17.2.2007. upper extremity surgery

UPPER EXTREMITY SURGERY

INTRODUCTIONMark E. Baratz 87

MEDIAL APPROACH FOR HUMERAL ROTATIONAL OSTEOTOMY IN CHILDREN WITH RESIDUALBRACHIAL PLEXUS BIRTH PALSY

Scott H. Kozin 88

PROXIMAL ROW CARPECTOMY AND A MODIFICATION FOR DORSAL CAPSULARINTERPOSITION

Thomas B. Hughes, Jr. 94

THE SYNOVIAL FLAP IN RECURRENT AND FAILED CARPAL TUNNEL SURGERYCaitlin Gannon, Katharine Baratz, and Mark E. Baratz 102

ARTHROSCOPICALLY ASSISTED REDUCTION AND INTERNAL FIXATION OF SCAPHOIDFRACTURES, DELAYED UNIONS, AND NONUNIONS

T. Greg Sommerkamp 106

ARTHROSCOPIC REPAIR OF ULNAR-SIDED TRIANGULAR FIBROCARTILAGE COMPLEX TEARSChad J. Micucci and Christopher C. Schmidt 118

THUMB CARPOMETACARPAL JOINT ARTHROSCOPY: A CLASSIFICATION SYSTEM ANDRATIONALE FOR TREATMENT

Alejandro Badia and Prakash Khanchandani 125

ARTHROSCOPY OF THE METACARPOPHALANGEAL JOINTJennifer Erdos, Caitlin Gannon, and Mark E. Baratz 133

ARTHRODESIS OF THE DISTAL INTERPHALANGEAL JOINT USING A HEADLESS SCREWDavid C. Rehak 140

INDIVIDUALIZED REHABILITATION PROGRAM FOR FLEXOR TENDON REPAIR: FROM PYRAMIDTO ALGORITHM

Pamela J. Steelman, Gail Groth, and John S. Taras 148

Operative Techniques in Orthopaedics

Volume 17 Number 2 April 2007

Operative Techniques in Orthopaedics (ISSN 1048-6666) ispublished quarterly by Elsevier Inc., 360 Park Avenue South,New York, NY 10010-1710. Months of issue are January, April,July and October. Business and Editorial Office: 360 Park AvenueSouth, New York, NY 10010-1710. Customer Service Office:6277 Sea Harbor Drive, Orlando, FL 32887-4800. Periodicalspostage paid at New York, NY and additional mailing offices.

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CONTRIBUTORS

Alejandro Badia, MD, FACSMiami Hand Center, Miami, FL; Chief of HandSurgery, Baptist Hospital, Miami, FL

Katharine BaratzDepartment of Orthopaedic Surgery, AlleghenyGeneral Hospital, Pittsburgh, PA

Mark E. Baratz, MDProfessor and Vice Chairman, Department ofOrthopaedic Surgery, Allegheny General Hospital,Pittsburgh, PA; Department of Orthopaedic Surgery,Drexel University College of Medicine,Philadelphia, PA

Jennifer Erdos, MDDepartment of Orthopaedic Surgery, AlleghenyGeneral Hospital, Pittsburgh, PA

Caitlin Gannon, BSDepartment of Orthopaedic Surgery, AlleghenyGeneral Hospital, Pittsburgh, PA

Gail Groth, MS, OTR, CHTDepartment of Industry and ManufacturingEngineering, College of Engineering and AppliedScience, University of Wisconsin-Milwaukee,Milwaukee, WI

Thomas B. Hughes, Jr., MDDepartment of Orthopaedics, Drexel UniversitySchool of Medicine, Philadelphia, PA; Departmentof Orthopaedic Surgery, Allegheny GeneralHospital, Allegheny Orthopaedic Associates,Pittsburgh, PA

Prakash Khanchandani, MSFellow, Miami Hand Center, Miami, FL

Scott H. Kozin, MDDepartment of Orthopaedic Surgery, TempleUniversity, Philadelphia, PA; Hand Surgeon,Shriners Hospitals for Children, Philadelphia, PA

Chad J. Micucci, MDDepartment of Orthopaedic Surgery, AlleghenyGeneral Hospital, Pittsburgh, PA

David C. Rehak, MDThe Hughston Clinic, Columbus, GA

Christopher C. Schmidt, MDDirector, Microsurgical Reconstruction of theUpper Limb, Department of Orthopaedic Surgery,Allegheny General Hospital, Pittsburgh, PA

T. Greg Sommerkamp, MDDepartment of Orthopedic Surgery, University ofCincinnati College of Medicine and Hand SurgerySpecialists, Inc, Cincinnati, OH

Pamela J. Steelman, CRNP, PT, CHTThe Philadelphia Hand Center, Philadelphia, PA

John S. Taras, MDThe Philadelphia Hand Center, Philadelphia, PA;Department of Orthopaedic Surgery, ThomasJefferson University, Drexel University,Philadelphia, PA



EDITORIAL BOARD

FREDDIE H. FU, MD

Editor

MARK E. BARATZ, MD

RICHARD BERGER, MD

CONSTANCE R. CHU, MD

ANTHONY DIGIOIA, MD

DOUGLAS R. DIRSCHL, MD

ANDREAS B. IMHOFF, MD

DARREN JOHNSON, MD

JAMES D. KANG, MD

MININDER S. KOCHER, MD

WILLIAM N. LEVINE, MD

RICHARD MCGOUGH, MD

MARK MILLER, MD

HANS-CHRISTOPH PAPE, MD

SEAN SCULLY, MD

MARK VRAHAS, MD

GERALD R. WILLIAMS, JR, MD

DANE K. WUKICH, MD

STEFANO ZAFFAGNINI, MD



Wlatst

Volume 17, Number 2 April 2007

1d

Introduction

tcCa

e have assembled a collection of hand and upper-extremity articles describing novel techniques for

imb positioning in brachial plexus injuries, arthroscopicallyssisted treatment of scaphoid fractures, as well as a variety ofreatment for wrist and hand maladies. The articles are con-tructed to provide an overview of the problem with illus-
rated examples of the author’s preferred treatment. We hope
048-6666/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.oi:10.1053/j.oto.2007.02.001

hat the issue will provide a workable solution for readersaring for upper-extremity condition. The editor thanksaitlin Gannon for her substantial effort in compiling theserticles.

Mark E. Baratz, MD
Guest Editor
87

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8

edial Approach for Humeral Rotational Osteotomyn Children with Residual Brachial Plexus Birth Palsycott H. Kozin, MD*,†

Residual brachial plexus birth palsy often results in an internal rotation contracture. Theconstant position of internal rotation leads to glenohumeral joint deformity that progresses overtime. In the older child, the glenohumeral joint deformity is advanced, and the joint cannot bereduced. Humeral osteotomy can reposition the limb into external rotation, which improvesappearance and enhances activities of daily living, such as eating, washing hair, and grooming.This article discusses my preferred technique for humeral osteotomy using a medial approachalong with its advantages and disadvantages. The technique involves a medial incision alongthe arm. The internervous plane is between the median and ulnar nerves. The intermuscularseptum is traced to the medial aspect of the humerus. The periosteum is incised andprovisional fixation is obtained. A transverse osteotomy is performed, and the humerus isrotated into the desired position. Rigid plate and screw fixation is applied. Postoperativeimmobilization is nominal, although the osteotomy is protected until union. Improvement infunction of activities of daily living, such as dressing, washing, self-cleaning, and feedingis obtained. An added benefit is better limb appearance with improved symmetry.Oper Tech Orthop 17:88-93 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS humeral rotation, brachial plexus, birth palsy, glenohumeral joint, transverseosteotomy, technique

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ncomplete recovery after brachial plexus birth palsy oftenresults in decreased movement and muscle imbalance

bout the shoulder because rotator cuff and deltoid innerva-ion is incomplete. The internal rotators usually overpowerhe external rotators, which results in an internal rotationontracture. The development of an internal rotation con-racture leads to glenoid retroversion and posterior humeralead subluxation (ie, glenohumeral dysplasia).1-3

The constant position of internal rotation leads to earlylenohumeral joint deformity by 6 months of age and ad-anced deformity by 2 years, which is characterized by in-reased glenoid retroversion and posterior humeral headubluxation (Fig. 1).1-5 Untreated muscle imbalance leads torogressive deformity.3

The treatment is controversial. In the young child, open orrthroscopic anterior capsulectomy and subscapularis re-ease can reduce the glenohumeral joint and promote remod-ling over time.6-8 Tendon transfers about the shoulder re-ults in better motion but fail to realign the glenohumeral

Department of Orthopaedic Surgery, Temple University, Philadelphia, PA.Hand Surgeon, Shriners Hospitals for Children, Philadelphia, PA.ddress reprint requests to Scott H. Kozin, MD, Shriners Hospitals for Children,

3551 North Broad Street, Philadelphia, PA 19140. E-mail: skozin@
cshrinenet.org
8 1048-6666/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.doi:10.1053/j.oto.2007.01.006

oint.9,10 The inability to improve joint alignment may ex-lain the loss in clinical improvement over time.11 In thelder child, the glenohumeral joint is no longer reducible.umeral osteotomy can reposition the limb into external

otation, improve appearance, and enhance activities of dailyiving, such as eating, washing hair, and scratching the backf the neck.12-14 There are multiple techniques for osteotomyf the humerus. We prefer the medial approach and thisrticle will discuss the technique along with its advantagesnd disadvantages.

elevant Anatomyerves

he internervous plane is between the median and ulnarerves. The brachial artery and median nerve are medial tohe biceps and brachialis muscles. The relationship betweenhe brachial artery and median nerve changes along the bra-hium. In the proximal aspect of the arm, the nerve is lateralnd travels anterior to the brachial artery. This arrangements reversed in the distal aspect with the median nerve medialo the artery.

The medial antebrachial cutaneous nerve exits the medial
ord along with the medial brachial cutaneous nerve. These

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Humeral rotational osteotomy in children with residual BPBP 89

erves travel longitudinally along the arm and must be pro-ected during this approach. The ulnar nerve is located pos-

igure 1 An 11-month-old child with right brachial plexus birthalsy and internal rotation contracture. (A) Magnetic resonance im-ging of the left shoulder reveals a glenoid version of –7° and theercentage of humeral head anterior to the middle of the glenoid

ossa 47.3%. (B) Magnetic resonance imaging of the right shoulderemonstrates a glenoid version of –30° and the percentage of hu-eral head anterior to the middle of the glenoid fossa 20.0%. (Cour-

esy of Shriners Hospital for Children, Philadelphia).

erior to the medial intermuscular septum and travels poste- C

ior to the medial epicondyle and into the cubital tunnel. Thelnar nerve provides no innervation in the arm.In the proximal portion of the arm, the musculocutaneous

erve pierces the posterior aspect of the coracobrachialisuscle.15 As the musculocutaneous nerve traverses the cor-

cobrachialis muscle, the motor branch to the biceps andrachialis muscles leaves the main trunk.16,17 The radialerve is not routinely exposed during the medial approach

igure 2 A 12-year-old girl with left residual brachial plexus birthalsy, internal rotation contracture, and deficient external rotation

s shown. (A) Lack of external rotation; (B) unable to touch back ofeck; (C) positive trumpeter sign (shoulder abduction on attemptedand-to-mouth positioning). (Courtesy of Shriners Hospital for
hildren, Philadelphia). (Color version of figure is available online.)

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nd travels across the posterior surface of the humerus in theidportion.

endonshe proximal aspect of the approach reveals the pectoralisajor tendon inserting on the greater tubercle and forming

he lateral lip of the intertubercular sulcus. Cephalad retrac-ion of the pectoralis major muscle exposes the underlyingatissimus dorsi tendon in the floor of the intertubercularroove. The latissimus dorsi tendon represents the proximaloundary for internal fixation via the medial approach.

sseoushe shaft of the humerus resembles a prism with the antero-edial surface ideal for plate application.18 This surface has a

road surface that is nearly equal to the diameter of the shaft.s the anteromedial surface propagates in a distal direction

here is a slight medial torsion. Fortunately, this rotation doesot impede osteotomy and plate application.

atient Evaluationhe child/adolescent with brachial plexus birth palsy is ex-mined about the shoulder, elbow, forearm, wrist, and hand.he shoulder is assessed with regards to active and passiveange of motion (Fig. 2). Global motion is assessed using theallet classification of shoulder motion.19 Passive glenohu-eral joint external rotation is measured with scapular stabi-

ization. External rotation less than neutral indicates under-ying glenohumeral dysplasia.1 External rotation beyondeutral implies a reasonable relationship between the glenoidnd humeral head. Advanced imaging studies, such as mag-etic resonance imaging or computed tomography, may be

ndicated in equivocal cases. The preferred study is depen-ent on the age of the child and their extent of ossification.1-5

Children without glenohumeral dysplasia are treated withendon transfers to promote external rotation, which rebal-

igure 3 Operative procedure on 12-year-old girl depicted in Fig. 2.ncision along medial side of left arm (distal is to the right, proximals to the left). Ulnar nerve is located posterior to intermusculareptum. (Courtesy of Shriners Hospital for Children, Philadelphia.)

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nces the glenohumeral joint.9,10 Young children are consid-red candidates for arthroscopic anterior capsulectomy, par-ial subscapularis release, and glenohumeral reduction.6,8

he precise age that negates joint remodeling is unknown. Inur practice, children older than 6 years of age with advancedlenohumeral dysplasia are no longer candidates for jointeduction; at that point, humeral osteotomy is considered. Ineneral, humeral osteotomy is recommended in the olderhild with an internal rotation contracture and glenohumeralysplasia.Before surgery, the patient and family are educated with

egards to the procedure and rehabilitation process. The ne-essity of avoiding contact sports until bony union and firmonsolidation is emphasized, typically 3 months’ duration. Inddition, the amount of correction necessary to maximizeunction is ascertained by examining current function andnticipating subsequent gain in external rotation and loss ofnternal rotation. Excessive external rotation inhibits midlineunction while inadequate correction curtails the benefits ofimb re-positioning.

urgical Techniquehe patient is placed on the operating room table in theupine position. General anesthesia is induced, and all bonyrominences are padded. Preoperative intravenous antibiot-

cs are administered. The arm is abducted and placed onto anrm table. The arm is prepped and draped with a U-drape tonclude the axilla and entire arm. No tourniquet is used.

A medial arm incision is performed along the medial in-ermuscular septum (Fig. 3). The length of the incision variesith the span of the internal fixation device. The intervaletween the anterior and posterior arm musculature is devel-ped and the medial intermuscular septum is identified. Thelnar nerve lies just posterior to the septum and is clearlyisualized. The ulnar nerve is mobilized in a posterior direc-ion with the triceps muscle. The median nerve and brachialrtery are palpated in the anterior compartment and reflectedith the biceps and brachialis musculature. The intermuscu-

igure 4 Identification and excision of intermuscular septum.Courtesy of Shriners Hospital for Children, Philadelphia.)

ar septum is traced to the medial aspect of the humerus and

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xcised (Fig. 4). The periosteum is incised and reverse retrac-ors are carefully placed anterior and posterior to the hu-erus.The length of the humeral shaft necessary for osteotomy

nd plate fixation is exposed. The size of the plate depends onhe size of the humerus. Usually, a 2.7-mm or 3.5-mm plates selected with 6 or 7 holes. The plate is placed along theumerus, and 3 bicortical screws are inserted in standardashion in the proximal plate (Fig. 5). The desired amount ofxternal rotation was determined before surgery. A Kirschnerire is drilled in an oblique angle to the plate equal to the

mount of anticipated correction. The wire is perpendicularo the humerus and adjacent to the hole in the plate next tohe proposed osteotomy site. The site of osteotomy is markedn the bone and the screws and plate removed. Malleableetractors are placed around the osteotomy site. A fine-laded saw is selected, and a transverse osteotomy performederpendicular to the bone is undertaken (Fig. 6). Irrigation issed to limit the heat and to prevent bone necrosis. Aftersteotomy, the humerus is externally rotated until the screws

igure 5 A 3.5-mm plate is secured proximal to intended osteotomysing bicortical screws. (Courtesy of Shriners Hospital for Children,hiladelphia.)

igure 6 Osteotomy between proximal screw holes and obliqueirschner wire inserted to gauge correction. (Courtesy of Shrinersospital for Children, Philadelphia.)

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oles and Kirschner wire are aligned. The plate is re-appliedith the Kirschner wire passing through the hole in the plate

djacent to the osteotomy. The proximal screws are insertednto their respective holes to secure the plate to the bone.

The osteotomy is reduced with manipulation of the limbnd bone reduction clamps. Manual compression is appliedcross the osteotomy site. A distal screw is placed in dynamicompression mode to increase bony coaptation. The Kirsch-er wire is removed and the remaining screws are placed ineutral mode (Fig. 7).Wound closure is straightforward using absorbable suture.

he limb is wrapped in a bulky dressing from the hand to thexilla. No splint is used, although ample dressing is applied

igure 7 Osteotomy reduced and secured with dynamic compres-ion via eccentric screw placement. (Courtesy of Shriners Hospitalor Children, Philadelphia.)

igure 8 X-rays demonstrate coaptation of osteotomy and good po-ition of internal fixation device. (Courtesy of Shriners Hospital for
hildren, Philadelphia.)

92 S.H. Kozin

Figure 9 A 12-year-old girl, depicted in Figure 2, at 2 months aftersurgery. (A) Overhead abduction; (B) hand to neck; (C) hand to ear;(D) hand to mouth without trumpeter sign; and (E) slight loss ofinternal rotation. (Courtesy of Shriners Hospital for Children, Phila-delphia.) (Color version of figure is available online.)

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o “immobilize” the limb. The elbow is positioned in 90-grees of flexion. The fingers are left free for early motion.he arm is placed into a sling when the child is walking.The dressings are removed 2 weeks after surgery, and

-rays taken to ensure bony alignment (Fig. 8). A fracturerace is fabricated about the humerus to allow shoulder andlbow motion. The brace is worn for an additional month andhen repeat x-rays taken to assess union. No gym or contactports are allowed until a firm union has formed.

omplicationsomplications are uncommon. Injury to the adjacent nerves

s possible during the surgical exposure or secondary to trac-ion. The surgeon and assistant must be aware of the degreef retraction, especially with the reverse retractors that canlace undue pressure on the median and/or ulnar nerves.onunion is a complication unrelated to this approach; how-

ver, children are notorious for misbehaving and hardwareailure has occurred before union.

dvantages/ Disadvantageshere are numerous advantages of this technique. The incon-picuous scar is hidden within the arm and heals better com-ared with the lateral incision. Arm positioning is easier asxternal rotation after osteotomy places the limb onto therm table, which facilitates internal fixation. In addition, thehape of the anteromedial humerus is ideal for plate applica-ion.18 The disadvantage of the technique is related to thenatomy. The surgical anatomy is more challenging and isess familiar for the orthopaedic surgeon. However, knowl-dge and experience breeds comfort, which quickly occursfter a few cases.

utcomeumeral osteotomy reliably improves activities that require

xternal rotation (Fig. 9).12-14 Before surgery many patientsre unable to perform self-care activities, such as grooming,eeding, and washing themselves. After surgery, most chil-ren can dress, wash, perform self-cleaning, and feed them-elves better and no longer require help with these activities.he Mallet score for shoulder function uniformly improvesfter osteotomy.13,14 During the last 4 years, surgeons at mynstitution have performed humeral osteotomy via a medialpproach in 26 children with consistent improvement inunctional activities. We have found the technique to betraightforward and reliable.

The level to perform the osteotomy is controversial. The-retically, rotational osteotomy of the proximal part of theumerus between the insertions of the subscapularis and
ectoralis major muscles enhances deltoid function.12 We
ave not found this to be a consistent finding and prefer theenefits of the medial approach.The methods of internal fixation are diverse.12-14 Osteot-

my stabilization has varied from flimsy catgut sutures toigid plate and screws. The fixation technique will dictate theostoperative immobilization. Regardless of fixation, im-roved outcome has been reported.12-14

eferences1. Kozin SH: The correlation between external rotation of the glenohu-

meral joint and deformity after brachial plexus birth palsy. J PediatrOrthop 24:189-193, 2004

2. Pearl ML, Edgerton BW: Glenoid deformity secondary to brachialplexus birth palsy. J Bone Joint Surg [Am] 80:659-667, 1998

3. Waters PM, Smith GR, Jaramillo D: Glenohumeral deformity secondaryto brachial plexus birth palsy. J Bone Joint Surg [Am] 80:668-677, 1998

4. Gudinchet F, Maeder P, Oberson JC, et al: Magnetic resonance imagingof the shoulder in children with brachial plexus birth palsy. PediatrRadiol 25:S125-S128, 1995 (suppl 1)

5. van der Sluijs JA, van Ouwerkerk WJR, de Gast A, et al: Deformities ofthe shoulder in infants younger than 12 months with an obstetric lesionof the brachial plexus. J Bone Joint Surg [Br] 83:551-555, 2001

6. Pearl ML: Arthroscopic release of shoulder contracture secondary tobirth palsy: An early report on findings and surgical technique. Arthro-scopy 19:577-582, 2003

7. Hui JHP, Torode IP: Changing glenoid version after open reduction ofshoulder in children with obstetric brachial plexus palsy. J PediatrOrthop 23:109-113, 2003

8. Pedowitz DI, Gibson B, Williams GR, et al: Arthroscopic treatment ofposterior glenohumeral joint subluxation secondary to brachial plexusbirth palsy. J Shoulder Elbow Surg 16:6-13, 2007

9. Kozin SH, Chafetz RS, Barus D, et al: Magnetic resonance imaging andclinical findings before and after tendon transfers about the shoulder inchildren with residual brachial plexus birth palsy. J Shoulder ElbowSurg, 15:554-561, 2006

0. Waters PM, Bae DS: Effect of tendon transfers and extra-articular soft-tissue balancing on glenohumeral development in brachial plexus birthpalsy. J Bone Joint Surg [Am] 87:320-325, 2005

1. Pagnotta A, Haerle M, Gilbert A: Long-term results on abduction andexternal rotation of the shoulder after latissimus dorsi transfer for se-quelae of obstetric palsy. Clin Orthop 426:199-205, 2004

2. Kirkos JM, Papadopoulos IA: Late treatment of brachial plexus palsysecondary to birth injuries: rotational osteotomy of the proximal part ofthe humerus. J Bone Joint Surg [Am] 80:1477-1483, 1998

3. Al-Qattan MM: Rotation osteotomy of the humerus for Erb’s palsy inchildren with humeral head deformity J Hand Surg [Am] 27:479-483,2002

4. Waters PM, Bae DS: The effect of derotational humeral osteotomy onglobal shoulder function in brachial plexus birth palsy. J Bone JointSurg [Am] 88:1035-1042, 2006

5. Flatow EL, Bigliani LU, April EW: An anatomic study of the musculo-cutaneous nerve and its relationship to the coracoid process. Clin Or-thop 244:166-171, 1989

6. Chiarapattanakom P, Leechavengrongs S, Witoonchart K, et al: Anat-omy and internal topography of the musculocutaneous nerve: the nerveto the biceps and brachialis muscle. J Hand Surg [Am] 23:250-255,1998

7. Yang ZX, Pho RW, Kour AK, et al: The musculocutaneous nerve and itsbranches to the biceps and brachialis muscles. J Hand Surg [Am] 20:671-675, 1995

8. Lancaster G, Kozin SH, Porter S: The medial approach to the humerus.Tech Hand Upper Extrem Surg 4:201-206, 2000

9. Mallet J: Primaute du traitement de l’epaule—methode d’expresion des
resultats. Rev Chir Orthop 58:166-168, 1972

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9

roximal Row Carpectomy and aodification for Dorsal Capsular Interposition

homas B. Hughes, Jr., MD*,†

Proximal row carpectomy is a time tested management technique for wrist arthritis. Thisreview article describes the surgical technique for proximal row carpectomy as well as theindications and post-operative protocol. Alternative methods of treatment are contrastedwith proximal row carpectomy. A modification of the standard technique using a dorsalcapsular interposition is also described that may be used to extend the indications for theprocedure to those not traditionally considered good candidates for proximal row carpec-tomy. A review of the literature presents the results of the procedure and its modification.Oper Tech Orthop 17:94-101 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS proximal row carpectomy, wrist arthritis, scapholunate advanced collapse, inter-position

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he surgical treatments that are available for the treatmentof wrist arthritis include complete fusion, partial fu-

ion, prosthetic replacement, and proximal row carpectomyPRC). PRC provides a combination of retained motion andood pain relief. It is a reliable treatment for scapholunatedvanced collapse (SLAC) wrist, Keinbock’s disease, scaph-id nonunion advanced collapse (SNAC) wrist, Presiser’s dis-ase, and severe perilunate dislocations that preclude recon-truction. It remains a good option for treatment because ofts durability, ease of recovery, and low complication rate.

The first PRC was described in a series published by Inglisnd Jones in 1937.1 PRC is an accepted treatment for ad-anced stages of Keinbock’s disease and post-traumatic ar-hritis.1-12 Common causes of posttraumatic arthritis includecaphoid nonunion, perilunate dislocations, and SLAC.3 PRClso has been used in the treatment of wrist flexion deformi-ies in conditions such as arthrogryposis multiplex congenita,erebral palsy, cerebral vascular accidents, and arthritis mu-ilans of psoriasis.13,14 PRC is contraindicated in the treat-ent of the rheumatoid wrist.6,15

Common complaints from patients with wrist arthritis in-lude pain, weakness, and decreased motion,1 although the

Department of Orthopaedics, Drexel University School of Medicine,Philadelphia, PA.

Department of Orthopaedic Surgery, Allegheny General Hospital, Allegh-eny Orthopaedic Associates, Pittsburgh, PA.

ddress reprint requests to Thomas B. Hughes, Jr., MD, Department ofOrthopaedic Surgery, Allegheny General Hospital, Allegheny Ortho-paedic Associates, 1307 Federal Street, Pittsburgh, PA 15212. E-mail:

[email protected]


oss of motion frequently is well tolerated. Patients may re-ort a specific traumatic event but, in the case of SLAC wrist,he initial injury may go unrecognized. The history shouldetail social factors such as employment in heavy labor, to-acco use, medical comorbidities such as diabetes, with doc-mentation of the functional deficits associated with the ar-hritic wrist. Some authors have suggested that PRC is not anppropriate treatment for manual laborers.6 However, manyther studies have shown that most laborers are able to returno their previous occupations.4,7-9,11 Smokers and diabeticsay be at higher risk for nonunion and, therefore, PRC may

e preferred to limited or complete fusions.Examination will demonstrate decreased motion in all

irections; flexion, extension, and radial and ulnar devia-ion. Grip strength is decreased. There may be focal, radial-ided, radiocarpal swelling, and point tenderness over thecapholunate articulation is common. In the early progres-ion of SLAC or SNAC, tenderness may only be noted at theadial styloid. A positive Watson test for instability may belicited, although it frequently becomes negative in moredvanced cases of SLAC. Careful examination can frequentlyifferentiate between radiocarpal and midcarpal symptoms,specially when correlated with radiographs. This informa-ion is important in making treatment decisions and selectingurgical options.

Radiographs of the wrist of patients with post-traumaticrthritis will usually demonstrate degeneration of the ra-ioscaphoid in SLAC wrist (Fig. 1). SNAC usually is indi-ated by the obvious scaphoid nonunion, although some
ases of Presier’s disease will have a similar appearance. Wrist

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PRC and a modification for dorsal capsular interposition 95

rthritis arising from SLAC or SNAC follows a predictableattern of articular degeneration.16 In stage I, which is typicalf early SNAC, arthritis is found in the radial half of thecaphoid fossa and the reciprocal surface of the scaphoid. Intage II, seen in early SLAC, wear involves the entire scaphoidossa. Stage III arthritis, common to both SNAC and SLAC,ccurs when the pattern of wear extends to the midcarpaloint involving the head of the capitate. Finally, in stage IV,here is widening diastasis between the scaphoid and lunateith proximal migration of the capitate. This radiographic

taging system is important in the surgical decision making

Figure 2 Dorsal approach. (A) After a longitudinal incisiothe third compartment, the dorsal capsule can be visuelevated and retracted ulnarly without releasing the tendradial aspect of the wrist. (B) A distally based “U-shaped(asterisk), as can the wear (dark arrow) noted in this stagachieved with a rongeur to provide tension on the soft-ti

igure 1 Anterior–posterior and lateral radiographs of stage I SLAC.n the Anterior–posterior view, note the scapholunate interval di-

stasis (asterisk), the triangular shape of the scaphoid signifyingcaphoid flexion, and the preservation of the joint space between theapitate and the lunate (white arrow). On the lateral view, note thecapholunate angle of approximately 90° and the dorsal intercalatedegmental instability (DISI) pattern of the lunate in extension.

a knife or elevator. (Color version of figure is available online.

rocess, as stage III or stage IV SLAC with capitate wear maye a contraindication to PRC.Patients with Keinbock’s disease are managed according to

he severity of their symptoms and the radiographic appear-nce of the lunate and lunate fossa of the radius. Keinbock’sisease was staged by Stahl and later modified by Lichtman.17

n stage I disease, avascular necrosis can be identified onlyith the use of magnetic resonance imaging. In stage II dis-

ase, radiographs show sclerosis, but no lunate collapse.tage IIIa is characterized by collapse of the lunate withoutcahpoid flexion. Revascularization procedures or perilunatesteotomies usually are recommended for Stage IIIa disease.n lower-demand patients, or those with significant comor-idities, PRC can be used to treat stage IIIa Keinbock’s. Inatients with stage IIIb Keinbock’s disease, lunate collapserogresses to the extent that there is proximal migration ofhe distal carpal row. To accommodate this loss of carpaleight, the scaphoid rotates into a palmar-flexed position. Intage IIIb Keinbock’s disease, PRC is the ideal salvage. StageV Keinbock’s is characterized by carpal arthrosis, includinghe lunate fossa, and may be a contraindication to PRC.

When PRC is being considered, specific attention shoulde focused on the lunate fossa of the radius and the proximalapitate. Historically, degenerative arthrosis at these sites haseen a contraindication to PRC.4,8,9,12,18 Culp and coworkers6

lassified radiolunate and capitolunate degeneration as mildf there was decreased joint space only, moderate if jointpace narrowing was accompanied by subchondral sclero-is, and severe if there was collapse and cyst formation.hey found, as have other authors, that PRC is unsuccess-

ul in patients with mild capitolunate and radiolunate ar-hritis.5-7,9,11 The debate continues concerning how muchadiocapitate degeneration is acceptable at the time of PRC.

Taking all of these factors into consideration, it wouldppear that the best candidates for PRC would be nonrheu-

elease of the extensor pollicis longus (EPL) tendon from. Note the fourth compartment (white arrow) can behe extensor carpi radialis brevis (ECRB) is noted at the

ular flap is raised (DC). The scaphoid can be visualizedAC wrist. (C) Rotational control of the scaphoid can beachments of the scaphoid while they are sectioned with

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atoid patients with stage I, II, or III SLAC disease withinimal capitolunate or radiolunate degeneration and pa-

ients with Stage IIIB Keinbock’s disease. It is important toelect each patient carefully and fully educate them to thereatment alternatives.

RC Techniquenformed consent should include PRC as well as any othernticipated procedures, including posterior interosseouserve neurectomy, anterior interosseous nerve neurectomy,apsular interposition, limited wrist fusion, or complete wristusion. Interoperative findings frequently can alter the surgi-al plan, and these possibilities should be discussed preop-ratively.

Axillary block combined with an intravenous sedative oreneral anesthesia is preferred. Although the procedure usu-lly is performed in the outpatient setting, postoperative painanagement can be challenging. Regional anesthesia should

e performed with long-acting medications to provide signif-cant postoperative analgesia. The use of a sustained releasend/or long-acting local anesthetic directly into the wrist can

Figure 4 PRC with capitate wear. (A) Anterior–posteriorRadiographs do not demonstrate significant midcarpal ato those in Fig. 3, focal full-thickness capitate head cartithis option with the patient so that appropriate treatmen
interposition was performed. The patient had excellent pain re
id in pain control postoperatively. This is particularly help-ul in those patients not a candidate for axillary block anes-hesia. Longer-acting narcotics should be considered as aupplement to more routine oral pain medications in the firsteveral postoperative days. The patient is positioned supineith the arm on a hand table. A tourniquet is used and is

eleased before closure to ensure hemostasis. Significantwelling can slow recovery of finger motion; therefore, he-ostasis and the use of a surgical drain can be critical.A dorsal approach is used to expose the carpus and distal

adius. The procedure has been described through both aransverse and longitudinal incision. The advantage of theransverse incision is the appearance of the resulting scar.he advantage of the longitudinal incision is the ability toetter visualize the radius, the midcarpal joint, and the distalarpal row. The longitudinal incision is easier to workhrough and the scar is acceptable to most patients. It is alsoore amenable to secondary salvage with a wrist fusion

hould the situation require it. The incision is made throughhe skin and subcutaneous tissue and the dorsum of thextensor retinaculum is identified. The extensor pollicis lon-us (EPL) is released from the third dorsal wrist compartment

Figure 3 Captitate wear. Focal capitatewear (white arrow) can be observed inthese 2 separate cases. These patientsmay be successfully treated with a PRCand dorsal caspsular interposition.

teral radiographs of a patient with stage III SLAC wrist., but intraoperative inspection revealed findings similarar. Preoperative planning should include discussion ofdelivered. (B) In this case, a PRC with a dorsal capsular

and larthritislage wet can be

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nd retracted radially (Fig. 2). The EPL is left transposedadially at the end of the procedure. The fourth extensorompartment is identified and elevated off of the radius as anit and retracted ulnarly. We frequently perform anteriornd posterior interosseous nerve neurectomies at thisoint.19

The capsular exposure can be longitudinal, although werefer that the capsule be elevated from the dorsal lip of theadius in a large U-shaped distally based flap. This allows forhe modification of the procedure to perform a capsular in-erposition if necessary (see technique modification below).raction applied to the hand at the time of capsular incision

acilitates preservation of the largest flap possible. Care isaken in elevating this capsular flap so that it can be repairedfter PRC. The capsule is elevated to expose the scaphoid,unate, capitate, hamate, and triquetrum.

Once the carpus is exposed, the wrist is palmar flexed toxamine the capitate head and the lunate fossa of the radiusFig. 3). If significant degenerative changes are present, con-ideration can be given to a scaphoid excision with limitedntercarpal arthrodesis, PRC with capsular interposition, oromplete wrist fusion (Fig. 4).

Once the decision to proceed with PRC has been made, its important to preserve the articular surfaces that will remainuring the carpal excisions. The scapholunate and lunotri-uetral ligaments, if intact, are sectioned. In unstable wrists,he lunate can be quite mobile and can usually be excised enloc at this point. In more rigidly fixed wrists, scaphoid ex-ision is performed first. Scaphoid and lunate excision areacilitated by maximally flexing the wrist.

A sharp bone tenaculum or penetrating towel clip is placednto the dorsal-proximal scaphoid. This method gives excel-ent rotational control of the bone, and the bone is rotatedadially and ulnarly, placing soft-tissue attachments underension where they are sharply sectioned. Routinely, thisechnique leads to fracture of the dorsal scaphoid beforeomplete release and loss of fixation by the bone tenaculum.econdary rotational control can be obtained with a rongeur

Figure 5 Technical pearls. (A) An osteotomy of the scaprovide access the the volar soft-tissue attachments. (B)thereby maintaing tension on the soft-tissue attachmentsto the articular surfaced of the capitate (C) throughout tand aids in the carpectomy. (Color version of figure is a

n the remaining scaphoid using it to hold, rather than crush, l

he dorsal scaphoid (Fig. 5). Sometimes a longitudinal osteot-my at the scaphid waist is necessary to gain access to theolar scaphoid for removal. All soft-tissue dissection is per-ormed directly on the carpus, as straying away from theigamentous attachments to the carpal bones puts importantoft-tissue at risk. Throughout the procedure, care is taken tovoid injury to the flexor policis longus tendon and the ra-ioscaphocapitate (RSC) ligament. Maintaining tension onhe thick ligaments can facilitate removal through subperios-eal dissection and prevent inadvertent injury. A freer eleva-or is used to lever on the distal scaphoid pole and a secondlevator or #15 blade is used to section the volar soft-tissuettachments. Occasionally, the distal pole of the scaphoidust be removed with a rongeur in a piecemeal manner.ecause the volar ligaments are attached distally, sharp dis-ection must be performed with care to remove the distalragments.

After scaphoid excision, a similar penetrating tenaculum islaced in the lunate to gain rotation control, and soft-tissueissection continues on this bone. Care is taken to avoid

njury to the RSC ligament and the articular surface of theapitate. Removal of the triquetrum follows lunate excision,sually without much difficulty. The flexor carpi ulnaris ten-on and pisiform articular surface are at risk with triquetralxcision.

Once the proximal carpal row is excised, the capitate restsn the lunate fossa of the radius. A small defect in the articularartilage frequently is seen on the radial aspect of the capitates the result of wear against the scaphoid. This wear shouldot dissuade the surgeon from continuing with PRC as longs it is not in the central, weight-bearing portion of the cap-tate head. Most authors no longer recommend pin fixation ofhe carpus to the radius as it increases complication ratesithout measurable benefit.The joint and subcutaneous tissues are irrigated with an-

ibiotic saline. The tourniquet is released, and bleeding isontrolled with electrocautery. The joint capsule is repaired ifo interposition is planned. The fourth compartment is al-

(S) can facilitate resection of the dorsal scaphoid andvator should be used to lever the carpal bones dorsally,g in their release. Care should be taken to avoid damagecedure. Wrist flexion improves access to the volar wriste online.)

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pened during the approach to the wrist, the retinaculum isepaired to prevent bowstringing. The EPL is left transposedadially in the subcutaneous tissues. If necessary, a drain islaced in the subcutaneous layer. An interrupted nylon clo-ure is performed on the skin. A sterile gauze dressing ispplied under a well-padded wrist splint. Care is taken toeave the metacarpal heads exposed to allow postoperativenger motion. A loosely wrapped elastic bandage is placedver the splint taking care to avoid any significant tension onhe dressing as postoperative swelling can lead to significant

Figure 6 Styloid fracture and scapholunate ligament teafracture and acute scapholunate dissociation in his nonda need for preoperative medical clearance, and a desire ta 5-week delay between his injury and his date of surreviewing the treatment options, we recommended primthe depressed position seen radiographically. The patiecapsular interposition was performed. Six weeks postopwork in a removable splint. At 3 months the patient repwrist flexion-extension, and requested to follow-up as n

Figure 7 Dorsal capsular interposition (courtesy of Markwide as possible. (B) Three sutures are then placed throuthe capsule again, creating 3 mattress-type sutures. (C) W
the head of the capitate and remains interposed between the c
ompression under a tight dressing. Patients should be in-tructed to loosen the elastic bandage if necessary because ofwelling to prevent an unnecessary trip to the emergencyepartment on the first postoperative evening.Most patients can be discharged home on the same day as

urgery. Early finger motion is encouraged. At 2 weeks post-peratively, the patient returns for skin suture removal andonversion of the splint to a short-arm cast. Wrist and fingerotion and strengthening are begun as a home physical ther-

py program. Patients with severe swelling or significant pre-

64-year-old patient presented with this distal radiusnt hand. His care was complicated by unstable angina,n to his sedentary job in less than 3 months. There wasecause of compliance with the medical workup. AfterC. (B) At the time of surgery, the styloid was healed inwear on the radial side of the capitate head. A dorsal

ly, the patient was removed from a cast and released too pain, no longer used the splint, and had a 45° arc of

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atz, MD). (A) The distally based capsular flap is kept ascapsule, into the volar wrist ligaments, and out throughhese 3 sutures are tied down, the dorsal capsule covers

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perative finger arthritis are sent for formal therapy while inhe cast to improve finger motion. The cast is removed in twoo four weeks. Formal therapy is begun after cast removal forrist and finger motion and strengthening.

RC With Capsularnterposition Modificationndicationsndications for PRC have been expanded in some series tonclude those patients with more advanced arthritis.12,18,20,21

Figure 8 Failed PRC. (A) A 50-year-old man underwenttranscaphoid perilunate fracture dislocation and ipsalatetear as well as a scaphoid fracture. (B) Despite 3 monthsincompetent, and he developed increased scaphoid flexiounderwent PRC for persistent pain 1 year after his injury. (radiocarpal fusion. Anterior–posterior and lateral radiograp
apparent fusion of the radiocapitate articulation. The patient had
capsular interposition can be added to PRC in patients withapitate or lunate fossa degeneration, especially in older orow-demand patients (Fig. 6). The role of capsular interposi-ion in those patients without capitate and lunate fossa ar-hrosis is not yet defined, but it may lead to increased motionnd it may have a protective affect on the new radiocarpalrticulation. Unpublished data from a cadaveric study in ouraboratory examined motion after PRC with and without dor-al capsular interposition. Flexion with PRC alone averaged4° and extension averaged 85°. PRC with interpositionielded average flexion and extension of 126° and 86°, re-pectively. This increased flexion–extension arc was signifi-

eduction and internal fixation and ligament repair of aplex elbow fracture-dislocation. He had a scapholunatend cast immobilization, his scapholunate ligament wasdosal intercalated segmental instability. (C) The patientr 1 year of persistent pain, the patient elected to undergow the radiocarpal fusion. (E) Magnification demonstrates

open rral comof pin an andD) Aftehs sho

good pain relief at 6 weeks after the fusion surgery.

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ant (P � 0.05). The increase in motion was theorized to beecondary to a release of the dorsal capsule.

In our experience, capsular interposition can be used toxpand the indications of PRC to include patients withome capitate wear or degeneration of the lunate fossa ofhe radius. Although these findings may be a reason to con-ider scaphoid excision and capitolunohamotriquetral fusionr complete radiocarpal fusion, interposition may allow for aimpler operation with fewer complications. Comparativehort-term and long-term outcomes of this procedure stillequire investigation. We have had success in the treatmentf stage III SLAC or SNAC with PRC combined with capsularnterposition as described below.

echniquedorsal approach to the wrist is used as was previously

escribed for PRC. A distally based U-shaped capsular flap isaised off of the distal, dorsal lip of the radius. The flap is kepts large as possible. We have not found distal capitate resec-ion necessary in those patients with capitolunate or radiolu-ate degeneration as described by Eaton.21 The PRC is per-ormed with sequential excision of the scaphoid, lunate, andriquetrum as described in the previous section. The head ofhe capitate is inspected. If cartilage wear is noted here orn the lunate fossa of the radius, an interposition is per-ormed. The proximal edge of the capsular flap is sutured tohe palmar wrist ligaments (Fig. 7). The postoperative man-gement for PRC with capsular interposition is identical tohat described above for PRC alone.

esults of PRCRC has had a 96% satisfaction rate with motion arcs aver-ging 91° and grip strength is returned to 84% of the con-ralateral hand.22 Seventy-one percent of laborers are able toeturn to their previous occupation. The results of PRC andcaphoid excision with limited arthrodesis have been com-ared.3,9,10 The use of PRC yields greater wrist motion andrip strength along with satisfactory pain relief. These com-arative studies demonstrate a 21% nonunion rate for limitedrthrodesis. Tomaino and coworkers10 and Krakauer and co-orkers3 recommended limited arthrodesis over PRC in

hose patients with stage III SLAC. However, others haveemonstrated good results when mild capitate articular wear

s present and treated with PRC and dorsal capsular interpo-ition.5-7,9,11 In older, low-demand patients, even with mod-rate-stage III SLAC changes we find that PRC and interpo-ition arthroplasty yields superior results to scaphoidxcision and limited wrist arthrodesis.

In Keinbock’s disease, the results of PRC have been good,lthough a clear superiority to intercarpal fusion has not beenemonstrated. Begley and Engber11 reported 14 patients thatnderwent PRC as the treatment of Lichtman stage IIIA andIIB Keinbock’s disease. Wrist motion averaged 46° of wristexion and 44° of wrist extension, grip strength was 72.5% ofhe unaffected side, and all patients returned to work.

Fitzgerald and coworkers18 described a distraction–resec-
ion arthroplasty. This procedure involves excision of the
unate and triquetrum followed by an osteotomy across theody of the capitate. The hamate and scaphoid are resected athe same level as the capitate, and the remainder of the carpuss then pinned in distraction. Satisfactory results were re-orted in 79% of patients with a flexion-extension arc of 79°nd grip strength averaging 56% of the contralateral wrist.here was no significant difference when compared with pa-

ients undergoing conventional PRC.Salomon and Eaton have described a partial proximal cap-

tate resection combined with a dorsal capsular interposi-ion.12 Theoretically, the stresses at the wrist are spreadcross the capitate and hamate, unloading the capitate–ra-ius articulation. At 55 months average follow-up, patientsad a 94° flexion/extension arc with no poor results. Griptrength was 62% the contralateral side. In the subset ofatients in whom the dorsal capsular interposition was per-ormed, the flexion/extension arc of motion averaged 111°.his increased motion with interposition mimics the unpub-

ished cadaveric data from our laboratory.

omplications and Salvage of PRChere have been few reported complications of PRC.1-12 Mostave been related to superficial pin tract infections, whichccur infrequently now that pinning is rarely recommended.are should be taken to avoid injury to the RSC ligamentolarly to prevent ulnar subluxation of the carpus. If the RSCs injured, it should be repaired and radiocarpal pinninghould be considered if the carpus appears to be unstable.

In patients with unsatisfactory pain relief, wrist arthrodesiss the treatment of choice (Fig. 8). The results of capitate toadius fusion after failed PRC23,24 are promising. Fusion ratesf 100% with grip strength 79% that of the contralateral sideave been demonstrated. Complications were primarily re-

ated to pain over the plate used to obtain fusion.

onclusionsRC is a reliable procedure in the treatment of wrist arthritis.t leads to consistent pain relief, wrist motion, and patientatisfaction with fewer complications than complete orartial wrist fusion. The addition of a dorsal capsular in-erposition arthroplasty may expand the indications forRC to include those with midcarpal arthritis. The role of

nterposition arthroplasty in earlier stages of SLAC has yeto be determined, but its protective affects in more ad-anced arthritis may show some usefulness in those with-ut capitate wear. This needs to be investigated with long-erm follow-up studies. Suffice to say that it may providedditional options in the treatment of wrist arthritis inertain patient populations.

eferences1. Inglis AE, Jones EC: Proximal row carpectomy for diseases of the prox-

imal row. J Bone Joint Surg 59A:460-463, 19772. Stamm TT: Excision of the proximal row of the carpus. Proc R Soc Med

38:74-75, 19443. Krakauer JD, Bishop AT, Cooney WP: Surgical treatment of scapholu-

nate advanced collapse. J Hand Surg 19A:751-759, 1994

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2


4. Jorgensen EC: Proximal row carpectomy: An end result study oftwenty-two cases. J Bone Joint Surg 51A:1104-1111, 1969

5. Neviaser RJ: Proximal row carpectomy for posttraumatic disorders ofthe carpus. J Hand Surg 8A:301-305, 1983

6. Culp RW, McGuigan FX, Turner MA, et al: Proximal row carpectomy:A multicenter study. J Hand Surg 18A:19-25, 1993

7. Tomaino MM, Delsignore J, Burton RI: Long-term results followingproximal row carpectomy. J Hand Surg 19A:694-703, 1994

8. Imbriglia JE, Broudy AS, Hagberg WC, et al: Proximal row carpectomy:Clinical evaluation. J Hand Surg 15A:426-430, 1990

9. Wyrick JD, Stern PJ, Kiefhaber TR: Motion preserving procedures inthe treatment of scapholunate advanced collapse wrist: Proximal rowcarpectomy versus four-corner arthrodesis. J Hand Surg 20A:965-970,1995

0. Tomaino MM, Miller RJ, Cole I, et al: Scapholunate advanced collapsewrist: Proximal row carpectomy or limited wrist arthrodesis withscaphoid excision? J Hand Surg 19A:134-142, 1994

1. Begley BW, Engber WD: Proximal row carpectomy in advanced Kien-bock’s disease. J Hand Surg 19A:1016-1018, 1994

2. Salomon GD, Eaton RG: Proximal row carpectomy with partial capitateresection. J Hand Surg 21A:2-8, 1996

3. Mennen U: Early corrective surgery of the wrist and elbow in arthro-gryposis multiplex congenita. J Hand Surg 18B:304-307, 1993

4. Omer GE, Capen DA: Proximal row carpectomy with muscle transfersfor spastic paralysis. J Hand Surg 1A:197-204, 1976

5. Ferlic DC, Clayton ML, Mills MF: Proximal row carpectomy: Review of

rheumatoid and nonrheumatoid wrists. J Hand Surg 16A:420-424,1991

6. Watson HK, Ballet FL: The SLAC wrist: Scapholunate advancedcollapse pattern of degenerative arthritis. J Hand Surg 9A:358-365,1984

7. Lichtman DM, Mack GR, MacDonald RI, et al: Keinbock’s disease: Therole of silicone replacement arthroplasty. J Bone Joint Surg 59A:899,1977

8. Fitzgerald JP, Peimer CA, Smith RJ: Distraction resection arthroplastyof the wrist. J Hand Surg 14A:774-781, 1989

9. Hofmeister EP, Moran SL, Shin AY: Anterior and posterior interosseousneurectomy for the treatment of chronic dynamic instability of thewrist. Hand 1:63-70, 2006

0. Eaton RG: Excision and fascial interposition arthroplasty in the treat-ment of Kienbock’s disease. Hand Clin 9:513-516, 1993

1. Eaton RG: Proximal row carpectomy and soft tissue interposition ar-throplasty. Tech Hand Upper Extremity Surg 1:248-254, 1997

2. Hughes TB, Baratz ME: Limited wrist arthroplasty, in Weiss A-PC,Hastings H (eds): Surgery of the Hand and Wrist. Philadelphia, PA,Lippincott Williams & Wilkins, 2002, pp 140-154

3. Louis DS, Hankin FM, Bowers WH: Capitate-radius arthrodesis: analternative method of radiocarpal arthrodesis. J Hand Surg 9A:165-169, 1984

4. Richards RS, Roth JH: Simultaneous proximal row carpectomy andradius to distal carpal row arthrodesis. J Hand Surg 19A:728-732,
1994

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1

he Synovial Flap in Recurrentnd Failed Carpal Tunnel Surgeryaitlin Gannon, BS, Katharine Baratz, and Mark E. Baratz, MD

Recurrent carpal tunnel syndrome is defined by a return of numbness after a symptom-freeperiod after surgical decompression. The most common reason for recurrent symptoms isthought to be the formation of a constrictive scar. In this event, it seems reasonable to laya barrier about the nerve after rerelease to try to prevent recurrent scar formation. Webelieve this approach is also reasonable during revision surgery for iatrogenic nerve injury.In this article, we describe the indications and technique and clinical experience using asynovial flap used to cover the median nerve after revision decompression at the wrist.Oper Tech Orthop 17:102-105 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS recurrent pain/numbness, carpal tunnel syndrome, synovial flap, carpal tunnelrelease

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ymptoms of median nerve compression at the wrist aftercarpal tunnel release can be defined as either failed or

ecurrent carpal tunnel syndrome (CTS). Recurrent symp-oms are uncommon and are defined by a symptom-free in-erval after surgery. Progressive constriction by scar forma-ion is the conventional wisdom regarding the cause ofecurrent symptoms. Failed carpal tunnel surgery occursith one of two “faces”: persistent symptoms or worsening

ymptoms. Persistent symptoms are relatively common, par-icularly in elderly patients and in patients with concurrenterve compression or medical conditions that affect nerveunction, such as diabetes. Increased numbness after carpalunnel release should be cause for immediate concern be-ause the most likely reason is nerve injury. The treatinghysician must be precise in his or her evaluation because thendings will define future treatment to a greater extent thanerve studies or imaging studies (Table 1).

valuationt is particularly useful to separate ongoing, recurrent, orncreased pain from numbness. An increase in pain may oc-ur for a number of reasons, including scar pain, aggravationf preexisting thumb carpometacarpal arthritis, or chronicegional pain syndrome. An increase in numbness suggestserve damage. If you were not the initial treating surgeon, ask

epartment of Orthopaedic Surgery, Allegheny General Hospital, Pitts-burgh, PA.

ddress reprint requests to: Caitlin Gannon, BS, 1307 Federal Street, 2nd
sFloor, Pittsburgh, PA 15212. E-mail: [email protected]

he patient whether the main complaint before the indexperation was numbness or pain. Carpal tunnel surgery per-ormed for numbness has a more predictable result than sur-ery performed for pain. It is helpful to obtain copies of thereoperative nerve conduction studies and the operative re-ort.Inspect the incision. Check for a Tinel’s around the inci-

ion. Test the 2-point discrimination. Normal or unchanged-point discrimination suggests that the nerve was not dam-ged during the procedure; expanded 2-point discriminationemands close scrutiny; absent 2-point discrimination withn increase in numbness suggests nerve injury.

Ancillary studies assume a secondary role in the manage-ent of failed or recurrent CTS. Nerve conduction studiesith electromyography can help support a diagnosis but

hould not be relied on to define the diagnosis. Magneticesonance imaging may reveal an extrinsic mass compressinghe nerve. In our opinion, magnetic resonance imaging is notufficiently accurate to diagnosis recurrent compression orerve injury.

ndications for Surgerye chose to offer revision surgery to patients with worsening

umbness immediately after their first operation, patientsith recurrent numbness after a previously successful oper-

tion, and a select subset of patients with persistent numb-ess after surgery. Persistent symptoms after carpal tunnelurgery must be approached carefully. Reasons for persistent
ymptoms include nerve compression at another site, such as

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The synovial flap in recurrent and failed carpal tunnel surgery 103

ronator Syndrome or cervical radiculopathy, and underly-ng neuropathy, such as occurs with diabetes, advanced age,r severe compression. In the absence of these conditions, weill offer repeat surgery, particularly to younger patients and

hose patients in whom it is suspected that transverse carpaligament was incompletely released through a small incision.

echniqueefore surgery, obtain consent to harvest nerve graft or use aerve conduit. We use nerve graft for gaps in the nerve largerhan 1 cm and for partial nerve lacerations that cannot beutured together without tension on the repair. Our choice oferve graft includes medial antebrachial cutaneous (MABC)erve and sural nerve. The MABC graft is used for partial

acerations and sural nerve graft for complete lacerations.The patient is placed under a general anesthetic and pos-

ioned supine with the arm on armboard or table. Loupeagnification is recommended. The incision is designed so

hat it extends into normal tissue at least 2 cm.s on either end.he median nerve is identified in the distal forearm directlyeneath the palmaris longus tendon. The nerve is traced to-ard the carpal canal working on the anterior, ulnar marginf the nerve. As the scarred region is approached care is takeno identify the plane between the nerve and the scar. Theresence of perineural fat creates a natural plane except inhose instances when the nerve has been lacerated. If you losehe plane between nerve and scar resume the dissection distalo the carpal tunnel starting in normal tissue. Start on the ante-ior margin of the third common digital nerve and trace thaterve to the anterior, ulnar margin of the median nerve,roper. When no there is no clear plane between the nervend scar, you can extrapolate the line of dissection from the

able 1 Guidelines for Treatment of Recurrent, Failed or Wor

Evolution ofSymptoms Examination

ecurrentCTS

Numbness completelyresolved thenrecurred

Findings range from noto (�) Tinel’s, PhalenCarpal compressionor expanded two poi

ailed CTSersistentCTS

Symptoms persistbeyond 6 months*

Key finding: normal orunchanged two-pointdiscrimination

orsenedCTS

Noticed by the patientin the immediatepost-operativeperiod

Tinel’s over incision.Expanded or absentpoint discrimination

This is an arbitrary number based in part on the literature and in p

istal and proximal anterior, ulnar margins of the nerve. Dis- c

ect just ulnar to this line leaving a cuff of synovial tissue onhe nerve. Once the nerve is freed from scar, inspect the nerveor signs of injury such as disruption of fasicles or proximaleuroma (Fig. 1). Identify the motor branch and commonigital nerve.To create a synovial flap, raise a flap of synovium from the

uperficial flexors starting on the ulnar aspect of the carpalanal (Fig. 2). Continue raising the flap from the level of theuperficial arch to the wrist crease. At the proximal and distalargins of the flap, cut transversely to allow the flap to be mo-

ilized. Continue raising the flap to the margin of the medianerve (Fig. 3). The flap is then draped over the nerve andewn to the inner margin of the radial remnant of the trans-erse carpal ligament (Fig. 4).

After surgery, the wrist is immobilized for 10 to 14 days forevision surgery done for recurrent symptoms. In cases ofrior nerve injury the wrist is immobilized for 4 weeks.plints and casts are kept low in the palm to permit full andmmediate finger motion. If feeling is not significantly im-roved within four weeks patients are referred to therapy toe instructed in sensory re-education. Scars are treated withassage and Elastomer.

linical Seriesince 2000, the senior author has performed 36 revisionarpal tunnel releases with synovial flap. The average age ofhe patient at the time of revision was 58.5 years. The averageime between index procedure and revision was 3.3 years.one of the patients reviewed initially underwent open car-al tunnel release; all patients underwent limited open carpalunnel release as the index procedure. None of the patientsad concurrent nerve repair or grafting. Eight patients had

CTS Based on Evaluation

Etiology Treatment

Most common: no obviousabnormality other thatadjacent, compressivescar.

Other reasons:tenosynovitis, masses,incomplete release

Revision decompression withbarrier to prevent re-recurrence.

Exception: Tenosynovitis, tryinjection of steroid beforere-release.

Advanced age, diabetes,intrinsic nerve disease,concurrent compressioneg. Cervicalradiculopathy,Incomplete release

Observation.Exception: in a young person

with no other reason forpersistent symptoms,consider exploration forpossible incompleterelease.

Nerve injury.Have seen one case

following incompleterelease

Nerve exploration; repair, ifnecessary; place barrier toprotect from scar formation

experience.

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omplete relief of their symptoms, 10 had partial relief, and 2

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104 C. Gannon, K. Baratz, and M.E. Baratz

ad no improvement. The average age of patients who hadomplete relief was 53.5 years, compared with 61.8 years foratients with partial relief and an average age of 61.5 years foratients who were no better.

iscussiontutz and coworkers1 describe a number of causes for recur-ent or unresolved CTS. Of the 200 patients included in theirtudy, 108 (54%) experienced persistent or recurrent symp-oms as a result of incomplete transection of the flexor reti-aculum. In 65 cases, the distal edge of the retinaculum was

ntact, in 27, the proximal edge was intact, and in 5 the entireigament was felt to be intact. Twelve patients experiencedatrogenic nerve lacerations from their initial procedure: 4atients had incomplete lacerations, and 2 had complete lac-rations of the median nerve; 2 patients had lacerated motorranches, and 3 had lacerated palmar branches. The incom-lete release and iatrogenic groups were thought to composehe patients with persistent CTS (120 patients). In the re-aining 80 cases, Stutz and coworkers felt that symptomsere recurrent. In 46 patients symptoms were caused by the

onstriction of the nerve as the result of scar tissue (23%). Aass within or adjacent to the carpal canal was responsible

or symptoms in 4 patients (2%). The remaining 13 patients7%) had no specific reason for recurrence documented. Demet and Vandeputte2 describe 14 cases in which the appar-nt cause of recurrent CTS is circumferential fibrosis of theedian nerve after either endoscopic or open release.We combined the data from 4 articles published on revi-

ion carpal tunnel surgery. In 280 cases, 107 were treatedith nerve decompression and placement of a flap. Pedicledaps were overwhelmingly favored. In Stutz’s series, 46 pa-ients with constriction of the median nerve caused by scarissue received either a hypothenar fat or synovial flap. Demet’s patients received either a distal ulnar fat flap or a

igure 4 The synovial flap wrapped loosely about the median nerve.

igure 1 Median nerve re-released. The dissection was extendedpproximately 2 cm on either end of the original incision into nor-

igure 2 The synovial flap raised from ulnar to radial off the super-

igure 3 The synovial flap raised to the level of the median nerve.he distal border is at the level of the superficial arch. The proximal

ypothenar fat flap. Wulle used a synovial flap in 27 pa-

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The synovial flap in recurrent and failed carpal tunnel surgery 105

ients.3 Lucheti and coworkers described 19 cases treatedith a hypothenar fat flap, 2 radial forearm flaps, 2 ulnar

orearm flaps, 1 ulnar fascial-fat flap, and 1 posterior in-erosseous flap.4 Dahlin and coworkers reviewed their expe-ience with 5 cases of pedicled ulnar flaps, 1 of which wasnsuccessful, resulting in the substitution of a pedicled dor-al flap.5 Dahlin also describes 9 cases of free flaps, includingscapular flaps and 5 lateral arm flaps. One of the scapularaps was unsuccessful and replaced by a groin flap.Of the 80 patients included in Dahlin, Wulle, Lucheti, and

e Smet’s studies, 64 were rated as excellent or good out-omes as determined by a decrease in pain and an increase inensibility and strength. The most frequent complaints werentermittent pain and scar tenderness without serious impair-

ent of function or work ability. Other complaints includedbnormal sensation and sensitivity to percussion.

Only Lucheti correlates etiology and outcome: the authorsetermined that the level of symptom improvement is in-ersely proportional to the amount of median nerve damage.e Smet suggests that improvement may be linked to the

nterval between procedures: 6 of the 8 patients with annterval of more than 1 year had satisfactory outcomes asompared with 3 of the 6 patients with shorter intervals.

On the basis of the presented literature, it appears thatedian nerve redecompression combined with placement offlap is an effective treatment for recurrent CTS. Pedicledaps appear to be preferable to free flaps, but there is novidence in the articles arguing for the specific donor. Unfor-unately, we are aware of no study that prospectively exam-nes the value of decompression alone versus decompressionith placement of a flap. Our approach has evolved to the

ollowing algorithm:

1. Re-release, no flap
a. Persistent symptoms caused by incomplete release;
supple skin and a layer of subcutaneous fat over thecarpal canal.

2. Re-release, synovial flapa. Recurrent carpal tunnelb. Nerve injuryc. Atrophic subcutaneous skin flaps over carpal canal

3. Re-release, hypothenar fat flapa. Above with rheumatoid synovium or atrophic

synovium4. Re-release, free flap

a. Above with atrophic skin and subcutaneous tissues.

onclusione have found the synovial flap to be a quick, simple, and

ffective manner to supplement median nerve decompres-ion in the setting of failed or recurrent CTS. There is essen-ially no donor site morbidity. In our series of 36 patientsuring the course of 6 years, there were only 2 patients whoid not experience at least a partial benefit and no instance ofe-recurrence.

eferences. Stutz N, Gohritz A, van Schoonhoven, et al: Revision surgery after carpal

tunnel release-analysis of the pathology in 200 cases during a 2 yearperiod. J Hand Surg 1:68-71, 2006

. De Smet L, Vandeputte G: Pedical fat flap coverage of the median nerveafter failed carpal tunnel decompression. J Hand Surg 4:350-353, 2002

. Wulle C: The synovial flap as treatment of the recurrent carpal tunnelsyndrome. Hand Clin 1:379-388, 1996

. Lucheti R, Riccio M, Zorli IP, et al: Protective coverage of the mediannerve using fascial, fasciocutaneous or island flaps. Handchir MilkrochirPlast Chir 38:317-330, 2006

. Dahlin L, Lekholm C, Kardum P, et al: Coverage of the median nervewith free and pedicled flaps for the treatment of recurrent severe carpaltunnel syndrome. Scand J Plast Reconsrt Surg Hand Surg 36:172-176,
2002

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rthroscopically Assistededuction and Internal Fixation of Scaphoidractures, Delayed Unions, and Nonunions

. Greg Sommerkamp, MD

The unstable scaphoid fracture can be treated by a variety of different methods, includingopen reduction and internal fixation (ORIF), percutaneous fixation with either k-wires orcannulated screws, and arthroscopically assisted reduction and internal fixation (AARIF)with various cannulated screw systems. The drawbacks of ORIF include extensive soft-tissue dissection, disruption of the nondominant volar blood supply, division of the ra-dioscaphocapitate and radioscapholunate ligaments and volar capsule, and prolongedrehabilitation. Percutaneous fixation avoids the aforementioned drawbacks, yet relies onfluoroscopic guidance alone to assure accurate reduction of the scaphoid fracture frag-ments and optimal positioning of the implant in the apex of the proximal pole. The technicallimitations of plain radiography as well as fluoroscopy in detailed visualization of the oddlyoriented scaphoid limit the accuracy of the percutaneous technique. AARIF avoids all thelimitations of ORIF, yet allows direct visualization of the scaphoid fracture site and assuresaccurate reduction of the fragments before and during definitive arthroscopically assistedinternal fixation. AARIF also assists in accurate targeting of the proximal pole apex or“sweet spot,” in addition to allowing detection of concurrent pathology in the radiocarpalor midcarpal joints. Delayed unions and stable nonunions with normal intrascaphoidangles, even with ischemic proximal poles, can be treated with AARIF augmented withpercutaneous cancellous bone grafting from the trapezial ridge plus autologous platelet-derived growth factor gel.Oper Tech Orthop 17:106-117 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS arthroscopic fixation, scaphoid fractures, delayed unions, nonunions, percutane-ous bone grafting

tiputoehhmsttfe

n

he fractured scaphoid continues to be a nemesis to boththe patient as well as his or her surgeon. This oddly

haped, peanut-sized, carpal bone has nearly 80% of its sur-ace area covered by hyaline cartilage and resides in a uniquerientation in the human carpus at 47° flexion and 20° radialeviation.1 The scaphoid is the most commonly fracturedarpal bone, with an approximate incidence of 140 per mil-ion population or roughly 40,000 fractures annually in thenited States alone.2 The tenuous vascular supply enters via

he dorsal ridge or spiral groove vessel, originating from theadial or dorsal intercarpal arteries or both, supplying up-ards to 70% to 80% of the scaphoid. In 86% of scaphoids,

epartment of Orthopedic Surgery, University of Cincinnati College of Med-icine and Hand Surgery Specialists, Inc., Cincinnati, OH.

ddress reprint requests to T. Greg Sommerkamp, MD, 20 Medical VillageDr., Suite 177, Edgewood, KY 41017. E-mail: gsommerkamp@handsurg.

pcom


his critical vascular supply enters the dorsal ridge at or prox-mal to the waist, exposing all fractures at or proximal to thisoint, to the potential complications of delayed union, non-nion, and/or avascular necrosis.3 It is a basic orthopedicenet that intracapsular fractures with, by definition, a tenu-us vascular supply require stable immobilization and pref-rably compression of the fragments to increase the likeli-ood of union and ward off avascular necrosis. Althoughistorically, the orthopedic community’s approach to treat-ent of the fractured scaphoid has not quite reflected it, the

caphoid is not all that dissimilar to its intracapsular coun-erparts, the femoral neck and the talus. In all of these loca-ions, union occurs by primary bone healing, with directormation of bone across the fracture site without the aid ofxternal callus.4

Currently, the accepted approach to treatment realizes theeed for stable internal fixation in a significant subset of
atients with an unstable scaphoid fracture pattern. An un-

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Scaphoid AARIF 107

table scaphoid fracture, and thus an absolute indication fornternal fixation, is “currently” defined as (1) any fractureisplaced �1 mm; (2) a scapholunate angle �60° or a capi-olunate angle �15°; (3) a lateral intrascaphoid angulationISA) �25 � 5° or a posteroanterior ISA �35 � 5°; and (4)roximal pole fractures, transscaphoid perilunate fractureislocations, and an avascular proximal fragment.1,5

Herbert6 even questions the wisdom of considering scaph-id fractures displaced �1 mm as being “stable.” In his ownlassification (Table 1), Herbert considers all complete frac-ures (B-1 and B-2) as unstable whether displaced or not andonsiders only incomplete fractures (A-1 and A-2) as trulytable injury patterns. As shown by Weber and Chao,7 theorce and rate of loading required to fracture the scaphoid islmost twice that of the distal radius, which is certainly a veryigh energy impact injury. After this significant hyperexten-ion–axial load force, it is only by the nature of the very snugapsular constraints surrounding the scaphoid that both frag-ents end up appearing in a rather benign, “nondisplaced”

onfiguration on plain radiography. To consider such an in-ury as “stable” only because there is displacement �1 mm onlain radiographs is precarious at best. Fortunately, with theid of computed tomography (CT) scanning in the oblique orongitudinal axial projection as described by Sanders,8 weave come to realize how displaced and unstable manycaphoid fractures actually are despite innocuous-appearinglain radiographs.Arthroscopically assisted reduction and internal fixation

AARIF), as introduced by Whipple9 in 1992, involves a can-ulated version of the original Hebert variable pitch screwnd a modification of the original Herbert-Huene in vivo jigo an ex vivo jig. To completely appreciate the additionaldvantages brought about by AARIF, one must thoroughlyeview the specific disadvantages of formal open reductionnd internal fixation (ORIF) of the fractured scaphoid. Therawbacks of ORIF include: extensive soft-tissue dissec-

ion, the obligatory ligation of the volar branch of the radialrtery, disruption of the nondominant volar scaphoid bloodupply, division of the radioscaphocapitate/radiolunate liga-ents, and the persistently altered postoperative intercarpal

ngles despite their repair.10 Add to this excessive scarringnd the need for relatively prolonged immobilization and,

able 1 Herbert Classification of Scaphoid Fractures

ype A: Acute fracture stableA-1: Tubercle fractureA-2: Waist fracture – incomplete

ype B: Acute fracture unstableB-1: Distal oblique fracture – completeB-2: Transverse waist fracture – completeB-3: Proximal pole fractureB-4: Transscaphoid perilunate fracture dislocation

ype C: Delayed union (>4 months)ype D: NonunionD-1: Fibrous nonunion (>6 months)D-2: Pseudarthrosis

ence, rehabilitation is required. It would certainly be advan- t

ageous if stable interfragmentary compression of the scaph-id could be reliably achieved without the drawbacks ofRIF.Percutaneous or limited incision techniques have several

nherent potential technical pitfalls, including (1) the well-nown limitations of plain radiography and fluoroscopy indequately visualizing scaphoid fracture anatomy and, henceheir reduction; (2) the tendency for problematic freehandcrew insertion potentially resulting in further displacement,otation, or even distraction of the fragments11,12; and (3) theotential in totally freehand systems without jig/barrel guid-nce for the narrow-diameter guidewire to bend resulting ininding of the subsequent instrumentation.1 Plain radio-raphs routinely understate the degree of displacement andngulation present in acute scaphoid fractures (Fig. 1). Evenhen rather innocent appearing nondisplaced scaphoid frac-

ures are studied by CT, significant displacement of up to 1m or more, or excessive ISA (posterior–anterior [PA] �40°,

ateral �30°) can become apparent (Fig. 1). We have, onore than one occasion, had the scaphoid fracture appear to

e anatomically reduced on flouroscopy, only to find a 1- to-mm dorsal gap in the fracture site when directly visualizedrthroscopically through the radial midcarpal portal. Thisiscrepancy is especially true if the axis of the screw is too farolar, resulting in compression of the volar cortex and slightistraction of the dorsal cortex (Fig. 2). Just as plain radio-raphs have given way to CT for accurate definition of precisecaphoid fracture anatomy preoperatively, fluoroscopyhould now be supplanted by arthroscopy in the intraopera-ive assessment of fracture reduction.

To further complement the percutaneous or limited inci-ion techniques that are performed only under fluoroscopicuidance, Whipple9 introduced the concept of AARIF. Withhe addition of arthroscopy, one can adequately visualize theracture site and confirm reduction under direct visualizationhrough the radial midcarpal portal. In addition, the proxi-al pole target site in the apex or “sweet spot” can be directly

isualized through the 3-4 portal aiding in proper centrallacement of the screw. The remainder of the midcarpal andadiocarpal joints can be inspected to assess for any coexis-ent pathology. In 1995, Whipple12 reported on his first 20atients treated with AARIF with the Herbert-Whipplecrew, with union in all.

iagnosis/ssessment of Fracture Stability

caphoid AARIF is indicated only for nondisplaced to mini-ally displaced fracture patterns that can be reduced via

rthroscopic manipulation. Relative contraindications wouldnclude displacement �2 mm, PA ISA �50°, lateral ISA

45°, comminution of any type, transscaphoid perilunateracture dislocations, and ipsilateral scapholunate ligamentuptures with widely displaced or dislocated proximal poleragments. These fracture patterns are essentially so unstablehat attempts at AARIF prove to be most frustrating, if notmpossible, and are best served by formal ORIF. Preopera-
ive-dedicated CT of the scaphoid is necessary for assessment

Figure 1 (A) PA radiograph of “nondisplaced” scaphoid fracture; (B) lateral radiograph of“nondisplaced” scaphoid
fracture; (C) coronal CT of same fracture showing PA–ISA; (D) sagittal CT of same fracture showing lateral ISA.

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Scaphoid AARIF 109

f the ISAs and, hence, the true degree of instability presentn each individual fracture pattern. Each fracture should be

easured with respect to displacement, PA and lateral ISAFig. 1), and SL/CL angles on both standard scaphoid radio-raphs and CT in the longitudinal axial plane 8 Preclinicalxperience in the cadaver laboratory with AARIF is helpful. Ifhis is not readily available, it would be advisable to limitneself to the more stable fracture patterns (A-2, completelyondisplaced B-2, or those with minimal increase in intra-caphoid or intercarpal angles) in patients who cannot toler-te long-term immobilization in a cast.

ARIF Surgicalechnique: Acute Fracturesnder regional or general anesthesia, with upper-arm tour-iquet control, the extremity is prepped and draped on aand table with a countertraction strap applied over a well-added brachium. The wrist traction tower (Linvatec, Largo,

Figure 2 (A) Sagittal sketch of screw axis that is too volascrew axis with good compression and no dorsal gap.

L) or other similar traction device is recommended. A 12- to

5-mm oblique incision is centered over the volar tuber ofhe trapezium just radial to the flexor carpi radialis tendonnd a transverse scaphotrapezial arthrotomy is performed.n inverted “T”-shaped extension is then made with a longi-

udinal incision distally over the trapezium with subperios-eal exposure of the proximal half of the trapezium (Fig. 3).omplete excision of at least 5 mm of the volar rim of the

rapezium is made with a small osteotome, facilitating expo-ure of the edge of the distal pole articular surface. It is criticalt this point to be absolutely sure that one has enough expo-ure of the distal pole articular surface to ensure adequatelacement of the alignment guide barrel teeth in articularartilage. If the dorsal teeth are not in articular cartilage, theventual screw axis will be far too volar, contributing to volarcrew cutout and dorsal gapping at the fracture site (Fig. 2).

small, self-retaining retractor (Heiss) is placed in theound, and the index and long fingers are placed in nylonnger traps and secured to the traction tower with 10 poundsf axial traction.

dorsal gapping of fracture; (B) Sagittal sketch of proper
r with
The midcarpal and radiocarpal joints are distended by inject-

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110 T.G. Sommerkamp

ng several milliliters of fluid in the radial midcarpal (RMC) and-4 portals respectively. The RMC, ulnar midcarpal (UMC), 3-4,nd 4-5 portals are established with dissection using a number1 blade through skin only, and the underlying tissue is spreadith a curved mosquito hemostat. The 2.7-mm arthroscope

heath and sharp trocar are gently introduced in the RMC portalp to the level of the joint capsule and then converted to thelunt trocar for completion of the portal. The UMC portal isstablished in similar fashion for the outflow catheter and thennflow is established through the RMC and any residual hemar-hrosis is flushed. The capitolunate, lunatotriquetral, triquetro-amate, and the distal aspect of the scapholunate joints are sur-eyed for any evidence of concurrent pathology. If anyignificant additional pathology exists, the index of suspicion forhighly unstable scaphoid fracture pattern beyond the realm ofARIF is increased. The radial aspect of the head of the capitate

s traced, the scope is walked distally following the ulnar borderf the scaphoid, and the fracture line is closely examined for anyvidence of displacement or angulation (Fig. 4). If displacementess than 1 mm is present, a reduction maneuver is attempted byecreasing the amount of traction to approximately 5 poundsnd simultaneously extending and supinating the wrist (Fig. 4).f that is not successful, 0.062-inch k-wire joysticks may belaced into the proximal pole dorsally and distal pole volarly toacilitate reduction. Once reduced, the fracture should be thor-ughly examined both arthroscopically through the RMC and-4 portals and fluoroscopically through a 180° arc of rotation.he arthroscope is usually much more critical of reduction, asne will frequently find the fracture to be well-reduced fluoro-copically yet have residual displacement by arthroscopic in-pection. If initial displacement is between 1 to 2 mm and theforementioned reduction maneuvers are not promptly success-ul, one should abort AARIF and convert to ORIF. Any displace-

ent greater than 2 mm is indicative of a highly unstable frac-ure pattern and one should strongly consider ORIF.

Figure 3 (A) Excision of volar rim of trapezium; (B) sapermission of Elsevier, Inc.).

gittal sketch of excised volar rim of trapezium (printed with

Once provisional reduction has been demonstrated, the t
igure 4 (A) RMC view of fracture displaced; (B) RMC view of frac- ure reduced.

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Scaphoid AARIF 111

cope is transferred to the 3-4 portal and the outflow trans-erred to the 4-5 portal; the radiocarpal joint is assessed forny concurrent pathology. A 1-2 portal is established, takingreat care to spread the subcutaneous tissue liberally avoid-ng injury to the dorsal division of the superficial radial nerve.he surgeon should stay as dorsal as possible in the 1-2 portal

o avoid the radial artery and then establish and dilate theortal to allow passage of the target hook on the tip of thelignment guide blade. The blade is advanced in an ulnarirection to the level of the scapholunate interosseous liga-ent (SLIL) with the target hook facing dorsally. The blade is

ently rotated distally and the target hook is swept onto theorsal aspect of the proximal pole about 1 mm from the SLILFig. 5). The target hook is firmly seated and then embeddednto the articular cartilage “sweet spot” under direct visual-zation. Optimal placement is critical to avoid penetration ofhe guidewire or screw through either the volar or ulnaroncave surfaces of the scaphoid.

Quite often, there is significant variability in the degree ofLIL breadth and, to achieve the “sweet spot” fluoroscopi-ally, one must be prepared to insert the hook anywhere frommm radial to the SLIL insertion or frankly in the fibers of theLIL on the proximal pole of the scaphoid. The hook must beept relatively dorsal to avoid volar screw cutout, which ischieved by placing the hook at the upper end of the visualeld when using a standard 2.7-mm, 30°angle arthroscopeith the scope rotated distally. When this most essential step

s completed, the concave surface of the blade will hug theonvex surface of the scaphoid, and the blade handle will ben a 45° angle to the long axis of the forearm in the sagittal planeith the wrist in neutral. Slight traction is maintained on thelade handle while the alignment guide barrel is attached.The thumb is hyperextended to shift the trapezium as far

orsal as possible, thus revealing access to the critical “start-ng hole” on the distal pole of the scaphoid. The barrel is slidown the alignment guide while distal traction is continu-usly maintained on the blade handle, and the barrel teeth

igure 5 Alignment guide target hook embedded in proximal pole
sweet spot.” (Color version of figure is available online.) g
re compressed against the distal pole articular surface (Fig.). If the barrel teeth are not predominantly on articularartilage, then the guidewire/intramedullary screw axis wille far too volar, leading to volar screw cutout and dorsalapping. Although, the various Herbert elevators are helpfuln elevating the distal pole, nothing is more effective thaniberal excavation of 4 to 5 mm off the volar rim of the trape-ium in allowing adequate exposure of the distal pole artic-lar surface and hence proper placement of the barrel teeth.racture reduction and placement of all hardware should beonfirmed both fluoroscopically and arthroscopically beforeroceeding, because there is little room for error from thisoint onward (Fig. 7). As with all cannulated screw systems,ll instrumentation should be inspected preoperatively to

igure 7 Fluoroscopic posterior–anterior (PA) view of alignment

igure 6 Alignment guide positioning on scaphoid (printed withermission of Zimmer, Inc.).

uide positioning.

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void bent guidewires, drill bits, taps, and in the specific casef the Herbert systems, the alignment guide blade as well.The screw length is determined from the distal edge of the

alibrated alignment guide. The guide sleeve is inserted intohe barrel of the alignment guide. Wire depth can be con-rolled by using the depth gauge to measure the length of therimary guidewire as it is inserted into the wire driver. Usingwire driver with minimal axial pressure, the primary guide-ire is inserted down the barrel insert sleeve. In young denseone, which is so common in this age group, the surgeonhould be patient and avoid excessive force as this compro-

igure 8 (A) PA view of primary guide wire inserted; (B) lateral viewf primary guide inserted with more than 2 mm of bone betweenire and volar cortex of scaphoid.

ises the cutting capability of the guidewire point and in- F

reases the risk of guidewire bending. The wire is inserted upo the premeasured stop point as it abuts the guide sleeve.lacement of the primary guidewire should be examined flu-roscopically to be absolutely certain there is at least 2 mm ofone around the guidewire in all projections. The surgeonhould critically assess the proximity of the wire to the “sweetpot” in the proximal pole on the PA view. On the lateraliew, the surgeon should make sure that the wire is at theare minimum 2 mm away from the volar cortex at the waistFig. 8). Next, the accessory guidewire length is measured offhe depth gauge and inserted into the wire driver to theremeasured depth. The guide sleeve is removed from thearrel and the wire is inserted through one of the 2 accessoryuidewire holes adjacent to the base of the barrel until theire driver bottoms out on the barrel at its predetermined

ength. The positioning should be confirmed fluoroscopicallynd then the trailing edge of the wire should be bent out ofhe way so that it does not interfere with the rest of thenstruments. The surgeon should be certain to remove theuide sleeve before inserting the accessory wire or it will alterhe angle of approach, contributing to possible bending ofhe accessory wire.

In preparation for drilling, the distal pole cortex can beroached with the cannulated modular hand held broach,ut this step is seldom necessary unless significant resistance

s encountered with the step drill. The cannulated step drill isnserted over the primary guide wire to drill the pilot holefter the adjustable stop sleeve is slid onto the drill and set forhe appropriate screw length. Although this can be done withower, it is preferable to attach the cannulated step drill tohe modular handle and drill the pilot hole manually, so as toeel any untoward changes in resistance. Drilling should lastntil the adjustable sleeve bottoms out on the guide barrelFig. 9). The narrow diameter of the step drill is for the 3.0

igure 9 PA view of cannulated step drill inserted.

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Scaphoid AARIF 113

m leading threads and the larger diameter for the 3.9-mmrailing threads. Because of the fairly dense bone, one mayccasionally have to remove the drill while continuing tootate clockwise and clean away debris from the flutes of therill bit. The Herbert-Whipple screw is self-tapping, but ifxtremely dense bone is encountered, one may wish to taphe pilot hole with the supplied tap attached to the modularandle. The surgeon should be certain to set the stop sleeve tohe predetermined screw length and only advance to within aillimeter of the barrel so as to avoid stripping of any

hreads.The Herbert-Whipple screw is inserted by the modular

igure 10 (A) PA view of final screw placement; (B) lateral view ofnal screw placement.

crewdriver over the primary guide wire and down the barrel (

f the alignment guide. The screwdriver is turned until itottoms out on the guide barrel. The screwdriver should bedvanced a few more turns to further bury the head of thecrew below the osteochondral junction to assist in hyalineartilage healing as espoused by Lange and coworkers13

he advancing screw will walk off the end of the screwdrivers it is seated. The final position of the implant is checkednder multiplanar fluoroscopy to be sure that it is acceptablend then the alignment guide and primary and accessoryires are removed. The accessory wire can be left in place for

everal weeks for rotational control, but this is seldom nec-ssary. The distal pole is inspected to make sure the trailinghreads are buried beneath the osteochondral junction. Thecrewdriver is reapplied for an additional turn or two, ifecessary. The reduction is reconfirmed arthroscopically bylacing the scope in the RMC portal and inspecting the com-ressed fracture site (Fig. 10). The wrist is placed through anrc of motion under direct arthroscopic visualization to con-rm fracture stability. The tourniquet is let down and bleed-

ng controlled while final radiographs are obtained (Fig. 11).he scaphotrapezial capsule is closed with 4-O absorbableuture and skin with 5-O nylon, and a volar thumb spicaplint is placed for 4-6 weeks.14

ARIF Surgical Technique:elayed Unions/Nonunions

ARIF with the Herbert-Whipple system also can be used inhe treatment of stable delayed unions/nonunions with nor-al ISAs, even in the face of mild cystic resorption and isch-

mic changes in the proximal pole (Fig. 12). Delayed union isefined as lack of osseous trabeculation by 4 months andonunion by 6 months. The procedure is exactly the same asutlined previously, except that after the surgeon is finished

igure 11 RMC portal view of fracture site reduced and compressed.
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ith the intramedullary drilling, a roton dissector or blunt tiprthroscopy probe is inserted through the jig and advanced tohe nonunion site via fluoroscopic guidance (Fig. 13). The

igure 12 (A) Coronal CT of 6-month-old delayed union with cysticesorption, but good maintenance of ISA. (B) Sagittal CT of-month-old delayed union with cystic resorption, but good main-enance of ISA. (C) Coronal T1-weighted magnetic resonance imag-ng scan with significant hypointensity in proximal pole.

nstrument is then rotated in an oscillating clockwise and t

hen counterclockwise direction, essentially curetting out theonunion site. The cancellous bone from the 5-mm rim ofrapezial ridge that was previously excised is then morselized,nd then inserted via a Jamshidi 11-gauge � 10-cm bonearrow biopsy/aspiration needle (Cardinal Health, McGraw

ark, IL) and delivered directly to the nonunion site (Fig. 14).nder direct fluoroscopic examination, the surgeon can ob-

erve the radiolucent area of cystic resorption disappear asew cancellous bone is tamped into place by the Jamshidilunt probe. After the Jamshidi needle is removed, autolo-ous platelet-derived growth factor (PDGF) gel from platelet-ich plasma is inserted into the nonunion site via a Fibrijetual carrier syringe (Micromedics, Inc., St. Paul, MN; Fig.5). PDGF is one of a variety of osteogenic cytokines derivedrom platelet-rich plasma. Although it contains no osteogenicells or osteoconductive matrix, its complement of cytokinesas been labeled as osteostimulatory.15 Even delayed unionsnd relatively longstanding nonunions heal in as little as 6 toweeks (Fig. 16).

omplicationsotential complications of scaphoid AARIF include the entire

ist of well-known complications of scaphoid fractures andheir subsequent treatment regardless of type, including de-ayed union, nonunion, malunion, avascular necrosis, injuryo the superficial radial nerve and/or the volar division of theadial artery, malpositioning of the implant, iatrogenic injuryo surrounding articular cartilage, post-traumatic arthritis,nd sympathetically maintained pain syndromes. There areo specific complications germane to scaphoid AARIF alone.linical experience with scaphoid AARIF is still relativelyew; however, in the few limited series reported, there haveeen no reports of the more severe complications: delayednion, nonunion, and avascular necrosis.12,16 On the other

igure 13 A Roton dissector (neurosurgical curette) is inserted after
he drill is removed and the nonunion site is cleaned out.

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Scaphoid AARIF 115

and, the incidence of implant malpositioning may bereater in AARIF, especially early in the learning curve, be-ause of limited visualization as compared with formal ORIF.reoperative training in the laboratory and strict adherenceo the aforementioned techniques are necessary to place theuide wire in the “sweet spot” of the proximal pole and guardgainst the tendency to place the wire too far volar in theagittal plane. Early in our series with the Herbert-Whipplecrew from the volar approach, one patient had a screw axislightly volar, and this malposition resulted in slight gappingf the dorsal cortex (�1 mm) with excellent compression ofhe volar cortex. CT at 6 weeks demonstrated trabecularridging along the volar half of the scaphoid, with delayedonsolidation of the dorsal aspect occurring over the next 6 to2 weeks.

ehabilitationostoperative care in our patients with the Herbert-Whipple

mplant has consisted of a bulky, cotton dressing in a thumbpica splint for the first week. After 1 week, sutures are re-oved, standard scaphoid radiographs are obtained, and a

hermoplastic thumb spica splint is applied. Specific rehabil-tation protocols are individualized based on specifics of frac-ure anatomy, stability, and relative vascularity of proximalole. In most patients active range of motion is initiated at 2o 3 weeks and splinting is discontinued at approximately 6eeks and light activity is allowed. A dedicated scaphoid CT

s obtained in approximately 6 weeks, depending on thelain radiographic appearance at that time. In most patients,rabeculations are visible on the CT crossing the fracture sitend a home strengthening regimen is initiated. Return toeavy manual tasks and contact sport is allowed as strengtheturns, usually within a few weeks. The rehabilitative coursef ischemic proximal poles and proximal third fractures muste individualized base on CT results and the extent of trabe-

igure 15 PDGF gel in the Fibrijet dual carrier syringe is insertedown to the level of the nonunion site, and then 1 to 2 cc is injectedround the bone graft. (Color version of figure is available online.)

igure 14 (A) Jamshidi needle (11 gauge) is inserted up to the non-nion site. (B) Cancellous bone graft from the previously excisedrapezial ridge is introduced into the Jamsidi needle. (C) The Jam-hidi probe then delivers the graft down the needle to the nonunionite. Note obliteration of radiolucent cystic changes. (Color version

ulation seen at 6 and 12 weeks.

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116 T.G. Sommerkamp

onclusionhe utopian goal in treatment of the patient with the frac-

ured scaphoid is prompt union with the lowest incidence ofomplications and the least amount of disability. In thosecaphoid fractures that are stable (Herbert A-1, A-2), conser-ative cast treatment is most appropriate, having the lowestate of potential complications. A significant subset of thecaphoid fracture population will unfortunately present withigher degrees of instability in their fracture pattern such aserbert B-1, B-2, and B-3 fractures. These fracture patterns,

specially those with displacement and elevated intrascaph-id or intercarpal angles indicative of increasing degrees ofnstability, will require some form of internal fixation, pref-rably with interfragmentary compression. The highly unsta-le fracture patterns with displacement greater than 1 to 2m, PA–ISA �50°, lateral ISA �40°, scapholunate angle70 to 80°, capitolunate angle �25°, trans-scaphoid perilu-

ate fracture dislocations (Herbert B-4), or concomitantcapholunate ligament injuries are undoubtedly best servedy ORIF to maximize union rates and minimize complicationates. Scaphoid AARIF is indicated for the subset of patientsn between these 2 extremes. AARIF can offer significantotential benefits over ORIF for the following patients: (1)he patient with a nondisplaced fracture who elects to shortenis or her course of immobilization with operative interven-ion, (2) patients with mild degrees of displacement (�1m) and only mild elevation in their intrascaphoid or inter-

arpal angles or both, (3) the patient with a proximal poleragment large enough to accept the leading threads of theerbert-Whipple screw and leave no threads across the frac-

ure site, and (4) patients with stable delayed unions andonunions with normal ISAs, which can be augmented withrapezial ridge cancellous bone grafting and the applica-ion of PDGF gel. It is in this select patient population thatne can offer stable interfragmentary compression by AARIFet avoid the disadvantages of formal ORIF, including exten-ive soft-tissue dissection, disruption of the volar vascularupply, division of the radioscaphocapitate and ra-ioscapholunate ligaments with the attendant permanent al-eration in intercarpal angles, and prolonged rehabilitation.

Scaphoid AARIF with the original Herbert-Whipple can-ulated screw system and alignment guide offers certain dis-inct advantages over freehand, percutaneous, nonalignmentuide systems. The alignment guide, with arthroscopic assis-ance, helps localize the proximal pole “sweet spot” in rela-ion to the SLIL landmark. The guide allows for precompres-ion of the proximal and distal pole fracture fragments,urther assisting the eventual compression provided by theariable pitch screw. Moreover, precompression with thelignment guide affords a preview of the final construct. Iforsal gapping is present at the fracture site as visualizedrthroscopically through the midcarpal portal, the surgeoneceives a valuable warning that the guide/screw axis is far tooolar. One can easily reposition the guide in a more dorsalosition before beginning the intramedullary drilling pro-

igure 16 (A) PA x-rays of Herbert-Whipple screw in position alongith trapezial bone graft and PDGF gel. (B) Coronal CT at week 6ith early trabeculation across nonunion site. (C) Sagittal CT at

ess. This is a great value when stabilizing a bone that is

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Scaphoid AARIF 117

known for” giving surgeons little in the way of “secondhances.”

This experience also underscores the fact that, despite ex-ellent anatomic alignment under magnified multiplanar flu-roscopic imaging, the arthroscope will still reveal persistentisplacement or gapping. Such displacement or dorsal gap-ing may well lead to delayed union or possibly even non-nion and is more prone to occur in percutaneous or limited

ncision “freehand” techniques that rely on fluoroscopic as-essment alone to determine the adequacy of fracture reduc-ion. The alignment guide compression also prevents distrac-ion of the fracture fragments as the screw is driven across theracture site; a problem that can be experienced in percuta-eous or freehand systems, especially when the proximalole is not drilled or tapped to the exact appropriate depthuring intramedullary preparation. The alignment guide ac-essory wire also decreases the probability of rotation duringhread engagement in the proximal pole. In addition, cannu-ated systems with alignment guides are less prone to guideire bending or binding during subsequent intramedullary

nstrumentation, as compared with those systems withoutlignment guides.

The alignment guide does have one distinct disadvantagen that it is highly technique dependent with little margin forrror. It is strongly recommended that one have full familiar-ty with the Herbert-Huene jig and the demanding techniquenvolved in ORIF before progressing to AARIF with the Her-ert-Whipple system. In that regard, cadaver training in the

aboratory is extremely valuable in developing surgical tech-ique. Undoubtedly, in the initial stages, AARIF is quite aumbersome and laborious process because of the dual me-iums of fluoroscopy and arthroscopy. In time, however,ith continued experience, operative times start to shorten,

nd the process becomes more streamlined.

eferences1. Herndon J: Scaphoid fractures and complications. AAOS Monogr Ser

1994;1, 26-27, 69-71.2. Barton NJ: Twenty questions about scaphoid fractures. J Hand Surg

[Br] 17B:289-310, 19923. Gelberman RH, Menon J: The vascularity of the scaphoid bone. J Hand

Surg [Am] 5A:508-513, 19804. Kozin SH: Internal fixation of scaphoid fractures. Hand Clin 13:573-

586, 19975. Smith DK, Linscheid RL, Amadio PC, et al: Scaphoid anatomy: Evalu-

ation with complex motion tomography. Radiology 173:177-180,1989

6. Herbert TJ: The Fractured Scaphoid. St. Louis, Quality Medical Pub-lishing, 1990, pp 51-67

7. Weber ER, Chao EY: An experimental approach to the mechanism ofscaphoid waist fracture. J Hand Surg [Am] 3A:142-148, 1978

8. Sanders WE: Evaluation of the humpback scaphoid by computed to-mography in the longitudinal axial plane of the scaphoid. J Hand Surg[Am] 13A:182-187, 1988

9. Whipple TL. Arthroscopic surgery. The wrist. Fractures of the scaph-oid. Philadelphia, Lippincott, 1992, pp 148-156

0. Garcia-Elias M, Vall A, Salo JM, et al: Carpal alignment after differentsurgical approaches to the scaphoid: A comparative study. J Hand Surg[Am] 13A:604-612, 1988

1. Haddad FS, Goddard NH: Acute percutaneous scaphoid fixation.A pilot study. J Bone Joint Surg [Br] 80B:95-99, 1998

2. Whipple TL: The role of arthroscopy in the treatment of intraarticularwrist fractures. Hand Clin 11:13-18, 1995

3. Lange RH, Vanderby R, Engber WD, et al: Biomechanical and histolog-ical evaluation of the Herbert screw. J Orthop Trauma 4:275-282, 1990

4. Sommerkamp TG. Scaphoid AARIF: Arthroscopically assisted reduc-tion and internal fixation of scaphoid fractures. J Am Soc Surg Hand1:192-210, 2001

5. Solchaga LA, Goldberg VM: Bone marrow and bone marrow productsas osteogenic aids for bone repair, in Friedlander GE, Mankin HJ,Goldberg VM (eds). Bone grafts and bone graft substitutes. Chicago,AAOS Monograph Series, 2006, pp 33-37

6. Slade JF, Gutow AP, Geissler WB: Percutaneous internal fixation ofscaphoid fractures via an arthroscopically assisted dorsal approach.
J Bone Joint Surg 84-A, 21-36, 2002 (suppl 2)

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rthroscopic Repair of Ulnar-Sidedriangular Fibrocartilage Complex Tearshad J. Micucci, MD, and Christopher C. Schmidt, MD

Injuries to the triangular fibrocartilage complex are a common source of ulnar wrist pain.This article reviews current literature on triangular fibrocartilage complex repair and furtherdescribes our preferred technique.Oper Tech Orthop 17:118-124 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS TFCC, arthroscopic TFCC repair, ulnar sided wrist pain, complications

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njuries to the triangular fibrocartilage complex (TFCC) area common cause of acute, ulnar-sided wrist pain. TFCC

ears can result from an axial loaded force, along with anxtension-pronation moment, as commonly occurs with aall on the outstretched hand.1 Also, sporting activities in-olving rapid forearm rotation with ulnar-sided loading,uch as tennis or golf, are common injury mechanisms.1 Fur-hermore, disruption of the TFCC commonly is seen in pa-ients with distal radius fractures.2,3 TFCC lesions in associ-tion with distal radius fractures have been reported as highs 80% in the literature.2,3 The true incidence of injuries tohe triangular fibrocartilage complex is said to be unknownecause it often is misdiagnosed.2,3

Surgical treatment of TFCC tears has been performed dur-ng the past 25 years.4-13 The long-term efficacy of arthro-copic TFCC repair has become widely accepted.1,11,7-12,14

he focus of this work is to describe our preferred techniqueor arthroscopic repair of ulnar-sided, peripheral triangularbrocartilage complex tears.

natomyalmer and Werner described the anatomic details of theFCC; they found a homogenous structure composed of

he articular disc, the dorsal and volar radioulnar ligaments,he meniscus homolog, the ulnar collateral ligament, and theheath of the extensor carpi ulnaris (Fig. 1).15 The TFCCroper arises from the articular cartilage of the radial sigmoidotch and inserts superficially on the ulnar styloid, with aeeper attachment to the ulnar fovea. This deeper attachment

epartment of Orthopaedic Surgery, Allegheny General Hospital,Pittsburgh, PA.

ddress reprint requests to Chad Micucci, MD, 1307 Federal Street, 2nd
nFloor, Pittsburgh, PA, 15212. E-mail: [email protected]

as been named the ligamentum subcruentum.16 The TFCClso has attachments to the carpus via the ulnolunate andlnotriquetral ligaments. The dorsal and palmar radioulnar

igaments are fibrous thickenings of the TFCC, which play aole in stabilizing the distal radioulnar joint (DRUJ) againstbnormal palmar or dorsal translation.3,17,18 The central por-ion, called the disc or meniscus, is situated between thealmar and dorsal radioulnar ligaments.1,15 This central por-ion is devoid of blood flow; in contrast, the ulnar peripheryf the TFCC is highly vascular.1,19 The ulnar artery and ante-ior interosseous artery supply the outer capsular rim of theFCC.19,20 This vascularity is believed to stimulate and main-

ain a healing response between the torn TFCC and adjacentapsule.21 Because of this healing potential, these ulnar-sidedisruptions are amenable to repair.21,22

iagnosisthorough history and physical examination is imperative

or diagnosis of TFCC tears. Many patients complain of ul-ar-sided wrist pain and report a sense of “clicking or pop-ing” with forearm rotation (ie, while turning a door knob,ouring coffee, or swinging a tennis racquet or golf club).ymptoms often worsen with activity and decrease with rest.hysical examination will usually elicit tenderness with directalpation just distal to the ulnar styloid between the extensorarpi ulnaris and flexor carpi ulnaris tendons (Fig. 2).13 Com-ression of the wrist joint with ulnar deviation and/or rota-ion may reproduce symptoms and/or a painful click. Theistal radioulnar joint, although usually stable, should alwayse assessed for instability and compared with the contralat-ral wrist.

Radiologic evaluation should always include plain films toule out fracture. If the diagnosis is in doubt, magnetic reso-
ance imaging (MRI) may be helpful. However, the useful-

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Arthroscopic repair of ulnar-sided TFCCs 119

ess of MRI in diagnosing TFCC injuries is controversial.verall accuracy of identifying TFCC lesions was reported toe 69% for experienced radiologist compared with 37% forhose with less experience.4 Sensitivity for diagnosing TFCCears with MRI ranges in the literature from 42% to3%.4,23-25 High-resolution MRI showed improved sensitiv-

ty (83-100%), but specificity (53%) and accuracy (79%)ere not improved.25 Recent studies suggest that MR ar-

hrography (MRA) may be the most useful imaging tool invaluating TFCC lesions.23 Schmitt and colleagues studiedRA and arthroscopic correlation in 125 patients; their

tudy demonstrated a sensitivity of 97%, specificity of 96%,nd accuracy of 97% for the detection of TFCC lesions.23

ultiple studies in the literature, however, report arthros-opy to have the highest sensitivity and specificity for diag-osing TFCC tears.5,10,24,26

ndicationsnitial care for acute ulnar-sided wrist pain with localizedenderness over the ulna fovea (Fig. 2) and stable DRUJ isplinting and/or short arm casting for 3 to 4 weeks. We havelso found cortisone injections efficacious in alleviating thenitial discomfort. If symptoms persist and the examination isighly suggestive of a TFCC injury, wrist arthroscopy andFCC repair is indicated. MRA should be performed beforeurgery when the diagnosis is in question.

In patients with ulnar-sided wrist pain and DRUJ instabil-ty, immediate TFCC repair and cross pinning of the distaladioulnar joint is recommended. The direction of instabilityetermines the position of the pinned forearm. With dorsallnar instability, cross pinning of the DRUJ is performedsing two 0.062 K-wires with the forearm in supination.

igure 1 Anatomy of the TFCC and dorsal ulnar sensory nerve.

onversely, volar ulnar instability is stabilized with K-wires t

n forearm pronation. If repair is unattainable, reconstructionsing a palmaris longus graft has been described.27

ther Techniquespen repair of ulnar-sided tears of the triangular fibrocarti-

age complex was described by Hermansdorfer and Klein-an.6 The surgical technique requires a capsular incision

etween the fifth and sixth dorsal compartments. The TFCCs debrided, and the avulsed portion is anchored to the ulnaith three 3-0 nonabsorbable sutures through drill holes in

he ulnar styloid. Before tying the sutures, neutral forearmotation is maintained with two 0.062 K-wires. Patients inhis series were immobilized in a long arm plaster splint for 2eeks, then a long arm cast for 4 weeks, followed by K-wire

emoval and a short arm cast for an additional 6 weeks.6

Instead of using bone tunnels, a suture anchor techniqueas also been described.28 A 2-cm incision is made betweenhe fifth and sixth dorsal compartments, followed by a dorsalapsular incision. After the TFCC tear is identified and de-rided, the ulnar fovea is drilled, and a Mitek (Mitek Prod-cts, Norwood, MA) anchor is inserted. The torn TFCC isdvanced and sutured down to the ulnar fovea with a hori-ontal mattress suture. Patients are placed in a long armplint post operatively and are immobilized in a splint or castor 6 weeks.

Several arthroscopic methods have been described forFCC repair. These techniques can be categorized based on

he direction of suture passage as either “inside-out” or “out-ide-in.” “Inside-out” technique was described using a TuohyBecton Dickson, Franklin Lakes, NJ) needle; this device isntroduced into the wrist joint from the radial side, passing ithrough the tear and out the palmar skin of the ulnar carpus.

second site of the TFCC is punctured and both ends of theuture are retrieved; the repair is done in a horizontal mat-ress fashion with 2-0 PDS suture. Postoperatively, a sugar

igure 2 Photo depicting clinical examination of the wrist. Pain onirect palpation over the TFCC/ulnar fovea is a clinical sign sugges-
ive of a TFCC tear. (Color version of figure is available online.)

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120 C.J. Micucci and C.C. Schmidt

ong forearm splint was applied and immobilization continuedor 4 weeks.8 In addition, Trumble and coworkers and Skie andoworkers described a modification of the “inside-out” tech-ique using flexible meniscal needles via the 4 to 5 portal. Inoth studies, patients were immobilized for approximately 6eeks7,10; Trumble and associates preferred a long arm cast in5° of supination postoperatively for all patients.9

The “outside-in” repair, which involves piercing the TFCCia the ulnar side of the wrist, has been described by severaluthors.5,10-13 The “outside-in” techniques vary among au-hors with instrumentation and subtle surgical modifications;ost commonly, a small incision is made adjacent to the tear

nd arthroscopic TFCC repair needle(s) are passed throughhe capsule and TFCC. A 2-0 PDS suture is passed throughhe needle and a grasper is often used to retrieve the suture,hich is then tied to the dorsal wrist capsule. Two to four

utures may be required.5,10-13 Length of immobilization hasanged in these studies from 4 to 6 weeks,5,10,12,13,18 withore recent studies reporting decreased time for immobili-

ation to 3.5 to 4 weeks.29,30

referred Techniquee advocate an “outside-in” technique to repair ulnar-sided

ears of the TFCC. With the patient supine and the upper

igure 3 Intraoperative photo of traction tower during arthroscopicFCC repair (Linvatec, Largo, FL). (Color version of figure is avail-ble online.)

xtremity on an arm table, 10 to 15 pounds of traction are (

pplied to the wrist with the aid of a traction tower (Linvatec,argo, FL; (Fig. 3). The 3-4, 4-5, and 6R portals are made toegin the procedure. A 2.3-mm arthroscope is placed in the-4 portal. We begin with a complete diagnostic arthroscopy.rthroscopic examination of the wrist includes viewing thentire radiocarpal and ulnocarpal joints, the intercarpal liga-ents, and the TFCC. The scapholunate ligament is probed

ia the 4-5 portal and the TFCC through the 6R portal. Thecope also may be placed in the 4-5 portal to further evaluatehe TFCC and lunotriquetral ligament. The diagnosis of aeripheral tear is made by either directly visualizing a tear of

igure 4 Intraoperative photo showing debridement of the inflamedynovium adjacent to the TFCC tears. (Color version of figure isvailable online.)

igure 5 Meniscal repair kit used in TFCC repair. (A) Curved me-iscal needle, used to pass suture for repair. (B) Straight meniscaleedle, placed above curved needle. C. Basket loop, passed throughtraight needle to retrieve suture (Smith Nephew, Memphis, TN).
Color version of figure is available online.)

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he TFCC and/or indirectly by loss of its normal tension.robing the central portion of the complex and assessing itsesiliency, as described by Hermansdorfer and Kleinman,6 de-ermine this “trampoline effect.” Loss of this normal tensionndicates a TFCC injury. Ulnar-sided tears are often marked bynflamed synovium that must be debrided with a 2.5-mm chon-rotome shaver (Stryker, Sunnyvale, CA) via the 6R portal (Fig.). This debridement is believed to stimulate healing once theear is sutured.

After the tear is identified, a 1.5- to 2.0-cm longitudinalncision is then made near the tear, which is usually ulnar toR portal. The dorsal ulnar sensory branch, along with itsransverse branch,31 is identified using blunt dissection. Therist capsule is not violated. The “outside-in” repair is per-

ormed using a meniscal repair kit (Smith Nephew), whichontains a curved needle, straight needle, and retrieval loopFig. 5). The curved meniscal needle is introduced throughhe ulnar capsule and under arthroscopic visualization theistal portion of the TFCC tear is pierced. Next, the straighteniscal needle is placed into the wrist joint above the curvedeedle (Fig. 6A). The suture retrieval instrument, or wire basket

oop, is introduced into the straight needle; it is “looped” aroundhe curved needle (Fig. 6B). A No. 3-0 polydioxanone (PDS)uture is advanced through the curved needle and the basketoop. The basket loop is retracted from the straight needle bring-ng the suture out of the capsule (Fig. 6C). With both limbs ofhe suture in hand, the curved needle is then removed. Theuture is tied down to the wrist capsule in a vertical mattressashion. Once the first suture is secured, another 1 or 2 suturesan be passed and secured in the same fashion.

We also describe an alternative method of tying our suturenots given the proximity of the dorsal sensory branches ofhe ulnar nerve. If the suture knot is close enough in that itay impinge on the nerve, we prefer to exteriorize the suture

hrough the dorsal skin. In this technique, Bunnell needlesre used to bring both suture limbs out through the skin onhe dorsal aspect of the wrist. The sutures are then advancedhrough a button and tied down to the back of the wristFig. 6D). A small piece of nonadherent dressing and castadding are placed between the skin and the button.

ostoperative Careatients are placed in a long arm splint in a supinated posi-ion for 2 weeks. Then, we place them in a long arm cast forweeks followed by occupational or physical therapy. Ther-

py consists of active and passive range of motion exerciseshat emphasize wrist flexion/extension as well as forearmotation. Hand and forearm strengthening are usually initi-ted 8 to 10 weeks after surgery. As the patient progressesith strengthening exercises, modified weight bearing activ-

ties are introduced followed by work specific activities.32

hen using the button technique, patients are splinted in theame fashion and the suture(s)/button(s) are removed at 5
eeks. t
esultst is difficult to compare the results of open versus arthro-copic TFCC repair because the literature consists of only aew case series measuring different outcomes. However, bothpen and arthroscopic repair have merit in alleviating painnd restoring wrist function. In the study by Hermansdorfernd Kleinman, 8 of 11 patients returned to normal painlessctivity; 3 patients had unsatisfactory outcome, and 2 wentn to have subsequent surgery.6

Good-to-excellent results were reported in 8 of 8 patientssing a single-suture anchor placed in the ulnar fovea withhe torn TFCC sutured down to this location.28 Mean wristange of motion was 89% (flexion/extension) and 83% (pro-ation/supination) compared with the opposite hand. Finalrip strength averaged 88% of the unaffected side. The au-hors state that 7 of 8 patients returned to previous employ-ent, and one returned to work with minimal restrictions.28

Recent literature shows arthroscopic TFCC repair to beuperior to open repair with regards to wrist motion andtrength.7,8,13,14,33 With the arthroscopic technique, greaterhan 90% satisfactory results have been reported in the liter-ture.13 A study of arthroscopic TFCC repair by Corso andoworkers found 93% (42 of 45 patients) satisfactory resultnd return to sports or work activities. They found wristange of motion to be normal and grip strength to be at least5% of the contralateral hand.12 In a retrospective study bye Araujo and coworkers, 16 of 17 patients were satisfied orery satisfied with their outcome.8 Ruch and associates reportverage grip strength of 88% in patients without pain afterFCC repair; average postoperative wrist range of motionas 80% for flexion/extension and 84% for pronation/supi-ation.29 These findings are consistent with other arthro-copic results in the literature.5,9,12

Our results of 23 consecutive patients undergoing arthro-copic TFCC repair with an average of 2-year follow-up havehown similar satisfactory results with motion, strength, painelief and return to work/sports. Overall, 22 of 23 patientsad relief of pain and have returned to sports or work activ-

ties.

omplications and Managementhere has been little morbidity reported in the literature fromrthroscopic TFCC repair. There are no reported infectionsr wound complications after arthroscopic repair. A fewtudies noted patient complaints of pain and/or parasthesiasn the distribution of the ulnar dorsal sensory nerve. Trumblend coworkers reported 1 patient (n � 24) with dorsal ulnarensory parasthesias that resolved without treatment atmonths.33 Another study of 44 patients reports 2 patientsith ulnar nerve symptoms.12 A recent article on a sutureelding technique has been described given a high rate oflnar-sided wrist discomfort during the postoperative periodompared with their previous arthroscopic technique.34

In our review, 8 of 23 patients developed parasthesias inhe region of the dorsal sensory branch of the ulnar nerve. Of
hese 8 patients, seven returned to the operating room for


Figure 6 Preferred technique. Schematic and intraoperative photos (see insets) of our preferred technique. (A) A curvedneedle is used to pierce the capsule and the distal portion of the tear. The straight needle is placed into the joint abovethe curved needle (not into the TFCC). (B) The suture basket is passed through the straight needle and situated over topthe curved needle. The suture (3-0 PDS) is then introduced via the curved needle. (C) The basket loop is removed withthe suture, creating a vertical mattress stitch. After removal of the instruments, the 2 limbs of the sutured are tied to the
ulnar capsule.


Figure 6 (Continued) (D) Alternative method: exteriorization of the suture using Bunnell needles on the dorsum of thewrist. The suture is tied to a button, whereas tension of the repair is visualized arthroscopically. (Color version of figure
is available online.)

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eurolysis of the dorsal ulnar sensory nerve and removal ofhe suture knot. In all seven, the nerve was intact and theuture knot was impinging on the nerve with forearm rota-ion. After neurolysis and suture removal, all seven patientsad resolution of their symptoms. The patient who did noteturn to the operating room had a resolution of symptoms atmonths without treatment. This resolution likely occurred

econdary to absorption of the PDS.We are concerned, however, of the occurrence of the nerve

rritation and have modified our technique by using 3-0 PDSnstead of 2-0 PDS suture. In addition, we make a small skinncision to enable direct visualization of the dorsal sensoryerve and have used the suture button technique, if duringepair the suture knot seems likely to impinge on the nerve.

onclusionsFCC tears are a common cause of ulnar-sided wrist pain.rthroscopic repairs of stable TFCC tears in our series, asell as the literature, have done as well or exceeded the

esults of open repairs.7-13,33 Repair of TFCC tears is impor-ant functionally with regard to wrist stability and load bear-ng.34,35 With arthroscopic repair, there seems to be im-roved ROM and grip strength.5,9,12,29 Arthroscopic repairs ofFCC tears can restore wrist function, permitting patients toeturn to sporting activities and labor.

Visualization and protection of the dorsal ulnar sensoryerve is imperative during repair of the TFCC. There are feweports in the literature regarding dorsal ulnar sensory nerverritation after TFCC repair. Concern for this complicationas prompted us to modify our surgical technique; therefore,e believe suture placement is crucial to ensure an optimalutcome.

eferences1. Cober SR, Trumble TE: Arthroscopic repair of triangular fibrocartilage

complex injuries. Orthop Clin North Am 30:279-294, 20012. Lindau T, Arner M, Hagberg L: Intraarticular lesions in distal fractures

of the radius in young adults. A descriptive arthroscopic study in 50patients. J Hand Surg 22B:638-643, 1997

3. Haugstvedt JR, Berger RA, Nakamura T, et al: Relative contributions ofthe ulnar attachments of the triangular fibrocartilage complex to thedynamic stability of the distal radioulnar joint. J Hand Surg 31A:445-451, 2006

4. Blazar PE, Chan PS, Kneeland JB, et al: The effect of observer experienceon magnetic resonance imaging interpretation and localization of tri-angular fibrocartilage complex lesions. J Hand Surg 26:742-8, 2001

5. Haugstvedt JR, Husby T: Results of repair of peripheral tears in thetriangular fibrocartilage complex using an arthroscopic suture tech-nique. Scand J Plast Reconstr Surg Hand Surg 33:439-447, 1999

6. Hermansdorfer JD, Kleinman WB: Management of chronic peripheraltear of the triangular fibrocartilage complex. J Hand Surg 16:340-46,1991

7. Skie MC, Mekhail AO, Ebraheim NE: Operative technique for inside-out repair of the triangular fibrocartilage complex. J Hand Surg 22:814-817, 1997

8. de Araujo W, Poehling GG, Kuzma GR: New Tuohy needle techniquefor triangular fibrocartilage complex repair: preliminary studies.
Arthroscopy 12:699-703, 1996
9. Trumble TE, Gilbert M, Vedder N: Isolated tears of the triangular fibro-cartilage: Management by early arthroscopic repair. J Hand Surg 22:57-65, 1997

0. Gan B, Richards R, Roth J: Arthroscopic treatment of triangular fibro-cartilage tears. Orthop Clin North Am 26:721-729, 1995

1. Ruch DS, Papadonikolakis A: Arthroscopically assisted repair of pe-ripheral triangular fibrocartilage complex tears: Factors affecting out-come. Arthroscopy 21:1126-30, 2005

2. Corso SJ, Savoie SH, Jenkins N, et al: Arthroscopic repair of peripheralavulsions of the triangular fibrocartilage complex of the wrist: A mul-ticenter study. Arthroscopy 13:78-84, 1997

3. Dailey SW, Palmer AK: The role of arthroscopy in the evaluation andtreatment of triangular fibrocartilage complex injuries in athletes. HandClin 16:461-476, 2000

4. Zachee B, De Smet L, Fabry G: Arthroscopic suturing of TFCC lesions.Arthroscopy 9:242-243, 1993

5. Palmer AK, Werner FW: The triangular fibrocartilage complex of thewrist—anatomy and function. J Hand Surg 6:153-162, 1981

6. Mikic Z: Detailed anatomy of the articular disc of the distal radioulnarjoint. Clin Orthop 245:123-132, 1989

7. Palmer AK, Werner FW: Biomechanics of the distal radioulnar joint.Clin Orthop 18:26-35, 1984

8. Fulcher S, Poehling G: The role of operative arthroscopy for the diag-nosis and treatment of lesions about the distal ulna. Hand Clin 14:285-296, 1998

9. Bednar MS, Arnoczky SP, Weiland AJ: The microvasculature of thetriangular fibrocartilage complex: Its clinical significance. J Hand Surg16A:1101-1105, 1991

0. Thiru-Pathi RG, Ferlic DC, Clayton MC, et al: Arterial anatomy of thetriangular Fibrocartilage of the wrist and its surgical significance.J Hand Surg 11A:258-263, 1986

1. Bednar JM, Osterman AL: The role of arthroscopy in the treatment oftraumatic triangular fibrocartilage injuries. Hand Clin 4:605-614, 1994

2. Palmer AK: Triangular fibrocartilage lesions: A classification. J HandSurg 14A:594-606, 1989

3. Coggins CA: Imaging of ulnar sided wrist pain. Clin Sports Med 25:505-526, 2006

4. Pederzini L, Luchetti R, Soragni O, et al: Evaluation of the triangularfibrocartilage complex tears by arthroscopy, arthrography, and mag-netic resonance imaging. Arthroscopy 8:191-97, 1992

5. Kato H, Nakamura R, et al: Does high resolution MR imaging havebetter accuracy than standard MR imaging for evaluation of the trian-gular fibrocartilage complex? J Hand Surg (Br) 25:487-491, 2000

6. Cooney W: Evaluation of chronic wrist pain by arthrography, arthros-copy, and arthrotomy. J Hand Surg 18A:815-822, 1993

7. Adams BD, Berger RA: An anatomic reconstruction of the distal radio-ulnar ligaments for posttraumatic distal radioulnar joint instability.J Hand Surg 27:243-251, 2002

8. Chou KH, Sarris IK, Sotereanos DG: Suture anchor repair of ulnar-sided triangular fibrocartilage complex tears. J Hand Surg [Br] 28:546-50, 2003

9. Conca M, Conca R, Pria AD: Preliminary experience of fully arthro-scopic repair of triangular fibrocartilage complex lesions. Arthroscopy20:79-82, 2004

0. Lourie GM, King J, Kleinman WB: The transverse radioulnar branchfrom the dorsal sensory ulnar nerve: its clinical and anatomical signif-icance further defined. J Hand Surg 19:241-45, 1994

1. Hunter JM, Mackin EJ, Callahan AD (eds): Rehabilitation of the Hand:Surgery and Therapy. Philadelphia, PA, Mosby, 1995.

2. Trumble TE, Gilbert M, Vedder N: Arthroscopic repair of the triangularfibrocartilage complex. Arthroscopy 12:588-597, 1996

3. Badia A, Jimenez A: Arthroscopic repair of peripheral triangular fibro-cartilage complex tears with suture welding: A technical report. J HandSurg 31A:1303-1307, 2006

4. Sagerman SD, Short W: Arthroscopic repair of the radial-sided trian-
gular fibrocartilage complex tears. Arthroscopy 12:339-342, 1996

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humb Carpometacarpal Joint Arthroscopy:Classification System and Rationale for Treatment

lejandro Badia, MD, FACS, and Prakash Khanchandani, MS

Osteoarthritis of the thumb basal joint is a very common and disabling condition.Arthroscopic assessment of the first carpometacarpal joint allows easy identificationand classification of joint pathology with minimal morbidity. The arthritis can then bemanaged either arthroscopically or via an open procedure. Different procedures havebeen described to treat different stages of this disease. The senior author (A.B.)recently has described an arthroscopic staging system to determine treatment for basaljoint osteoarthritis. Arthroscopic stage I patients can be managed with arthroscopicsynovectomy and, occasionally, thermal capsulorraphy. Arthroscopic stage II patientsrequire an extension–abduction closing wedge osteotomy that redirects the axial loadsin this joint. Arthroscopic stage III patients can be treated by interposition procedures,joint replacement, or arthrodesis depending on the patient’s requirement and surgeon’spreference.Oper Tech Orthop 17:125-132 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS thumb, carpometacarpal, osteoarthritis, arthroscopy

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he thumb carpometacarpal (CMC) joint is the secondmost common site for osteoarthritis in the hand, after the

istal interphalangeal joint.1,2 There have been many studiesn the literature that have shown a correlation between volarigament instability and development of early degenerativehanges in this joint.1-9

A number of treatment option for this condition have beenescribed in the literature, ranging from splinting to resec-ion arthroplasty.1,3-5,9-35 Advances in arthroscopic technol-gy have allowed examination of the small joints throughouthe body with minimal morbidity.36 Synovitis, osteophytes,ractures, loose bodies, and ligamentous tears have been suc-essfully managed with the arthroscopic surgery. Moreover,rthroscopy has already been proven to be reliable for directvaluation of the first CMC joint.32 Recently, many authorsave described new portals to help further define the topo-raphic anatomy of this joint.37-39

The senior author (A.B.) has described an arthroscopiclassification for thumb CMC osteoarthritis that has thera-eutic implications when compared with radiographic clas-ification (Table 1).9 Arthroscopic assessment of the CMCoint facilitates easy identification and classification of the

iami Hand Center, Miami, FL.ddress reprint requests to Alejandro Badia, MD, FACS, Hand, Upper Ex-

tremity and Microsurgery, Miami Hand Center, 8905 SW 87th Avenue,
Suite #100, Miami, FL 33176. E-mail: [email protected]

oint pathology without compromising the capsular integrityf the joint. It allows direct visualization of all the compo-ents of the joint including synovium, articular surfaces, lig-ments, and the joint capsule9 and allows the pathology to bereated either arthroscopically or by an open procedure in theame sitting, as warranted by the initial arthroscopic assess-ent.

ndications for Arthroscopyrthroscopic evaluation of thumb CMC joint is indicated inll patients with basal joint arthritis who fail the conservativereatment, with the following exceptions:

1. Eaton stage IV arthritis with severe scapho-trapezial-trapezoid changes. In this situation, trapezial excisionalsuspensioplasty using a slip of abductor pollicis longusor arthrodesis is our preferred treatment.

2. Older, low-demand patients who are candidates forcemented total joint arthroplasty, as this requires min-imal immobilization and therapy.

3. Patients with severe adduction contracture of thethumb.

4. Younger patients with high demand, as in a manuallaborer. Arthrodesis may be a better option in this sit-
uation. Open insertion of an Artelon (Small Bone Inno-
125

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126 A. Badia and P. Khanchandani

vations, New York, NY) spacer in subluxed joint alsocan be considered.

5. Thumbs with severe CMC subluxation may not beamenable to arthroscopic techniques because this min-imally invasive technique does not enhance jointstability

able 1 Badia’s Arthroscopic Classification

Stage Arthroscopic Changes

I Intact articular cartilage. Disruption of thedorsoradial ligament and diffuse synovialatrophy. Inconsistent attenuation of theanterior oblique ligament (AOL)

II Frank eburnation of the articular cartilage on theulnar third of the base of first metacarpal andcentral third of the distal surface of trapezium.Disruption of the dorsoradial ligament andmore intense synovial hypertrophy. Constantattenuation of AOL.

III Widespread full-thickness cartilage loss with orwithout a peripheral rim on both articularsurfaces. Less severe synovitis. Frayed volarligaments with laxity.

Tigure 1 Insufflation of the first CMC joint after palpation.

rthroscopic andadiographic Correlation

rthroscopic stage I correlates with radiographic stage I. Ar-hroscopic stage II usually corresponds to radiographic stageI changes, but some radiographic stage I patients may dis-lay focal loss of articular cartilage consistent with arthro-copic stage II. Herein lays one of the great advantages of thisechnique. Only the rare case demonstrates less cartilageear than expected on the plain radiograph. Radiographic

tage III usually will reveal widespread cartilage loss whenrthroscopy is performed.

urgical Techniquehe procedure is performed under wrist block regional an-sthesia with tourniquet control. A single Chinese finger traps used on the thumb with 5 to 8 lbs of longitudinal traction.

shoulder holder, rather than traction tower, is used toacilitate easy use of flouroscopy. The thumb CMC joint isocalized by palpation. The incision for the 1-R (radial) portals placed just volar to the abductor pollicis longus tendon.

igure 2 Basal joint arthroscopy using ulnar viewing portal.

his portal is used for assessment of the dorsoradial ligament,

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Thumb carpometacarpal joint arthroscopy 127

osterior oblique ligament, and ulnar collateral ligament.he incision for the 1-U (ulnar) portal is made just ulnar to

he extensor pollicis brevis tendon. This portal is helpful forisualizing the anterior oblique ligament and ulnar collateraligament. Joint distension with 1 to 3 mL of normal salineFig. 1) facilitates the placement of a short-barreled, 1.9-mm0° arthroscope (Fig. 2). A full radius mechanical shaver withuction is used in all the cases, particularly for initial debride-ent.In arthroscopic stage I disease (Fig. 3), management

ncludes arthroscopic synovectomy using a 2.0 mechani-al shaver augmented with radiofrequency ablation. Liga-entous laxity and capsular attenuation are treated with

hermal capsulorraphy using a radiofrequency shrinkagerobe (Fig. 4). We are careful to avoid thermal necrosis

igure 3 Arthroscopic appearance of the first CMC joint showingynovitis in arthroscopic stage I disease.

igure 4 Arthroscopic view demonstrating thermal capsulorraphyith radiofrequency probe in corticosteroid laden capsule. Note the

ittenuation of the ligaments caused by the effect of steroids.

nd, hence, a stripping technique is more appropriate toighten the capsule of the lax joints. A short thumb spicaast is placed for 4 weeks, in the presence of dorsal sub-uxation. Lesser changes allow immediate mobilization ofhe thumb.

Arthroscopic stage II patients have focal wear of the artic-lar surface that requires a procedure to alter the forcescross the joint (Fig. 5). After arthroscopic synovectomy,ebridement, and occasional loose body removal, the joint

s reassessed to determine the extent of instability andapsular attenuation. A thermal shrinkage capsulorraphys performed to tighten the attenuated ligaments and cap-ule. A thermal chondroplasty is performed to anneal theartilage borders at the sites of cartilage erosions and fi-rillation. The arthroscope is then removed and the ulnarortal is extended distally to expose the metacarpal base. Aorsoradial closing wedge osteotomy is performed to placehe thumb in a more extended and abducted position,hich minimizes the tendency for subluxation and

hanges the contact points of worn articular cartilage (Fig.A). The osteotomy is fixed by a single oblique 0.0045-

nch Kirschner wire placed across the first CMC joint in aeduced position (Fig. 6B). A short arm thumb spica issed for 4 to 5 weeks until the wire is removed.Arthroscopic stage III disease is characterized by severe

artilage loss and frayed volar ligaments (Fig. 7). Thisondition requires an interposition procedure, an arthro-esis, or a joint replacement depending on the patient’sequirement and surgeon’s preference. For an interposi-ion procedure, an arthroscopic hemitrapezectomy is per-ormed by burring away the remaining articular cartilagend removing the subchondral bone to a bleeding surface.his technique not only increases the joint space but also

orms an organized thrombus, which helps stabilize the

igure 5 Arthroscopic view of arthroscopic stage II basal joint arthri-is. Note the deep cartilage loss on the metacarpal base and centralartilage loss on distal trapezium.

nterposition material. Ideally, approximately 3 to 4 mm of

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he distal trapezial articular surface should be resectedFig. 8). The interposition material can either be palmarisongus graft or the volar slip of the abductor pollicis lon-us (palmaris deficient patients). The graft is insertedhrough the dorsal portal with the arthroscope in the volarortal. The tendon end is brought into the trapeziometa-arpal joint using a large, smooth needle holder throughhe slightly enlarged dorsal portal (Fig. 9). The remainingendon is packed into the joint. The joint capsule and theortal are closed with a horizontal mattress stitch to min-

mize chance of tendon slip extrusion. A thumb spicaplint is applied at the end of the procedure and changedo a cast some days later. Alternatively, an Artelon spaceran be used as an interposition material, which also can be

igure 6 (A) Dorsoradial metacarpal osteotomy by extension of thelnar portal. (B) Centralizing K wire fixation of the metacarpal os-
eotomy. d
laced in the joint arthroscopically (Fig. 10A and B) orpen (when there is severe joint subluxation). In older,ow-demand patients, a cemented total joint replacements a good option. A resection arthroplasty or an arthrodesisan be performed in late stage III disease and stage IVisease depending on the extent of joint damage, patient’seeds and the surgeon’s preference.

iscussionlinical assessment and radiological studies have been thenly tools available to define for thumb CMC arthritis.aton and Glickel proposed a radiographic staging system

igure 7 Arthroscopic view showing arthroscopic stage III basal jointrthritis. Note the steroid deposition and intact cartilage rim in bothetacarpal base and the trapezium.

igure 8 Arthroscopic view of burr resection of trapezial subchon-
ral bone.

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or this disease that has been widely applied not only totage the disease but also to define treatment.1 Bettingernd coworkers described the trapezial tilt as a parameter toredict further progression of the basal joint disease.30 Weelieve that the radiographic classification is important forhe assessment of progression of this disease; however, it isery difficult to make an accurate diagnosis regarding thextent of arthritis by this method alone.

Arthroscopy has already proven to be reliable for the eval-ation of the thumb carpometacarpal joint.32 The arthro-copic classification proposed by the senior author (A.B.) fillshe niche of a suitable diagnostic modality for this commonnd disabling condition.9 This classification helps the sur-eon not only to reach an exact diagnosis but also to choosen appropriate treatment (Fig. 11).

We see patients who have thumb pain with normal radio-raphs that don’t respond to nonoperative treatment. Theseatients often have mild-to-moderate synovitis that respondso joint debridement with thermal capsulorraphy. The result-ng change in the joint milieu may even arrest further artic-lar cartilage loss.9

Tomaino concluded that first metacarpal extension os-eotomy is a good treatment option for Eaton stage I dis-ase.25,26 We find this technique to offer the greatest ben-fit to patients with focal cartilage loss as is seen inrthroscopic stage II (Fig. 12A and B). In a retrospective

igure 9 Technique of tendon interposition procedure. A slip ofbductor pollicis longus was used in this palmaris-deficient patient.

tudy of 43 thumbs in whom we performed extension C

steotomies, only one developed progressive arthritis, thatequired further surgery.9 Studies suggest that metaphy-eal osteotomy results in decompression of the medullaryanal and reactive hyperemia, which not only relieves theain but also retards the progression of arthritic destruc-ion of the joint.40,41

If arthroscopic evaluation depicts complete articularartilage loss, the next logical step is to perform a partialrapezial resection with an interposition procedure. Me-on described a technique for arthroscopic debridementf the trapezial articular surface and interposition of au-ogenous tendon or gortex into the CMC joint in pa-ients.31 We have modified this technique by resectingnly the most distal aspect of the trapezial articular sur-ace. An Artelon spacer for interposition is a good options it obviates the need for tendon procurement. Nilssonnd coworkers in their prospective study comparing ten-on interposition arthroplasty and Artelon spacer haveoncluded that Artelon is a non reactive material thatarkedly improved tripod and key pinch strengths, as

ompared with tendon interposition arthroplasty.35 Inummary, arthroscopic evaluation of the thumb CMC

igure 10 (A) Arthroscopic technique for Artelon insertion in firstMC joint. (B) Arthroscopic view of Artelon well placed in first
MC joint.


DORSAL SUBLUXATION

STABLE

ARTHROSCOPIC STAGE III • DIFFUSE ARTICULAR

WEAR

MIDDLE AGE, ELDERLY PT WITH AVERAGE ACTIVITY

YOUNG ACTIVE HEAVY WORKER

MILD SUBLUXATION

GROSSSUBLUXATION

ARTHRODESIS

THUMB BASAL JOINT PAIN

CMCARTHROSCOPY

ARTHROSCOPIC STAGE I • SYNOVITIS • INTACT ARTICULAR

CARTILAGE

ARTHROSCOPIC SYNOVECTOMY + ARTHROSCOPIC DEBRIDEMENT

ARTHROSCOPIC SYNOVECTOMY + ARTHROSCOPIC DEBRIDEMENT + THERMAL CAPSULORRAPHY

R

R

TRAPEZIOMETACARPAL OSTEOARTHRITIS CONFIRMED CLINICALLY AND RADIOGRAPHICALLY

ARTHROSCOPIC STAGE II • FOCAL ARTICULAR

WEAR

• ARTHROSCOPIC DEBRIDEMENT • SHRINKAGE CAPSULORRAPHY • EXTENSION ABDUCTION OSTEOTOMY

Ist METACARPAL BASE • THUMB SPICA CAST FOR 5 WEEKS

R

ELDERLY LOW DEMAND PATIENT

ARTHROSCOPIC ARTELON ORARTHROSCOPIC TENDON INTERPOSITION

OPEN ARTELON

TOTAL JOINT ARTHROPLASTY

EXCISIONAL ARTHROPLASTY

R

R

R

RADIOGRAPHIC STAGE I, II AND III

RADIOGRAPHIC STAGE IV WITH SEVERE STT JOINT ARTHRITIS

R - RECURRENCE

BASAL JOINT ARTHRITIS- TREATMENT ALGORITHM FLOW CHART

Figure 11 Flowchart showing the treatment algorithm of basal joint arthritis by arthroscopic assessment.

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oint defines the degree of cartilage loss and allows theurgeon to select further operative intervention.

eferences1. Eaton RG, Glickel SZ: Trapeziometacarpal osteoarthritis. Staging as a

rationale for treatment. Hand Clin 3:455-471, 19872. Barron OA, Glickel SZ, Eaton RG: Basal joint arthritis of the thumb.

J Am Acad Orthop Surg 8:314-323, 20003. Freedman DM, Eaton RG, Glickel SZ: Long-term results of volar liga-

ment reconstruction for symptomatic basal joint laxity. J Hand Surg[Am] 25:297-304, 2000

4. Eaton RG, Littler JW: Ligament reconstruction for the painful thumbcarpometacarpal joint. J Bone Joint Surg 55:1655-1666, 1973

5. Eaton RG, Lane LB, Littler JW, et al: Ligament reconstruction for thepainful thumb carpometacarpal joint: a long-term assessment. J HandSurg [Am] 9:692-699, 1984

6. Kuczynski K: Carpometacarpal joint of the human thumb. J Anat 118:119-126, 1974.

7. Pellegrini VD Jr: Osteoarthritis of the trapeziometacarpal joint:the pathophysiology of articular cartilage degeneration. I. Anatomy andpathology of the aging joint. J Hand Surg [Am] 16:967-974, 1991

8. Pellegrini VD Jr: Osteoarthritis of the trapeziometacarpal joint: thepathophysiology of articular cartilage degeneration. II. Articular wearpatterns in the osteoarthritic joint. J Hand Surg [Am] 16:975-982, 1991

9. Badia A: Trapeziometacarpal arthroscopy: A classification and treat-ment algorithm. Hand Clin 22:153-163, 2006

0. Wilson JN, Bossley CJ: Osteotomy in the treatment of osteoarthritisof the first carpometacarpal joint. J Bone Joint Surg Br 65:179-181,1983

1. Burton RI, Pellegrini VD Jr. Surgical management of basal joint arthritisof the thumb: Part II: Ligament reconstruction with tendon interposi-

Figure 12 (A) Preoperative radiograph showing the first Cshowing healed osteotomy and reduced joint after 3 monshown to maintain itself for long time.

tion arthroplasty. J Hand Surg [Am] 11:324-332, 1986

2. Eaton RG, Glickel SZ, Littler JW: Tendon interposition arthroplasty fordegenerative arthritis of the trapeziometacarpal joint of the thumb.J Hand Surg [Am] 10:645-654, 1985

3. Barron OA, Eaton RG: Save the trapezium: Double interposition arthro-plasty for the treatment of stage IV disease of the basal joint. J HandSurg [Am] 23:196-204, 1998

4. Swigart CR, Eaton RG, Glickel SZ: Splinting in the treatment of arthritisof the first carpometacarpal joint. J Hand Surg [Am] 24:86-91, 1999

5. Varley GW, Calvey J, Hunter JB, et al: Excision of the trapezium forosteoarthritis at the base of the thumb. J Bone Joint Surg Br 76:964-968,1994

6. Froimson AI: Tendon arthroplasty of the trapeziometacarpal joint. ClinOrthop 70:191-199, 1970

7. Tomaino MM, Pellegrini VD Jr, Burton RI: Arthroplasty of the basaljoint of the thumb: Long-term follow-up after ligament reconstructionwith tendon interposition. J Bone Joint Surg Am 77:346-355, 1995

8. Lins RE, Gelberman RH, McKeown L, et al: Basal joint arthritis: Trape-ziectomy with ligament reconstruction and tendon interposition ar-throplasty. J Hand Surg [Am] 21:202-209, 1996

9. Eaton RG: Replacement of the trapezium for arthritis of the basal artic-ulations: anew technique with stabilization tenodesis. J Bone Joint SurgAm 61:76-82, 1979

0. Diao E: Trapezio-metacarpal arthritis. Trapezium excision and liga-ment reconstruction not including the LRTI arthroplasty. Hand Clin17:223-236, 2001

1. Klimo GF, Verma RB, Baratz ME: The treatment of trapeziometacarpalarthritis with arthrodesis. Hand Clin 17:261-270, 2001

2. Fulton DB, Stern PJ: Trapeziometacarpal arthrodesis in primary osteo-arthritis: A minimum two-year follow-up study. J Hand Surg [Am]26:109-114, 2001

3. Lisanti M, Rosati M, Spagnolli G, et al: Trapeziometacarpal joint arth-rodesis for osteoarthritis. Results of power staple fixation J Hand Surg

int subluxation in stage II. (B) Postoperative radiographthe osteotomy. This metacarpal centralization has been

MC joths of

[Br] 22:576-579, 1997

2

2

2

2

2

2

3

3

3

3

3

3

3

3

3

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4

4


4. Wilson JN: Basal osteotomy of the first metacarpal in the treatment ofarthritis of the carpometacarpal of the thumb. Br J Surg 60:854-858,1973

5. Tomaino MM: Treatment of Eaton stage I trapeziometacarpal disease.Ligament reconstruction or thumb metacarpal extension osteotomy?Hand Clin 17:197-205, 2001

6. Tomaino MM: Treatment of Eaton stage I trapeziometacarpal diseasewith thumb metacarpal extension osteotomy. J Hand Surg [Am] 25:1100-1106, 2000

7. Hobby JL, Lyall HA, Meggitt BF: First metacarpal osteotomy for trape-ziometacarpal osteoarthritis. J Bone Joint Surg Br 80:508-512, 1998

8. Holmberg J, Lundborg G: Osteotomy of the first metacarpal for osteo-arthrosis of the basal joints of the thumb. Scand J Plast Reconstr SurgHand Surg 30:67-70, 1996

9. Molitor PJ, Emery RJ, Meggitt BF: First metacarpal osteotomy for carpo-metacarpal osteoarthritis. J Hand Surg [Br] 16:424-427, 1991

0. Bettinger PC, Linscheid RL, Cooney WP III, et al: Trapezial tilt: Aradiographic correlation with advanced trapeziometacarpal arthritis.J Hand Surg [Am] 26:692-697, 2001

1. Menon J: Arthroscopic management of trapeziometacarpal joint arthri-tis of the thumb. Arthroscopy 12:581-587, 1996

2. Berger RA: A technique for arthroscopic evaluation of the first carpo-metacarpal joint. J Hand Surg [Am] 22:1077-1080, 1997

3. Badia A, Young L, Riano F: “Bilateral arthroscopic tendon interposition
arthroplasty of the thumb carpometacarpal joint in a patient with
Ehlers-Danlos syndrome: A case report.” J Hand Surg [Am] 30:673-676, 2005

4. Kriegs-Au G, Petje G, Fojtl E, et al: Ligament reconstruction with orwithout tendon interposition to treat primary thumb carpometacarpalosteoarthritis. A prospective randomized study. J Bone Joint Surg Am86:209-218, 2004

5. Nilsson A, Liljensten E, et al: Results from a degradable TMC jointspacer (Artelon) compared with tendon arthroplasty. J Hand Surg [Am]30:380-389, 2005

6. Chen YC: Arthroscopy of the wrist and finger joints. Orthop Clin NorthAm 10:723-733, 1979

7. Bettinger PC, Berger RA: Functional ligamentous anatomy of the trape-zium and trapeziometacarpal joint (gross and arthroscopic). Hand Clin(Thumb Arthritis) 17:151-169, 2001

8. Orellana MA, Chow JC: Arthroscopic visualization of the thumb car-pometacarpal joint: introduction and evaluation of a new radial portal.Arthroscopy 19:583-591, 2003

9. Walsh EF, Akelman E, Fleming BC, et al: Thumb carpometacarpalarthroscopy: A topographic, anatomic study of the thenar portal.J Hand Surg [Am] 30:373-379, 2005

0. Arnoldi CC, Lempberg RK, Linderholm H: Immediate effect of osteot-omy on the intramedullary pressure of the femoral head and neck inpatients with degenerative osteoarthritis. Acta Orthop Scand 42:357-65, 1975

1. Illarramendi AA, De Carli P: Radius decompression for treatment of
kienbock disease. Tech Hand Up Extrem Surg 7:110-113, 2003

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rthroscopy of the Metacarpophalangeal Jointennifer Erdos, MD,* Caitlin Gannon, BS,* and Mark E. Baratz, MD*,†

The use of arthroscopy in the diagnosis and treatment of disorders involving small joints isgrowing. In 1979, Chen was the first to describe arthroscopy of the metacarpophalangeal(MP) joint for arthroscopic synovectomy in a patient with rheumatoid synovitis (Chen,Orthop Clin North Am 10:723-733, 1979). Since then, MP joint arthroscopy has been usedto release contractures, reduce Stener lesions, and assist in the reduction of intra-articularfractures. This work describes the technique for MP arthroscopy with a review of ourexperience in 20 patients.Oper Tech Orthop 17:133-139 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS metacarpophalangeal joint, arthroscopy, synovectomy, intra-articular fractures,debridement

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he use of arthroscopy in the diagnosis and treatment ofmetacarpophalangeal (MP) joint disorders is growing as

urgeons become more comfortable with small joint arthro-copy. The first account of MP joint arthroscopy was by Chenn 1979, when he reported on arthroscopic synovectomy for

patient with rheumatoid arthritis.1 Since then, MP jointrthroscopy has been used to release contractures, reduceisplaced ruptured ulnar collateral ligaments, and assist inhe reduction of intra-articular fractures.2-8 Arthroscopy ofhe MP joint provides an excellent view of the joint withouteleasing the sagittal band of the extensor hood. Motion cane started immediately, dramatically shortening the period of

nfirmity and rehabilitation.6,8

ndicationshe indications for MP joint arthroscopy include synovec-

omy, removal of foreign or loose bodies, capsular debride-ent and release, debridement of osteochondral lesions,

reatment of intra-articular fractures, reduction of acutelyuptured and displaced ulnar collateral ligament tears, andreatment for a locked MP joint.7 Patients with inflammatoryrthritis are particularly well suited to arthroscopic synovec-omy. The diagnosis is easily confirmed on examination. Weecommend synovectomy after failed treatment with anti-nflammatory agents, including oral nonsteroidal drugs, dis-ase-modifying drugs, and intra-articular injection of ste-

Allegheny General Hospital, Pittsburgh, PA.Department of Orthopaedic Surgery, Drexel University College of Medi-

cine, Philadelphia, PA.ddress reprint requests to Jennifer Erdos, MD, 1307 Federal St., 2nd Floor,

gPittsburgh, PA, 15212. E-mail: [email protected]


oids. The collateral ligaments are usually lax and the capsuleatulous, 2 factors that permit easy access to the joint andasy maneuverability once within the joint. Arthroscopy isore challenging in joints with post-traumatic contractures.he joint space is small. Care must be taken to avoid damag-

ng the joint surfaces while introducing and maneuvering theannula and shaver.

echniquehe procedure usually is performed under local anesthesiaith sedation. Before the procedure, a single dose of antibi-tics is administered. The patient is placed in the supineosition with the affected arm on a hand table with the shoul-er abducted and the elbow flexed at 90°. A tourniquet islaced on the upper arm and preset to 250 mm Hg. The arm

s prepped and draped. The affected finger is placed in fingerraps and suspended in a traction tower with 5 to 10 poundsf traction. Coban (3 mol/L) elastic wrap can be used to helpecure smaller digits (Fig. 1). Use of a tourniquet is optional.

The extensor tendon(s) are palpated on the dorsal surfacef the MP joint. The “soft-spots” are marked dorsal to theoint and radial and ulnar to the extensor tendons. The joints filled with saline using a 25-gauge needle. Based on theurgeon’s preference, either the radial or the ulnar portal isstablished first. Through a 2- to 3-mm transverse skin inci-ion, the joint is entered using a small, curved hemostat fol-owed by a cannula with blunt probe. A 1.9-mm arthroscopes placed through the cannula into joint. Under direct arthro-copic visualization, an 18-gauge needle is introduced intohe joint opposite the initial portal, just radial or ulnar to thextensor tendon. For initial inspection of the joint, the 18-
auge needle serves as an outflow. Further joint distention is
133

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134 J. Erdos, C. Gannon, and M.E. Baratz

ccomplished by adding additional fluid through the needleFig. 2). The orientation of the needle within the joint defineshe orientation for instruments placed through the same por-al. The 18-gauge needle is removed and, using the technique

Figure 1 Set-up for MP joint arthroscopy of the small fingcannula is in the radial portal. (Color version of figure i

Figure 2 Saline is introduced into middle finger MP joint
figure is available online.)
escribed previously, the second portal is established (Fig.). A 2.5-mm full-radius resector is used to debride synovitisr release the joint capsule. These same tasks can be per-ormed with a 2.3-mm underwater bovie (ie, Mitek VAPR,

oint. The arthroscope is in the ulnar portal. The outflowble online.)

ial portal to increase joint distension. (Color version of

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Arthroscopy of the metacarpophalangeal joint 135

orwood, MA). An 18-gauge needle also can be used as acalpel to assist in the release of capsule or collateral liga-ents. The same small joint arthroscopic instruments used inrist arthroscopy, such as a probe or grasper, can be used inP joint arthroscopy. After completion of the procedures,

he portals are loosely closed with 4-O nylon and the woundovered in a nonconstrictive dressing.

echnical Pointshere are several technical points that we find useful in per-

orming safe and effective MP arthroscopy.

oint 1n establishing the portals, caution should be taken to avoidnjury to the extensor tendon. Be sure the incision is lateral tohe tendon and incise only skin.

oint 2n understanding of the MP joint anatomy is needed to per-

orming an adequate and safe arthroscopy and debridement.ozmaryn and colleagues provided a comprehensive reviewf the arthroscopic anatomy of the MP joint.7 A systematicpproach should be taken in performing an arthroscopic de-ridement. First, the cartilage surfaces of the metacarpal andhe proximal phalanx should be inspected for arthritis orther chondral lesions. Both the ulnar and radial sides of theoints should be visualized, with care to fully visualize thelnar and radial recesses, which contain synovium that mayeed to be removed. In addition, the dorsal capsule, collateral

igaments, and volar plate should be inspected.

oint 3are should be taken to avoid damage to the cartilage with

Figure 3 A radial portal is created with a curved

he instruments because the MP joint is such a small working s

pace. Use the orientation of an 18-gaug needle to help definesafe position for placing instruments. One should

choke-up” on the arthroscope and instruments (Fig. 4); fineovements help the surgeon to avoid scratching the joint

urface and help keep the scope from slipping out. The por-als for the arthroscope and the instruments should bewitched. The radial side of the joint is debrided with thecope in the ulnar portal and vice versa.

oint 4emember the intimate relationship between the dorsal cap-ule and the extensor tendon during release of the dorsalapsule. If you see tendon, the capsule has been fully re-eased. It is less obvious than is seen when releasing the dorsalapsule during wrist arthroscopy. Proceed with caution.

oint 5e recommend the use of an underwater bovie (ie, Mitek

APR, Norwood, MA) to assist in synovectomies, especially inatients with inflammatory disorders. To avoid heat injury tohe joint and the camera lens, use a low setting, short blasts, andontinuous outflow through an 18-gauge needle (Fig. 5).

ase Reporthe fifth finger MP joint of a 19-year-old male was puncturedith a thorn when he slid-out on his dirt bike. Before evaluation

n our office, he had been seen on 2 occasions in emergencyepartments for pain and swelling. He had been treated with 2ourses of antibiotics, neither of which alleviated his symptoms.n examination, his joint was “boggy” and tender; however,

here was no erythema (Fig. 6). He had full motion of the MPoint with minimal discomfort. An injection of cortisone into the

P reduced his pain and swelling; however, 6 weeks later, both

tat. (Color version of figure is available online.)

ymptoms recurred. The use of magnetic resonance imaging

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howed evidence of a synovitic reaction with mild signalhanges within the metacarpal head (Fig. 7).

The portal radial and ulnar to the extensor pollicis bre-is and extensor pollicis longus (EPL) was created as de-cribed in the aforementioned technique (Fig. 1). Theoint was entered with a curved hemostat and then withhe cannula using a blunt probe. The joint was inspected.here was evidence of a full-thickness defect on the pal-ar aspect of the proximal phalanx. There were numerous

mall shards of cartilage within the joint. An accessoryortal was established ulnar to the EPL and through thatas placed first an 18-gauge needle and then a hemostat

Figure 4 “Choking up” on arthroscope and instruments hversion of figure is available online.)

Figure 5 An 18-gauge needle used as outflow to minimiz
version of figure is available online.)
ollowed by a full-radius resector. With the full-radiusesector, all of the small fragments of cartilage were fullyebrided. Inflamed synovium was present in both radialnd ulnar gutters (Fig. 8). Synovitis on the radial side wasemoved with the arthroscope in the ulnar portal and thehaver in the radial portal (Fig. 9). The scope and shaverere switched to remove synovitis from the ulnar side

Fig. 10). After the debridement, the thumb was stable.he portals were loosely closed with 4-O nylon and aterile dressing was applied. Motion was permitted imme-iately. The patient had a remarkable recovery. He has noain, full motion, and is not limited in any activity.

improve control while working in small spaces. (Color

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linical Seriesince 1997, the senior author has performed metacarpopha-angeal arthroscopy on 20 patients. The ages of the patientsanged from 17 to 60 years. Nine patients had surgery fornflammatory arthritis, 7 for rheumatoid arthritis, 1 for gout,nd 1 for thorn synovitis, as described previously. Six pa-ients had residual effects from trauma, and 2 from intra-rticular fractures. Two of the 6 with an injury were hurthile playing volleyball. Five patients underwent arthros-

opy of finger MP joints for symptomatic osteoarthritis.hree patients had arthroscopy of thumb MP joints and 17

Figure 6 Painful and swollen MP joint of the small finge

igure 7 Magnetic resonance imaging shows a synovitic reaction of
he MP joint. F
n finger MP joints. All patients had not improved underonoperative treatment, including at least one injection oforticosteroid. The procedures were performed under localnesthesia with sedation. All procedures were performedith 1.9-mm arthroscope and traction, in most cases, using a

raction tower.An excellent view of the joint was obtained in all cases.

ynovectomy alone was performed in 14 cases. In a patientith rheumatoid synovitis of the thumb MP joint and asso-

iated joint laxity, the thumb was pinned in a reduced posi-ion for 4 weeks. A spicule of bone on the joint margin wasebrided in a patient treated for a stiff joint following an

ntra-articular fracture (Figs. 11 and 12). We were unsuccess-

igure 8 Synovitis of the MP joint is shown.

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ul in our attempt to pin with arthroscopic-assistance an in-ra-articular avulsion fracture off the palmer–ulnar margin ofhe proximal phalanx of an index finger. The fracture wasasy to see, debride, and reduce; however, capturing andinning the fracture exceeded our technical abilities and wasreated with open reduction and pinning. In 2 cases, a releasef the dorsal capsule was attempted to improve flexion. Thisrocedure was successfully performed in one case. In theecond, a patient with marked stiffness from osteoarthritis,

igure 9 A full-radius resector in the MP joint is used to perform aynovial debridement. (Color version of figure is available online.)

igure 10 MP joint after synovectomy. (Color version of figure is
Mvailable online.)
e were unable to improve flexion with either arthroscopicr a concurrent open release.Relief of pain and swelling was excellent in all patients

reated with synovectomy for inflammatory arthritis. Re-ief with rapid return to activity was particularly evident inself-employed carpenter, who was able to return to workdays after arthroscopic synovectomy of the middle fingerP joint on his dominant hand. Marginal or no benefit was

ealized in patients who underwent joint debridement forsteoarthrosis. Mixed results also were seen in patientsreated after traumatic injuries. Dramatic improvementas noted in a 34-year-old woman who underwent arthro-

copic releases of a stiff MP joint resulting from prolongedmmobilization for a palmer plate injury. The thumb wasxed in 15° of thumb MP hyperextension. Arthroscopicelease of the dorsal capsule and dorsal half of the collat-ral ligament was performed with a shaver. Full motionas achieved intra-operatively. Rehabilitation proceeded

lowly, but by 4 months the patient had achieved a 35° arc� 5–30°) of motion at the MP joint and the patient wasthrilled” with her result.

iscussionn 1987, Wilkes performed arthroscopic synovectomy on 13

igure 11 Spicule on fourth finger metacarpal head in depressed,alunited, intra-articular metacarpal head fracture is shown.

P joints in 5 rheumatoid patients who all obtained tempo-

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ary relief of symptoms.2 In 2002, Sekiya and coworkersssessed the value of arthroscopy of the PIP and MP joints in1 rheumatoid patients. They concluded that arthroscopy is

igure 12 Fourth finger metacarpal head after an arthroscopic exci-ion of an intra-articular spicule of bone.

seful in assessing the articular cartilage and synovium and

hat arthroscopic synovectomy can be performed safely.5 De-lercq and coworkers reported on motion after open versusrthroscopic debridement and release in a patient who had 3oints treated for pain and stiffness associated with hemo-hromatosis. Better motion was achieved in the 2 joints thatere debrided and released with arthroscopy compared with

ingle joint treated with open arthrotomy.3 MP joint arthro-copy also has been used in the treatment of gamekeeper’shumbs. Ryu and Fagan successfully treated eight patientsith acute, complete ruptures of the ulnar collateral ligamenty arthroscopically reducing the ulnar collateral ligament to

ts origin and pinning the joint with a Kirschner wire.4

onclusionP joint arthroscopy is being used with increasing frequency

n the treatment of MP joint disorders. Although there are aumber of indications, arthroscopic treatment of inflamma-ory synovitis is the easiest to perform and has the mostredictably favorable outcome.

eferences. Chen YC: Arthroscopy of the wrist and finger joints. Orthop Clin North

Am 10:723-733, 1979. Wilkes LL: Arthroscopic synovectomy in the rheumatoid metacarpopha-

langeal joint. J Med Assoc GA 76:638-639, 1987. Declercq G, Schmitgen G, Verstreken J: Arthroscopic treatment of meta-

carpophalangeal arthropathy in haemochromatosis. J Hand Surg [Br]19:212-214, 1994

. Ryu J, Fagan R: Arthroscopic treatment of acute complete metacarpo-phalangeal ulnar collateral ligament tears. J Hand Surg (Am) 20:1037-1042, 1995

. Sekiya I, Kobayashi M, Tenada W, et al: Arthrscopy of the proximalinterphalangeal and metacarpophalangeal joints in rheumatoid hands.Arthroscopy 18:292-297, 2002

. Rozmaryn LM, Wei N: Metacarpophalangeal arthroscopy. Arthroscopy15:333-337, 1999

. Rozmaryn LM, Lamott K, Crawford P: Metacarpophalangeal arthros-copy: technique and Indications. Tech Hand Up Extrem Surg 4:167-175, 2000

. Wei N, Delauter SK, et al: Arthroscopic synovectomy of the metacarpo-phalangeal joint in refractory rheumatoid arthritis: a technique. Arthro-
scopy 15:265-268, 1999

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rthrodesis of the Distalnterphalangeal Joint Using a Headless Screwavid C. Rehak, MD

Distal interphalangeal joint fusion is a procedure used to achieve stability, to restore handfunction, to relieve pain, and to correct deformity. A successful arthrodesis depends oncareful preparation of the joint surfaces, careful positioning, and accurate placement of thefixation. There are multiple fixation techniques described in the literature: the author’spreferred technique involves the use of a headless screw.Oper Tech Orthop 17:140-147 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS arthrodesis, finger, distal interphalangeal joint, headless screw, arthritis

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he primary functions of the distal interphalangeal (DIP)joint are to provide a stable, painless joint for pinch

particularly the index and middle digits) and to provideexion for grasp (particularly the ring and little fingers). Pa-hology of the DIP joint resulting in pain or instability canompromise function. When this joint is damaged to such aegree that nonoperative treatment or reconstruction is noteasible, arthrodesis may be the best option to restore handunction. A painless, stable, properly positioned DIP joint is

ore important than motion. Despite the loss of motion, theunction of a hand with a painful DIP joint can be dramati-ally improved with arthrodesis.1

istory andoals of Arthrodesis

here are multiple implants and techniques for performingrthrodesis of the DIP joint, including Kirschner wires, in-erosseous wiring, plates and screws, tension band wiring,nterfragmentary compression screws, headless screws, bio-bsorbable rods and pins, and external fixators.1,2 All haveeen shown to have similar results and complications.3,4 Noingle method has been shown to be superior to others oravored by a majority of surgeons.2 Screws have been re-orted to have favorable results.5,6 The goal of any arthrode-is technique is to provide a painless stable union with properositioning in a reasonable length of time.7 The techniquehosen to achieve this goal should be simple to perform, be

he Hughston Clinic, Columbus, GA.ddress reprint requests to David C. Rehak, MD, The Hughston Clinic, 6262

Veterans Parkway, Columbus, Georgia, 31908-9517. E-mail: rehakdc@
pyahoo.com

eproducible, and provide rigid internal fixation, allowingarly range of motion of the more proximal joints. Postoper-tive care and rehabilitation can also be influenced by theype of fixation chosen.

ndications for Arthrodesisndications for arthrodesis of the DIP joint include pain, in-tability, and deformity of the joint. These symptoms areost commonly caused by degenerative osteoarthritis, pri-ary or secondary (trauma), and inflammatory arthritis, in-

luding rheumatoid arthritis. Patients with swan-neck andoutonniere deformities can occasionally benefit from arth-odesis of the DIP joint.8 Deformity also can be a relativendication. However, a deformed joint that is painless andas maintained motion and stability can often provide excel-

ent function.

ontraindicationsontraindications to arthrodesis are poor skin condition and

nsufficient bone stock. The use of bone grafting9 may help inases of deficient bone stock. Grafting is rarely needed inatients with osteoporosis.10

urgical Planninghe condition of the soft-tissue envelope should be evaluatedarefully, particularly in cases of inflammatory arthritis andrevious trauma. Radiographs in the anteroposterior, lateral,nd both oblique planes should be obtained to examine theone quality, deformity, and presence or absence of osteo-
hytes.

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Arthrodesis of the distal interphalangeal joint using a headless screw 141

The anteroposterior diameter of the distal phalanx—and atimes the middle phalanx at the isthmus—is the limitingactor with respect to the size of an intramedullary implant.he narrowest point can be measured to help determine im-lant selection. The middle phalanx also should be assessedor previous procedures using internal fixation and to deter-

ine whether future reconstruction of the proximal inter-halangeal (PIP) joint may be necessary. If internal fixationas been placed in the intramedullary canal of the middlehalanx, using a long intramedullary screw for arthrodesis ofhe DIP joint could be contraindicated. If a joint arthroplastyr other reconstructive procedure is anticipated for the PIPoint in which the implant would occupy a significant portionf the intramedullary space of the middle phalanx, a longntramedullary headless screw could again be contraindi-ated. In these situations, other forms of fixation should beonsidered.

eadless Compression Screwsultiple headless compression screws are on the market:cutrak Screw System (Accumed Systems, Inc., Ann Arbor, MI),.0-mm Headless Compression Screw (Synthes, Inc., West

Figure 1 Preparation of the bone surface should result inthe longitudinal axis.

hester, PA), TwinFix 3.2-mm Cannulated Compression fi

crew System (Stryker, Kalamazoo, MI), Kompressor Com-ression Screw System (KMI, San Diego, CA), and Herbertannulated Bone Screw (Zimmer, Warsaw, IN). The featureommon to all of them is that they are designed to provideompression between 2 segments of bone while being com-letely contained within the bone. Although these screws haveore similarities than differences, they have individual design

haracteristics that result in some unique differences in applica-ion and use. The Acutrak screw is completely threaded along itsntire length. It comes in multiple diameters—the smallest ofhich is the fusion screw. The fusion screw and the Mini are

he 2 most common sizes used for this technique. The fusioncrew is always used in smaller digits, particularly in the littlenger. Unlike all other Acutrak screws, the fusion screw isolid not cannulated; however, the surgical technique is iden-ical except the final screw placement is performed withoutse of a guide wire. The Mini screw can be used in largerigits. This is a cannulated screw that comes in lengths up to0 millimeters. The Standard screw can be used for larger

oints, such as the interphalangeal joint of the thumb. Occa-ionally, in very large thumbs and individuals with osteopo-otic bone, the 4/5 screw can be helpful. When in doubt, themaller-sized screw should always be selected. If inadequate

flat surface of cancellous bone that is perpendicular to
a large
xation results, a larger screw can be substituted.

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The technique described here encourages the use of theongest screw possible. It combines features of a compressioncrew with an intramedullary rod. In addition, the larger thecrew, the better the chance the threads have to engage thesthmus of the middle phalanx and provide extremely rigidxation. The fully threaded design of the Acutrak screw al-

ows advancement of the screw tip past the isthmus withoutosing fixation.11 However, if reconstruction of the PIP jointas been or may be needed subsequently and a headlesscrew is desired, a Herbert-type screw with leading and trail-ng threads, where the leading threads end at the isthmus,

ay be a better choice for fixation.

urgical Techniquehe patient is positioned supine with the arm extended on anrm board. Anesthesia typically is administered via a digitallock combined with intravenous sedation and monitorednesthesia care. Regional or general anesthesia is also accept-ble. A tourniquet is placed on the finger, forearm, or upperrm depending on the anesthesia technique. The arm is pre-ared and draped in the usual sterile manner and intravenousntibiotics are administered.

Multiple incisions have been described for this procedure.1

orsal incisions are preferred.1 Full-thickness flaps are ele-ated directly from the extensor tendon. The dorsal veinshould be identified and cauterized with bipolar electrocau-ery. The extensor tendon should be transected proximal tohe joint and preserved for later repair. Next, a dorsal arth-otomy is done, and the joint is hyperflexed as the collateraligaments are released. It is important to stay dorsal to the

idlateral line to avoid damage to the neurovascular struc-ures, which lie just volar to this level. The skin is very closeo the proximal aspect of the distal phalanx, and great carehould be taken to elevate the soft tissue from the base of the

Figure 2 Place the pin in the middle phalanx by

istal phalanx. The nail matrix is at the level of the extensor a

endon insertion and should be protected. If there is no sig-ificant deformity, it may be helpful to mark the rotationcross the dorsal aspect of the joint before releasing the col-ateral ligaments. This maneuver can aid the surgeon in de-ermining rotation during final fixation.

osition of Arthrodesishe DIP joint should be fused in 0° of flexion without radialr ulnar deviation. Slight supination of the index and middlengers may be appropriate; however, in general, the rotationf the digits should be based on the bordering digits. One ofhe benefits of a long intramedullary longitudinal screw ishat the position in the sagittal and coronal planes is easilychieved with proper initial pin placement and rotation isasily adjusted during screw insertion.

one Preparationither the middle or the distal phalanx can be prepared first.t is often easier to first remove the condyles of the middlehalanx to aid in exposing the base of the distal phalanx. Theondyles of the middle phalanx are removed with a saw orongeur. A flat cut is made perpendicular to the longitudinalxis of the middle phalanx with a large surface area of can-ellous bone (Fig. 1).12 Osteophytes are removed. Dissectionround the proximal aspect of the distal phalanx is carefullyerformed while protecting the skin, nail matrix, and theolar structures. Occasionally, a small sesamoid is presentnd can be removed if it hinders reduction. A small rongeurs used to prepare the articular surface, which should be flat,xposing the largest surface area of cancellous bone as possi-le, and perpendicular to the longitudinal axis of the bone.he size of the bone here is often small, and, if there is aeficit from erosion or deformity, it is often easier to contourhe cut of the middle phalanx to match the deficit than it is tory to get two perfectly flat perpendicular surfaces. A cup-

ing it in the anteroposterior and lateral planes.

nd-cone configuration for bone surface preparation is also

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n option, however, it is somewhat more difficult, particu-arly with the small surface of the distal phalanx.8 In addition,his technique does not offer much advantage over perpen-icular cuts because the arthrodesis is positioned withoutexion. Bone grafting is rarely necessary, but it can be used inatients with significant bone loss. Once the 2 surfaces haveeen prepared, they should be assessed visually and fluoro-copically. When the bone surfaces are reduced, they shouldave complete contact over the entire surface area of bothones. Osteophytes can be misleading and should be re-oved. Up to this point in the procedure, the technique is the

ame for almost any type of fixation chosen.Next, the preliminary intramedullary guide pin is placed

nto the middle phalanx (Fig. 2). The key to using a headlesscrew system for a DIP arthrodesis is proper positioning ofhe guide wires before drilling or screw placement. Properositioning will almost guarantee appropriate alignment inhe sagittal and coronal planes. The pin should be placed inhe exact center in both the anteroposterior and laterallanes. The bone in this region is often extremely soft, andhe pin can be placed manually. However, in more denseone, power may be required. The medial-lateral center inhe coronal plane is easily determined visually; however, thenteroposterior placement of the pin in the sagittal plane cane more difficult, and fluoroscopy is used to position the pin

n the center of the middle phalanx. Once the pin is posi-ioned, it provides a pilot guide hole for subsequent drill orcrew placement, or both. Next, the distal aspect of the mid-

Figure 3 Initial guide pin placement through the distal phand lateral planes and advance the pin through the tip o

le phalanx can be drilled. The Acutrak II is a self-drilling and v

elf-tapping screw, and drilling is not necessary. However, alightly larger pilot hole with the drill can be made, particu-arly in more dense bone, to aid in final screw placement.ven when screw systems that are not self-drilling and self-

apping are used, only minimal drilling is needed. This bones often very osteoporotic and screws pass without difficulty.n dense bone, drill only into but not past the isthmus. Do notverdrill or drill to the anticipated screw length. Next, theuide pin is removed. It is important to understand that thisechnique varies from the typical bone preparation for a com-

egins proximally. Center the pin in the anteroposteriornger.

igure 4 To measure the screw, place the Acutrak screw directly onr beside the digit and assess it visually and fluoroscopically. (Color

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ression screw in that each bone is prepared individuallyefore the final reduction.

istal Phalanx Guide Pin Placementhe guide pin is then placed from proximal to distal through

he distal phalanx (Fig. 3). It is much easier to place the guidein through the exact center of the arthrodesis surface of theistal phalanx by starting proximally. Again, the lateral ra-iograph can be extremely helpful in placing this pin in the

ntramedullary canal, particularly through its most narrowortion. Very careful advancement of this pin with fluoro-copic control is essential. The pin should exit the tip of thenger just volar to the nail. The dorsal cortex should be

Figure 5 With the guide pin in place, assess the final refluoroscopy in the anteroposterior and lateral planes.

voided, and if necessary, the pin can be placed slightly vo- t

arly. One potential complication is fracture through the dor-al cortex during drilling and screw placement. However,ith careful pin placement and proper screw size selection,

his complication can be avoided. Once acceptable position-ng of the pin is confirmed, a small incision is made in the tipf the finger where the pin exits to allow for atraumatic dril-ing and screw insertion. At this point, the drill can be used.rilling is performed in the direction of screw placementeginning at the tip of the finger. Again, the Acutrak II is aelf-drilling and self-tapping screw; however, it is often help-ul to perform limited drilling to aid in screw insertion. Theusion screw is not self-drilling, but it will often advanceasily in osteoporotic bone with little drilling. It is important

n and alignment of the surface of the arthrodesis with
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o remember that if the drill is used, it should only be inserted

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ntil the tip of the drill just exits the proximal aspect of theistal phalanx: complete drilling to the anticipated length ofhe screw is usually not done. The guide pin is removed. Theounds are copiously irrigated with antibiotic containing

olution.The length of the screw can be measured in several ways.

he actual screws from the Acutrak II set can be placed on orext to the digit and viewed with fluoroscopy (Fig. 4). Theuide wire can also be measured or the measuring device cane used. If the fusion screw is used, it is almost always 24 mm.The guidewire, if necessary, is placed in a retrograde man-

er through the tip of the finger and distal phalanx across therthrodesis site and into the middle phalanx (Fig. 5). It is

Figure 6 Insert the screw by applying compression acrofrom the screwdriver.

xtremely important to check the position of this wire with b

uoroscopy before inserting the screw to ensure that it reen-ered the previous tract. The fusion screw is not cannulated,owever, the narrow diameter of the middle phalanx willuide the screw along with the guide hole. The screw is thennserted with the screwdriver (Fig. 6). It is easier to place thecrew in the distal phalanx and advance it until the tipeaches the proximal aspect of the distal phalanx before per-orming the reduction. At this point, the bones are reducednd manual compression is placed across the arthrodesis sitend additional compression is applied with a longitudinalorce through the screwdriver. The rotation initially is setsing visual inspection and the previously placed dorsalarkings, if present. Compression of the arthrodesis site can

rthrodesis site manually along with longitudinal force
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hile applying manual compression across the site, addi-ional compression can be accomplished with the screw-river while advancing the screw. As the surgeon maintainshe correct rotation, the screw is advanced until it obtainsood purchase and the arthrodesis site appears to be stable.t this point, the construct can be checked with fluoroscopy.he rotation of the digits is checked visually and with fullexion of all of the digits simultaneously through the MP andIP joints. With all the finger joints flexed simultaneously,he rotation should follow the alignment of the borderingigits. The screw is advanced until the threads engage the

sthmus. Once this is achieved, rigid internal fixation is ac-omplished. If there is rotational malalignment, the screwan be backed out, the rotation adjusted, and the screw re-pplied. If the position of the screw and arthrodesis are ac-eptable, the screwdriver and guide wire can be removed.inal radiographs are then obtained.After the tourniquet is deflated, homeostasis is obtained,

nd the vascularity of the finger is assessed, the extensorendon is repaired. The skin is closed in a routine fashion,nd a sterile dressing is applied. A splint is not usually nec-

Figure 7 Shown are (A) anteroposterior and (B) laterainterphalangeal joint of the ring finger of the right hand

ssary; however, one can be applied across the DIP joint. It is p

mportant to leave the proximal interphalangeal joint free totart early range of motion.

ostoperative Managementatients return to clinic within 1 to 2 weeks for removal of theutures and initiation of therapy. If rigid internal fixation haseen achieved, a splint is not absolutely necessary; however,ne is often provided for protection across the DIP joint. TheIP joint is never splinted and early active and passive rangef motion of the PIP joint is encouraged. The splint can beemoved for bathing and at other times for exercise. Therapyan be helpful for edema control, splint fabrication, and earlyange of motion of the MP and PIP joints. Union usuallyccurs within 4 to 8 weeks (Fig. 7).The key difference in this surgical technique is that the

ones are each prepared separately for the screw placement,nd the bone surfaces are not reduced to each other duringin placement and drilling. In addition, the initial guide pinor the distal phalanx is placed in an antegrade fashion, op-

graphic views 7 weeks after arthrodesis of the distal0-year-old female patient.

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osite to the direction of the screw placement.

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omplicationsnfection is a rare complication. Nonunion has been reportedor all techniques of arthrodesis, and the rates are essentiallyhe same for all forms of fixation.3,4 Fracture through theorsal cortex of the distal phalanx can occur at its most nar-ow anteroposterior diameter beneath the nail leading to naileformity and possible infection.11 This complication can bevoided with proper pin placement and an appropriate sizedcrew.

onclusionrthrodesis of the distal interphalangeal joint can bechieved using the Acutrak headless screw system. The tech-ique described is simple, reproducible, and provides earlyigid internal fixation that allows early range of motion and auccessful union. The technique described here has relativelyew complications, and patients have been extremely satisfiedith the surgery.

eferences1. TW Kiesler: Osteoarthritis of the hand and digits: distal and proximal

interphalangeal joints, in Berger R, Weiss A-PC (eds): Hand Surgery,

vol 2. Philadelphia, Lippincott Williams & Wilkins, 2004, pp1253-1268

2. AJ Weiland: Small joint arthrodesis, in Green DP, Hotchkiss RN, Ped-erson WC (eds): Green’s Operative Hand Surgery, vol 1 (ed 4). NewYork, Churchill Livingstone, 1998, pp 95-102

3. Stern P, Fulton D: Distal interphalangeal joint arthrodesis: An analysisof complications. J Hand Surg Am 17:1130-1145, 1992

4. Jones BF, Stern PJ: Interphalangeal joint arthrodesis. Hand Clin 10:267-275, 1994

5. Engel J, Tsur H, Farin I: A comparison between K-wire and compres-sion screw fixation after arthrodesis of the DIP joint. Plast Reconstr Surg60:611-614, 1977

6. Wyrsch B, Dawson J, Aufranc S, et al: Distal interphalangeal joint arth-rodesis comparing tension band wire and Herbert screw: A biome-chanical and dimensional analysis. J Hand Surg 21:438-443, 1996

7. Moberg E: Arthrodesis of finger joints. Surg Clin North Am 40:465-470, 1960

8. Carroll RE, Hill NA: Small joint arthrodesis in hand reconstruction.J Bone Joint Surg Am 51:1219-1221, 1969

9. Nalebuff EA, Garrett J: Opera-glass hand in rheumatoid arthritis.J Hand Surg Am 1:210-220, 1976

0. Potenza AD: Brief note: A technique for arthrodesis of finger joints.J Bone Joint Surg Am 55:1534-1536, 1973

1. Feldon P, Terrona AL, Green EA, et al: Rheumatoid arthritis and otherconnected tissue diseases, in Green DP, Hotchkiss RN, Pederson WC(eds): Green’s Operative Hand Surgery, vol 2 (ed 4). New York,Churchill Livingstone, 1998, p 1708

2. Robertson DC: The fusion of interphalangeal joints. Can J Surg 7:433-
437, 1964

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ndividualized Rehabilitation Program forlexor Tendon Repair: From Pyramid to Algorithm

amela J. Steelman, CRNP, PT, CHT,* Gail Groth, MS, OTR, CHT,† andohn S. Taras, MD*,‡

During the past 3 decades, significant advances have been made in the surgery andpostoperative rehabilitation of flexor tendon injuries of the hand. Stronger tendon repairs,facilitated by improved suture techniques and stronger suture materials, have drivenpostoperative rehabilitation programs. These programs are designed to maintain tendonexcursion and prevent tendon adhesion through the early application of forces appropriateto maintain tendon gliding while preventing gapping at the repair site. It is postulated thatearly active mobilization increases tendon excursion, decreases the likelihood of tendonadhesion, and improves function of the repaired tendon. Protocol-driven therapy programshave become the mainstay of flexor tendon rehabilitation. These protocols provide aframework to apply progressively increasing forces to the tendon at specific time intervals.The timelines have been based on the best-available evidence available to therapists andsurgeons. Lacking in experimental clinical trials, the best-available evidence to support thesupposed tensile strength of repaired tendon at various stages of tendon healing is derivedfrom laboratory experiments. Although these time-based protocols provide a formula fortreatment of tendon repairs, they fail to accommodate human and individual variations inresponse to treatment, and tendon adhesion continues to be a common complication oftendon repair.Oper Tech Orthop 17:148-154 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS flexor tendon, repair, rehabilitation, therapy

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rehabilitation model is available to guide clinical deci-sion-making among hand therapists rehabilitating

exor tendon injuries (Fig. 1).1 This pyramid describes aequence of 9 exercises and an adhesion-grading system. Theequence of exercises is derived from a careful review of thevailable laboratory evidence (internal tensile strength andorce loads of exercises). The exercise at the lowest level of theyramid loads the flexor tendon the least (and is prescribedost frequently), and the exercise at the apex of the pyramid

oads the tendon the most (and is prescribed least fre-uently). The adhesion-grading system is used to assist in thelinical decision of when to progress from one level of the

The Philadelphia Hand Center, Philadelphia, PA.Department of Industry and Manufacturing Engineering, College of Engi-

neering and Applied Science, University of Wisconsin-Milwaukee, Mil-waukee, WI.

Department of Orthopaedic Surgery, Thomas Jefferson University, DrexelUniversity, Philadelphia, PA.

ddress reprint requests to Pamela J. Steelman, CRNP, PT, CHT, Philadel-phia Hand Center, PC; 834 Chestnut Street, Suite G-114; Philadelphia,

gPA 19107. E-mail: [email protected]


yramid to the next (Fig. 2). The adhesion-grading systememoves a rigid timeline from the progression of exerciseshile preserving the traditional sequence of exercises used in

stablished flexor tendon protocols. It is this way that theyramid offers an individualized tailored exercise regimen.Use of the pyramid requires evaluation of tissue responses

uring each and every rehabilitation session. Evaluation (go-iometry and visual observation) provides information to theherapist to be considered in the clinical decision of when toove up a level of exercise in the pyramid. The therapistrescribes one level of exercise per session (given no adverseissue response ie, swelling, inflammation) when the fingeroes not produce the desired range of motion. Exercise pre-cription always begins at the lowest level of the pyramid androgresses one level per session until the desired treatmentffect is achieved.

In theory, the patient is only progressed to the next level ofhe pyramid if an unresponsive lag is encountered (Fig. 2).n unresponsive lag is defined as passive flexion greater thanctive flexion of 15° or greater, which does not improve at a
iven level of therapeutic intervention. A lag typically is first

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Individualized rehabilitation program for flexor tendon repair 149

dentified at place hold (second level of the pyramid), al-hough it may be identified at any level higher than that.heoretically, a patient who performs full motion in activesting (third level of the pyramid) could be held at this levelnd not receive additional exercises until discharge from re-abilitation. Conversely, a patient who demonstrates an un-esponsive lag could progress to the hook and straight fistfourth level) within 2 weeks of surgery. Finger motion, notime elapsed from surgery, drives how exercises are pre-cribed. The pyramid approach attempts to match the forceevel of the therapy program to the force tolerance of theepaired tissue. We have found the pyramid useful in ourractice. It has reliably improved the outcomes of flexor ten-on repair and rehabilitation.Some therapists are slow to adopt the pyramid because

hey find interaction between the levels and the adhesion-rading system unclear. The purpose of this work is to advancehe model of the pyramid through the development of an algo-ithm. The purpose of this algorithm is to clarify the decisionathway of the pyramid and to facilitate utilization of the pyra-id in hand rehabilitation. This algorithm was born of the ques-

ion: “When the tissue response to the desired response, wheno you progress to the next level of the pyramid?”

escription ofhe Pyramid Algorithmhe pyramid algorithm is presented in Fig 3. The steps of thelgorithm have been color coded to correspond directly tohe levels of the pyramid (Fig. 1). The left side of the algo-ithm addresses unresponsive tissue and the right side ad-resses expected tissue response. An example is provided to

igure 1 Pyramid of progressive forcexercises. Reprinted with permissionrom Elsevier, Inc. (Color version ofgure is available online.)

larify how the algorithm is applied. t

Similarly to the pyramid, the pyramid algorithm is dedi-ated to clarifying the clinical decisions surrounding exerciserescription. It is not, however, intended to dominate other

mportant considerations in clinical decisions. Physicians’references (based on their knowledge of the individual’s

njury and repair process) and patient’s preferences (based onheir pain and risk tolerances) also form the basis for postop-rative care.

During the first rehabilitation session, protected passivextension exercises are performed. They involve placing theoint or joints proximal to the target joint to be moved inexion and then passively extending the target joint. The goal

s to achieve tendon excursion without undue tension onhe repaired flexor tendon. In our clinic, we also routinelyave patients perform “place and hold fists” in the first ses-ion. We have found this to be safe, and it allows us toetermine whether the tendon is gliding. If the patient exhib-

ts an active lag (ie, cannot hold the “place and hold fists”) werescribe this exercise as part of their home exercise program.f there is no active lag, we prescribe protected passive exten-ion exercises only.

During the second rehabilitation session, both levels ofxercise are performed in the clinic. Evaluation of a patient’serformance (goniometry and visual observation) is docu-ented. Progression of the individual from one level of ac-

ivity to the next is based on the therapist’s judgment. Asemonstrated by the algorithm, the exercises can be held at aiven level or progressed through the levels for this group.he decision as to which way to proceed may be based on

herapist or physician experience and preference. Patientutliers who have significant tendon adhesion would be ex-ected to fall to the left of the algorithm and progress quickly
hrough the steps of the pyramid. Patient outliers who have

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ery light scarring and excellent tendon function would bexpected to fall to the right side of the algorithm and progresslowly, with caution, and incompletely through the steps ofhe pyramid. It should be noted that if an adverse tissueeaction (ie, swelling, infection, pain) is encountered at anyevel, the patient may be held at a level or even “demoted” aevel to promote the desired tissue response (decreased swell-ng, infection, pain). As experience is gained in use of theyramid, individual therapist preferences in the timing andxtent of progression through the pyramid will be developed.

In our practice, flexor tendon repairs are seen for the firstherapy session on the second or third postoperative day. A
tatic forearm based dorsal blocking splint is fabricated with w
neutral wrist, metacarpophalangeal (MCP) joints at 40° ofexion, and interphalangeal (IP) joints neutral. Given no ad-erse signs or symptoms, patients are progressed through therst two levels of the pyramid with the addition of short arcctive flexion exercises during the first therapy session. Weave developed our own version of short arc active flexionFig. 4) in which the patient positions the wrist in neutral andhe forearm in supination on the tabletop and they are in-tructed to gently bring their fingertips to the tip of theirpposed thumb and then back to neutral. This has proven toe a safe and effective method of exercise in our patientopulation. The second therapy session typically occurs

Figure 2 Adhesion grading system.Reprinted with permission fromElsevier, Inc. (Color version of figureis available online.)

ithin 5 days of the first session and progression through the

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emainder of the steps of the pyramid depends on individualesponse to treatment. The splint is discontinued at foureeks postoperative unless there is reason to suspect an in-

reased risk for rupture.The pyramid can be particularly effective in the treatment

f patients insured by managed care plans. Many of theseatients do not have adequate insurance coverage to coverhe completion of a typical flexor tendon protocol. In ourxperience, patients reach therapy goals and discharge statusn a timelier manner with the individually tailored pyramidhan with treatment with standard tendon protocols. In ourractice, we have treated patients who never progress beyondctive fisting (level 3) until discharge to a home strengthening

igure 3 Pyramid algorithm. (Colorersion of figure is available online.)

rogram and patients who progress to hook and straight a

sting (level 4) by the third postoperative visit. We havencountered one case of tendon rupture over the past threeears. This rupture occurred late, after the patient was re-urned to work.

ase Examples ofhe Pyramid Approacho Flexor Tendon Rehabilitationase 1: Treatment to theeft Side of the Algorithm36-year-old patient sustained a saw injury to his left thumb

nd index fingers on his job as a self-employed carpenter. His

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njury to his index finger included an intra-articular fracturenvolving the head of the index finger middle phalanx andaceration of the ulnar digital nerve and artery. On his thumb,e lacerated his flexor pollicis longus, ulnar digital artery,nd both digital nerves. All injuries were addressed the dayfter trauma (Figs. 5 and 6). The digital nerves were repairedith collagen conduits. He was seen in therapy on his secondostoperative day. Surgical dressings were removed and aorsal blocking splint was fabricated with the wrist neutral,P joint at 30° flexion, and IP joint neutral (Fig. 7). A clam-

hell splint was fabricated for the index finger. He was begunn protected passive thumb exercises in the clinic. The fifthostoperative day he was seen for his second therapy session.e was begun on place and hold thumb flexion but could notaintain active thumb flexion (Fig. 8). He was progressed

his same therapy session to short arc flexion exercises con-isting of active opposition of the tip of the thumb to the tipf the index finger. On the ninth postoperative day, he con-inued to demonstrate the inability to produce active flexionf the flexor pollicis longus. He was progressed to isolatedoint motion of blocked active IP joint motion (Fig. 9). Heemonstrated minimal ability to actively flex the thumb IP

oint. He was instructed to begin place and hold and short arcctive range of motion exercises at home. The twelfth post-perative day he was able to actively flex the thumb IP joint0° when blocked in full extension but had continued diffi-

igure 4 Short arc active digital flexion to opposed thumb.

igure 5 Flexor pollicis longus laceration. F

ulty maintaining active flexion of the IP joint during placend hold. He was progressed to light resisted isolated jointotion. On the fourteenth postoperative day F.C. demon-

trated the ability to maintain 10° of IP joint flexion withlace and hold. At the time of this writing, he is currentlyweeks away from his surgery. His therapy program has

emained unchanged since postoperative day 14 excepthat his dorsal splint has now been discontinued. He cur-ently has 30° of active IP joint flexion in the place andold position.

ase 2: Treatment to theight Side of the Algorithm37-year-old man sustained a laceration of his left small

nger flexor digitorum superficialis, flexor digitorum pro-undis, and ulnar digital nerve while cutting a piece of fruit.oth tendons and the ulnar digital nerve were repaired 4 daysfter his injury. He was seen for his first therapy session onostoperative day 3. His hand was placed in a static, forearm-ased dorsal blocking splint with the wrist at neutral, the ringnd small finger MP joints at 40° of flexion and the IP jointst neutral. He was initiated on passive protected extensionnd place and hold exercises and was found to have flexionrom the digit tip to the distal palmer crease measuring 4.0m. He was also started on short arc active flexion exercises.

igure 6 Tendon fixation via suture through nail.

igure 7 Dorsal blocking splint for flexor pollicis longus repair.

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e was not instructed in a home program. The second ther-py session occurred on the eighth postoperative day. He hadull passive digital flexion and extension. During place andold, his pulp to palm distance was 3.0 cm. He was notrogressed any further along the pyramid at this point; how-ver, he was allowed to perform the exercises performed inherapy at home. With the addition of two more therapyessions he continued to exhibit a 2.75 cm deficit from the tipf the fifth digit to the distal palmer crease with place andold so he was progressed to active composite fist exercises atis fourth postoperative week. The protective splint was con-inued until six weeks postoperative as he was considered toe at risk for tendon rupture based on his excellent progress.n this program, at 8 weeks postoperatively, he progressed

o active range of motion as follows: MCP 0° to 86°, PIP 0° to

igure 8 (A) Passive place and hold flexion. (B) Active hold of place
nd hold. (Color version of figure is available online.)
8°, and distal interphalangeal (DIP) 0 ° to 62°. He now hadn 8° flexion lag at the DIP joint; therefore, hook and straightst and isolated joint motion exercises were added to thereatment program. There were no further changes to thereatment program. He was discharged from care to a homexercise program at 3 months postoperatively with the fol-owing active range of motion: MCP joint 0° to 95°, PIP joint° to 97°, and DIP 0° to 70°. He reported full function of hisand at discharge. We opted to forego resisted exercise as head no occupational or avocational demands for forceful gripctivity.

onclusionshe pyramid is a major advancement for hand rehabilitation

n developing individualized clinical pathways. We havesed the pyramid (and algorithm) successfully with our pa-ient population. In fact, the publication of the pyramid sim-ly provided a citation for how we have prescribed exercises

able 1 Adhesion Grading System

bsent <5° discrepancy between digital activeand passive flexion

esponsive >10% resolution of active lag betweentherapy sessions

nresponsive <10% resolution of active lag between

igure 9 Isolated joint motion, thumb IP joint. (Color version ofgure is available online.)

therapy sessions

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or over a decade. We strongly encourage therapists to studyhe pyramid, to test it clinically and intellectually, and tostablish a dialogue regarding its strengths and weaknesses.n doing so, perhaps a hand therapist or a clinic will developnd publish individualized treatment regimens for other di-
gnoses or scenarios. Many more pyramids or algorithms
wait creation to provide individualized care to the injuredand.

eference. Groth GN: Pyramid of progressive force exercises to the injured flexor

tendon. J Hand Ther 17:31-42, 2004

17.2.2007. upper extremity surgery

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