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The Journal of Hand Surgery (Eur) 40(9)
New procedures for precisely establishing volar wrist arthroscopic portals Dear Sir, Volar wrist arthroscopic portals are recognized but used rarely because of concerns over damaging normal structures (Abe et al., 2003). We conducted a cadaver study, approved by the institutional research board of our hospital, to see whether there are safe zones for the volar portals.
Cadaver studies The dorsal wrist tissues were all removed leaving the distal radio-ulnar and wrist joints, and volar soft tissues in six cadaveric upper limbs. We used 20 gauge syringe needles, inserted in a dorsal-palmar direction, to pierce the volar structures between different capsular ligaments. The needle tips appeared out of the volar aspect of the wrist to mark the different volar portals. We defined the volar portals as follows: there were two volar radial portals, VR1 and VR2, and one volar ulnar portal (VU). VR1 was between the radioscaphocapitate (RSC) ligament and long radiolunate (LRL) ligament, and VR2 was between the LRL and radioscapholunate (RSL) ligament; and VU was between the ulnolunate (UL) ligament and ulnotriquetrum (UT) ligament. Dissection and measurement were performed among the tendons, vessels and nerves surround the needles. We found that the needles placed through the VR1, VR2 and VU portals were several millimeters (ranged from 3.0 mm to 13.5 mm) away from the important palmar structures (radial and ulnar arteries, and median and ulnar nerves and their branches). These vessels and nerves around do not form an interdigital plexus reducing
the risk of iatrogenic injury from blunt dissection in the process of establishing volar portals. The needles through the VR1 and VR2 portals always pierced the flexor carpi radialis (FCR) tendon. The needle through the VU portal was closely ulnar to the digital flexor tendons (Figure 1). We hypothesized that procedures combining inside-out arthroscopically guided introducers with outside-in blunt dissection to form a path between the palmar tendons, vessels and nerves would facilitate establishing the volar portals more safely. The procedure for establishing the VR portals: for the VR1 portal an arthroscope was inserted into the 3/4 portal distinguishing the sulcus between the RSC and LRL ligaments and the 1/2 portal was established under trans-illumination. Via the 1/2 portal, the arthroscope was used to guide a switching stick (SS, a tip-round K-wire of 2.0 mm in diameter) through the 3/4 portal and into the sulcus between the RSC and LRL ligaments. With an index fingertip we identified the tip of the SS and made a shallow longitudinal skin incision of about 0.5 cm. The subcutaneous tissue was dissected bluntly with a curved mosquito hemostat between the FCR tendon and radial vessels. The SS was advanced and the arthroscope sleeve railroaded over the SS (Figure 2). VR2 was established with the SS through interligamentous sulcus between the LRL and RSL ligaments. VU was established with the arthroscope introduced through the 6U portal and used to guide the SS from the 4/5 portal into the sulcus between UL and UT ligaments. The volar track was dissected bluntly between the flexor digital tendons (flexor digitorum superficialis and flexor digitorum profundus) and the ulnar neurovascular bundle.
Patient experience If at standard dorsal wrist arthroscopy the dorsal structures were not clear or needed furthermore
Figure 1. Left, the distal radius and ulna (covered with TFCC), the proximal carpal bones, and the volar ligaments inside the wrists were exposed. Syringe needles directly piercing the volar structures through interligamentous sulcus to the palmar side labelled the volar portals. VR1 was through RSC and LRL, and VR2 was through LRL and RSL. VU was through UL and UT. Right, VR1 and VR2 all pierced the FCR tendon. VU was ulnarly close to the digital flexor tendons. FDS: flexor digitorum superficialis; FCR: flexor carpi radialis; L: lunate; LRL: long radiolunate; RSC: radioscaphocapitate; RSL: radioscapholunate; S: scaphoid; T: triquetrum; UL: ulnolunate; UT: ulnotriquetrum; VR1/2: volar radial portals; VU: volar ulnar portal. Downloaded from jhs.sagepub.com by guest on November 15, 2015
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Short report letters
Figure 2. Establishing the volar radial portal (VR1). (a) An arthroscope was inserted through the 1/2 portal and the SS was inserted through the 3/4 portal. (b) Arthroscopic view, the SS was advanced into the interligamentous sulcus of the RSC and LRL ligaments. (c) A path between the FCR tendon and the radial vessels was dissected bluntly with mosquito forceps. (d) The scope was inserted through the VR portal for inspection and a probe was inserted through the 3/4 portal for instrumentation. 6R: compartment 6 radial portal; LRL: long radiolunate; MCR: midcarpal radial portal; MCU: midcarpal ulnar portal; RSC: radioscaphocapitate; S: scaphoid; VR: volar radial portal.
identification, or if the arthroscope through the dorsal portal impeded the instrumentation or vice versa, we considered establishing volar portals. We performed wrist arthroscopy through VR1, VR2 or VU portals with these techniques in 20 cases. With the arthroscope introduced through the VR1 or VR2 portals, the dorsal radiocarpal ligament and radial part of the triangular fibrocartilage complex (TFCC) could be inspected. With the arthroscope through the VU portal, the dorsal triangular fibrocartilage complex (TFCC) could be inspected. Moreover, the palmar scapholunate interosseous ligament and the lunotriquetral interosseous ligament, the dorsal radiocapal ligament, the dorsal rim of radius articular surface and its conjunction with the capsule could be inspected through the volar portals, whereas these structures are not visible through the routine dorsal portals (Slutsky, 2004; Van Meir et al., 2011). There were no complications from use of the volar portals. We believe that we have developed safe techniques for volar arthroscopic portals and have shown clinical value in their use.
Conflict of interests None declared.
Funding Supported by Natural Science Fund of China.
References Abe Y, Doi K, Hattori Y, Ikeda K, Dhawan V. A benefit of the volar approach for wrist arthroscopy. Arthroscopy. 2003, 19: 440–5. Slutsky DJ. The use of a volar ulnar portal in wrist arthroscopy. Arthroscopy. 2004, 20: 158–63. Van Meir N, Degreef I, De Smet L. The volar portal in wrist arthroscopy. Acta Orthop Belg. 2011, 77: 290–3.
R.-G. Xie, S.-G. Xing and J.-B. Tang Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China Corresponding author: [email protected] © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193414561592 available online at http://jhs.sagepub.com
Downloaded from jhs.sagepub.com by guest on November 15, 2015
The Journal of Hand Surgery (Eur) 40(9)
New procedures for precisely establishing volar wrist arthroscopic portals Dear Sir, Volar wrist arthroscopic portals are recognized but used rarely because of concerns over damaging normal structures (Abe et al., 2003). We conducted a cadaver study, approved by the institutional research board of our hospital, to see whether there are safe zones for the volar portals.
Cadaver studies The dorsal wrist tissues were all removed leaving the distal radio-ulnar and wrist joints, and volar soft tissues in six cadaveric upper limbs. We used 20 gauge syringe needles, inserted in a dorsal-palmar direction, to pierce the volar structures between different capsular ligaments. The needle tips appeared out of the volar aspect of the wrist to mark the different volar portals. We defined the volar portals as follows: there were two volar radial portals, VR1 and VR2, and one volar ulnar portal (VU). VR1 was between the radioscaphocapitate (RSC) ligament and long radiolunate (LRL) ligament, and VR2 was between the LRL and radioscapholunate (RSL) ligament; and VU was between the ulnolunate (UL) ligament and ulnotriquetrum (UT) ligament. Dissection and measurement were performed among the tendons, vessels and nerves surround the needles. We found that the needles placed through the VR1, VR2 and VU portals were several millimeters (ranged from 3.0 mm to 13.5 mm) away from the important palmar structures (radial and ulnar arteries, and median and ulnar nerves and their branches). These vessels and nerves around do not form an interdigital plexus reducing
the risk of iatrogenic injury from blunt dissection in the process of establishing volar portals. The needles through the VR1 and VR2 portals always pierced the flexor carpi radialis (FCR) tendon. The needle through the VU portal was closely ulnar to the digital flexor tendons (Figure 1). We hypothesized that procedures combining inside-out arthroscopically guided introducers with outside-in blunt dissection to form a path between the palmar tendons, vessels and nerves would facilitate establishing the volar portals more safely. The procedure for establishing the VR portals: for the VR1 portal an arthroscope was inserted into the 3/4 portal distinguishing the sulcus between the RSC and LRL ligaments and the 1/2 portal was established under trans-illumination. Via the 1/2 portal, the arthroscope was used to guide a switching stick (SS, a tip-round K-wire of 2.0 mm in diameter) through the 3/4 portal and into the sulcus between the RSC and LRL ligaments. With an index fingertip we identified the tip of the SS and made a shallow longitudinal skin incision of about 0.5 cm. The subcutaneous tissue was dissected bluntly with a curved mosquito hemostat between the FCR tendon and radial vessels. The SS was advanced and the arthroscope sleeve railroaded over the SS (Figure 2). VR2 was established with the SS through interligamentous sulcus between the LRL and RSL ligaments. VU was established with the arthroscope introduced through the 6U portal and used to guide the SS from the 4/5 portal into the sulcus between UL and UT ligaments. The volar track was dissected bluntly between the flexor digital tendons (flexor digitorum superficialis and flexor digitorum profundus) and the ulnar neurovascular bundle.
Patient experience If at standard dorsal wrist arthroscopy the dorsal structures were not clear or needed furthermore
Figure 1. Left, the distal radius and ulna (covered with TFCC), the proximal carpal bones, and the volar ligaments inside the wrists were exposed. Syringe needles directly piercing the volar structures through interligamentous sulcus to the palmar side labelled the volar portals. VR1 was through RSC and LRL, and VR2 was through LRL and RSL. VU was through UL and UT. Right, VR1 and VR2 all pierced the FCR tendon. VU was ulnarly close to the digital flexor tendons. FDS: flexor digitorum superficialis; FCR: flexor carpi radialis; L: lunate; LRL: long radiolunate; RSC: radioscaphocapitate; RSL: radioscapholunate; S: scaphoid; T: triquetrum; UL: ulnolunate; UT: ulnotriquetrum; VR1/2: volar radial portals; VU: volar ulnar portal. Downloaded from jhs.sagepub.com by guest on November 15, 2015
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Short report letters
Figure 2. Establishing the volar radial portal (VR1). (a) An arthroscope was inserted through the 1/2 portal and the SS was inserted through the 3/4 portal. (b) Arthroscopic view, the SS was advanced into the interligamentous sulcus of the RSC and LRL ligaments. (c) A path between the FCR tendon and the radial vessels was dissected bluntly with mosquito forceps. (d) The scope was inserted through the VR portal for inspection and a probe was inserted through the 3/4 portal for instrumentation. 6R: compartment 6 radial portal; LRL: long radiolunate; MCR: midcarpal radial portal; MCU: midcarpal ulnar portal; RSC: radioscaphocapitate; S: scaphoid; VR: volar radial portal.
identification, or if the arthroscope through the dorsal portal impeded the instrumentation or vice versa, we considered establishing volar portals. We performed wrist arthroscopy through VR1, VR2 or VU portals with these techniques in 20 cases. With the arthroscope introduced through the VR1 or VR2 portals, the dorsal radiocarpal ligament and radial part of the triangular fibrocartilage complex (TFCC) could be inspected. With the arthroscope through the VU portal, the dorsal triangular fibrocartilage complex (TFCC) could be inspected. Moreover, the palmar scapholunate interosseous ligament and the lunotriquetral interosseous ligament, the dorsal radiocapal ligament, the dorsal rim of radius articular surface and its conjunction with the capsule could be inspected through the volar portals, whereas these structures are not visible through the routine dorsal portals (Slutsky, 2004; Van Meir et al., 2011). There were no complications from use of the volar portals. We believe that we have developed safe techniques for volar arthroscopic portals and have shown clinical value in their use.
Conflict of interests None declared.
Funding Supported by Natural Science Fund of China.
References Abe Y, Doi K, Hattori Y, Ikeda K, Dhawan V. A benefit of the volar approach for wrist arthroscopy. Arthroscopy. 2003, 19: 440–5. Slutsky DJ. The use of a volar ulnar portal in wrist arthroscopy. Arthroscopy. 2004, 20: 158–63. Van Meir N, Degreef I, De Smet L. The volar portal in wrist arthroscopy. Acta Orthop Belg. 2011, 77: 290–3.
R.-G. Xie, S.-G. Xing and J.-B. Tang Department of Hand Surgery, Affiliated Hospital of Nantong University, Jiangsu, China Corresponding author: [email protected] © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193414561592 available online at http://jhs.sagepub.com
Downloaded from jhs.sagepub.com by guest on November 15, 2015
![[Arthroscopic procedures at the wrist].](/assets/img/hold.png)
