Volar Portals NORMAL 3/11/2015. I have no potential conflicts with this presentation

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1 Innovations in Wrist and Small Joint Arthroscopy Arthroscopic treatment of scapholunate instability The Hand & Wrist Institute Torrance, CA David J. Slutsky MD Assistant Clinical Professor Harbor-UCLA Medical Center Volar Portals David J. Slutsky M.D. I have no potential conflicts with this presentation Arthroscopic Classification of SLIL injury NORMAL This classification quantifies the resultant instability and not the actual size of the tear. *note that this was reported in acute distal radius fractures, not chronic injury Geissler WB, Freeland AE, Savoie F et al. JBJS(Am)

2 Geissler I Geissler II Geissler III Geissler IV Intercarpal ligamentous laxity in cadaveric wrists 83 fresh frozen cadaver wrists age-related progression of laxity of the SL and lunotriquetral joints SLIL LTIL Grade I 4 17 Grade II Grade III Grade IV 11 1 Geissler II? Geissler classification cannot by itself distinguish between laxity and pathological instability Rimington TR, Edwards SG, Lynch TS. JBJS(Br) Nov

3 Geissler III? Dynamic Wrist Arthroscopy Geissler IV The Scapholunate ligament Complex Elsaidi et al sequentially divided the RSC, LRL,SRL, SLIL and finally the dorsal capsule insertion on the scaphoid. 1 There was no appreciable change in the radiographic appearance of the wrist. When the DRCL was then divided, a DISI deformity occurred Short et al determined that the SLIL is the primary stabilizer of the SL articulation and that the DRCL, DIC, ST and RSC ligaments are secondary stabilizers. 2 The SL joint is therefore dependent on a complex of ligaments, each having a separate role but working in concert. 1.Elsaidi GA, Ruch DS, Kuzma GR, et al: CORR:152-7, Short WH, Werner FW, Green JK, et al: J Hand Surg 32: , 2007 Volar Palmar SLIL plication Palmar capsulodesis STT ligament plication STT fusion shrinkage Brunelli Tri-ligament tenodesis Dorsal Capsulodesis DRCL repair Arthroscopic capsuloplasty SLLC arthroscopic assessment Palmar SLIL volar radial portal, MCR Dorsal SLIL 3,4 and 4,5 portal, MCU Dorsal capsule volar radial portal, 6R ST ligaments MCR, STT portal Interosseous Tendon graft RASL Bone-ligament-bone Slutsky DJ. Current Innovations in Wrist Arthroscopy. J Hand Surg Sept

4 Arthroscopic Tx of SL instability Thermal Shrinkage In general, arthroscopic Tx is most applicable for Geissler grade I and II lesions Arthroscopic Tx for acute grade III lesions but consider open treatment with chronic lesions. Grade IV lesions require open TX Palmar SLIL plication 4 patients, mixed pathology uncertain effect del Pinal et al. J Hand Surg Am 2011 Arthroscopic assisted scaphoid screw insertion 126 acute fractures treated with percutaneous screw fixation using a dorsal approach. 65 proximal pole fractures; 67 grossly displaced fractures; 12 transcaphoid perilunate dislocations, 4 transscaphoid trans-capitate fractures; 10 combined scaphoid and distal radius fractures. CT scan showed healing in 125/126 cases Slade and Gillon. Scand J Surg

5 Arthroscopic Treatment of Distal Radius Fractures Arthroscopic reduction and pinning with nonbridging external fixation Arthroscopic assisted ORIF 6 month follow up Arthroscopic assisted osteotomy DRUJ arthroscopy 5

6 Foveal tear TM arthroscopy 1-R portal is just radial to the APL. 1-U portal, just ulnar to the EPB. D-2 Portal ulnar to the EPL tendon and 1 cm distal to juncture of the index and thumb metacarpal bases. allows one to look down on the trapezium rather than across it, which facilitates resection of medial osteophytes Arthroscopic Bennetts Slutsky DJ. Journal of Arthroscopy Mar 2008 Arthroscopic Bennetts 6

7 Arthroscopic resection without interposition 7

8 Scaphoid nonunion advanced collapse (SNAC) radial side of radioscaphoid joint scaphocapitate joint capitolunate joint *radiolunate joint spared Arthroscopic Distal Scaphoid Resection Vender, Watson, Wiener, Black. J Hand Surg 1987 Arthroscopic CL fusion 8