin creases and lines and they close by themselves, which is really convenient for patients. Let’s use our second friend, and let’s go inside and control. We can see that there is some synovitis here, so the wrist is painful. Here we can see the entering of our second friend. We will use the shaver; there are several types, the full radius resector or the aggressive cutter that I personally prefer and that bears well its name as it is aggressive and it cuts. We enter the shaver and pay attention to this as this is essential: I do not manage to enter, this is annoying, I have lost time and I use the instrument to find my access route again. I control the access route, which is perfect. I grab the shaver and without any tension, I can enter the wrist. The shaver is used with the objective of cleaning the synovial membrane that will be cleaned entirely. The wrist will be cleaned. We can see the triangular ligament, which is slightly involved and which accounts for the synovial problem. The patient does not complain from this synovial problem but we can see that it is slightly damaged at this place but the ligament is intact. We can see the ligament’s insertion on the radius and the “trampoline” effect. Here’s the pull out test described by Andrea Atzei thanks to EWAS (European Wrist Arthroscopy Society) and with this test, we can see that the triangular ligament is perfectly normal. We will now complete the exploration by modifying the position of both the camera and shaver. We will introduce the optic through the “6 R” portal always without tension. This is particularly useful since we move from the triangular ligament following the radius and you can see the lunate fossa of the radius here, the small crest that separates the 2 fossas of the radius and we reach the scaphoid fossa of the radius there and just opposite the scapholunate ligament. Here I have the palpator. Here this is the cartilage of the lunate bone, here it is the anterior portion of the scapholunate ligament, which can be well visualized here. This ligament is followed on the entire dorsal surface. It is healthy in this young female patient. I reach the dorsal part and here we find regular bony relationships between the scaphoid bone here and the scapholunate ligament there, and the lunate bone with a dorsal attachment that is strictly normal. This was the radiocarpal exploration. We will now deal with the midcarpal exploration.
5. Exploring the midcarpal joint 15'15''
For the midcarpal exploration, we need a trick to correctly enter this joint with the needle. The trick is here: there is a point between the 4 bones, between the hamate, the capitate, the lunate and the triquetral bone that can be felt easily. This point was well known by the Romans when they crucified Jesus!!!: this is the place where the nail was placed. If the nail had been placed here, the body would have fallen due to the weight. This is a very strong point. This soft point can be easily felt. The needle is placed in this direction taking into consideration the obliqueness of the lunate bone and the second row. This point was easily found. It is called the ulnar midcarpal portal. A very microscopic incision is again made. The skin is only cut to avoid injuring the tendons, the nerves or the vessels. As usual, entrance was without tension through the capsule. We finally enter the midcarpal joint. This is a dry arthroscopy technique, we are in the midcarpal joint and you can immediately see the space between the hamate and capitate bones. If I go slightly to the right, I can see a scapholunate space. But this is a smaller joint. Here’s the scapholunate space and there is the lunotriquetral space. We will use a little water to clean. We progress within this joint and we find the capitate bone here, the hamate bone here, the triquetral bone there. We can follow and reach the distal anterior end of the hamate bone. This is a clear view and there is no difficulty in progressing in this wrist even if it is a narrow wrist in this young female patient. We reach the level of the joint between the lunate bone to the left the triquetral bone. The joint is normal in this case. And we will move to the other side and reach on to the scapholunate space. Remember this picture well because it is a normal scapholunate space. We then need to find the radial midcarpal portal. It is situated slightly above the other, at about 1cm, and the needle is seen coming obliquely at the level of the scapholunate space. What you can see here is the posterior horn of the lunate bone. Imagine that there is an isolated fracture of the posterior horn of the lunate bone. We understand that it could be removed easily through arthroscopy. A small hole is made and we enter the joint with the instrument. We use the Mosquito. When access is difficult, I never use force. The tip of the mosquito is straight and slightly curved and not as the blunt tip but I never use force. I try to re-identify the access route. I can see it and I can feel it too. I will remember it and normally if I enter the probe through here, I am in. Here is the test that will allow us to analyse the instability or not of the scapholunate space. Here we cannot go through this space, therefore there is a perfect stability: the scapholunate space is normal.
6. Exploration of the STT joint 19'18''
We will then invert the position of the scope. The camera is now in a midcarpal radial position and we can immediately identify the capitate bone, the lunate bone, the scapholunate space, the scaphoid bone. If I go onto the internal part, I will find the space between the triquetral and the lunate bone and we can even manage to see the joint between the hamate and the capitate bone through this approach. This joint is well visible here. Interestingly enough with this portal, we are at the level of the scaphoid bone. Here is the scapholunate space. We will then follow the scaphoid bone to the left, the capitate bone to the right and if we go up, we will reach within the scapho-trapezo-trapezoid joint very easily. And here you can see that I am at the level of the scapho-trapezo-trapezoid joint. With a similar lateral principle, I can see the light and I use the needle and if I want to enter, I can go in, and I reach the exact place. Here obviously I will not go in since she has a normal space but you can see here the trapezoid, and there the trapezium, here the scaphoid bone. I will try to demonstrate even better this joint. And this STT joint can be seen perfectly, which is absolutely normal in this patient. With the lateral view, we could envisage performing a small incision, the STT approach here if we needed to perform a cleaning or a resection or place prosthesis. We can also follow the capitate bone and go up to the dorsal part of the capitate and here we are at the level of the joint between the capitate and the third metacarpal, and we can obviously go down to enter the joint. This concludes our trip inside the wrist.