|3475 Torrance Blvd., Ste F
Torrance, CA 90503
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.
ARTHROSCOPIC RELEASE OF
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.
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.
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.
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.
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.
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.