David J. Slutsky


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3475 Torrance Blvd., Ste F
Torrance, CA 90503


Appointments: 310.792.1809
Fax: 310.792.1811

Office hours: M-F, 9am – 5 pm

Worker’s compensation, Medicare and most insurance plans accepted.

In September 2008, we will be moving to a beautiful new 4,400 sq ft, state of the art dedicated hand center located at 2808 Columbia Ave in Torrance, CA., which will feature onsite nerve conduction studies, occupational hand therapy and digital x-ray.
 


PROCEDURES

ARTHROSCOPIC RELEASE OF WRIST CONTRACTURE

Indications
Patients lacking a functional arc of wrist motion who have failed a trial of dynamic/static progressive splinting are candidates for this procedure. Lee et al devised a classification system based on pathologic anatomic location. Type I represents intrinsic adhesions which are subdivided into radiocarpal (A), midcarpal (B), distal radioulnar joint (C) , and combined (D). Type II represents extrinsic contracture which can be dorsal (A), Volar (B), DRUJ (C) and combined (D). The operative approach should be wrist arthroscopy for Types IA (radiocarpal adhesions) and IB (midcarpal adhesions) where intraarticular adhesions are present. Types IC (distal radioulnar joint adhesions) and II C (distal radioulnar joint capsular contracture) are best approached in an open manner where dorsal and palmar capsulectomies of the distal radioulnar joint are performed. For Types IIA, B, and D (dorsal, palmar, and combination extrinsic contracture, respectively), both open and arthroscopic methods are utilized.

Contraindications
A frank carpal instability pattern is a contraindication since release of the volar and/or dorsal extrinsic ligaments would likely exacerbate this condition. Similarly significant posttraumatic OA will limit any ultimate gains. Division of the radioscaphocapitate (RSC), long radiolunate (LRL) and short radiolunate (SRL) ligaments should be performed with caution in patients who are at risk for ulnar translocation such as those patients with rheumatoid arthritis and those who have undergone previous radial styloidectomies. Patients who cannot comply with postoperative dynamic/static progressive splinting due to low pain threshold or psychological disorder are not appropriate candidates.

Surgical Technique
Volar Capsulotomy
A blunt trocar and cannula are initially inserted in the 3-/,4 portal and used in a sweeping fashion to clear a path. A full radius resector is used to clear adhesions. The radial artery passes within 5.2 mm, the median nerve 6.9 mm and the ulnar nerve passes within 6.7 mm of the volar capsule, which should be kept in mind. An arthroscopic knife is introduced through a cannula in the 4-/,5 portal (link to capsulotomy 1,2). The RSC ligament is gently divided until the volar capsular fat and/or the flexor carpi radialis tendon is seen. The ulnolunate and ulnotriquetral ligaments should not be released in the presence of a ulnotriquetral joint instability since in sectioning studies this combination results in a volar intercalated segmental instability (VISI) pattern, especially when the dorsal radiocarpal ligament is also released.

Dorsal Capsulotomy
It is the author’s preference to view through the VR portal, although the 1-/,2 portal may be substituted. In patients with a partial or complete SLIL tear, sectioning the DRCL should be done with caution since it may exacerbate any pre-existing scapholunate instability. An arthroscopic knife is introduced through a cannula placed in the 3-/,4 portal (link to capsulotomy 3). The dorsal capsule and the DRCL are gently sectioned until the dorsal capsular fat and/or the extensor tendons can be seen. Bain uses an umbilical tape to retract and protect the extensor tendons. If it is desirable to release the dorsoulnar capsule it is necessary to establish a VU portal, or to view through the 6U portal. The adhesions are cleared through utilizing the 4-/,5 and 6R portals and then a capsulotomy is performed in a similar fashion. Postoperatively the patient is placed in a bulky splint for 2-3 days to reduce hematoma formation followed by aggressive wrist mobilization.

Results
Osterman described his experience with 23 patients with an average preoperative wrist flexion of 5° and extension of 15°. At a 2 year follow up flexion improved to 48°and extension to 58°. Hatori et al noted an average increase of 22° in their series of 11 patients. Luchetti et al reported on 28 patients. Radiocarpal, midcarpal and distal radioulnar portals were used. At a mean of 28 months wrist flexion/extension increased from an average of 84° degrees to 99° degrees and mean pronation/supination increased from 144 degrees to 159 degrees.

Work Considerations
Most people can perform one-handed work activity by the 2nd week followed by light duty including clerical work at 6-8 weeks. Heavy manual labor can often be resumed by 8 -12 weeks.