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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_574_Библиотеки_им_академика_М_И_Перельмана.pdf
13. Percutaneous Fixation of Acute Scaphoid Fractures 95
John T. Capo, To sca Kinchelow,and Virak Tan
14. Percutaneous and Arthroscopic Management of Scaphoid Nonunions 105
William B. Geissler
15. Reductionand Associationofthe Scaphoid andLunate(RASL)Reconstructionfor
Scapholunate Instability 117
Steven H. Goldberg, Charles M. Jobin, and Melvin P. Rosenwasser
16. Prosthetic Arthroplasty of Proximal Pole Scaphoid Nonunions 125
Christophe L. Mathoulin
PART V: MINIMALLY INVASIVE PROCEDURES FOR DISTAL RADIUSFRACTUREFIXATION
17. Augmented External Fixation for Distal Radius Fractures 133
John T. Capo, Kenneth G. Swan, Jr., and Virak Ta n
18. Non-Bridging External Fixation of the Distal Radius 143
Margaret M. McQueen
19. Spanning Plating for Distal Radius Fractures 151
Anthony J. Lauder,David S. Ruch, and Douglas P. Hanel
20. Minimally Invasive Tr eatment of Distal Radius Fractures with the MICRONAIL 161
Virak Ta nand John T. Capo
21. Dorsal Nail Plate Fixation for Distal Radius Fractures 167
Jorge L. Orbay and Amel To uhami
22. Balloon Reduction and Grafting of Distal Radius Fractures 175
Jose´M. Nolla and Jesse B. Jupiter
23. LimitedApproach Open Reduction andInternal FixationofDistalRadius
Fractures 181
Jose´M. Nolla and Jesse B. Jupiter
24. Repair of Distal Radial Malunions with an Intramedullary Nail 191
John T. Capo, Damon Ng, and Vi rak Ta n
25. Repair of Distal Radial Malunion with Vo lar Plating 203
David A. Fuller
PART VI(A): WRIST AND HAND ARTHROSCOPY TRAUMATIC
26. Surgical Setup and Intra-articular Anatomy 209
David J. Bozentka
27. Arthroscopic Tr eatment of Interosseous Ligament Te ars, Carpal Instability,and Capsular
Electrothermal Shrinkage Te chniques 217
Gregory K. Deirmengian and Pedro K. Beredjiklian
28. Percutaneousand Arthroscopic-Assisted Reduction of Intraarticular Dis talRadius
Fractures 223
William B. Geissler
29. Arthroscopic Tr eatment of Metacarpophalangeal Joint Fractures in the Hand 235
Rocco A. Barbieri, Jr.
viii&Contents
PART VI(B): WRIST AND HAND ARTHROSCOPY RECONSTRUCTION
30. Triangular Fibrocartilage Te ars and Ulnocarpal Impaction 239
Vincent Ruggiero
31. Minimally Invasive Tr eatment of Arthritis Associated with Scapholunate and Scaphoid
Nonunion Advanced Collapse 247
Charles M. Jobin, Steven H. Goldberg, and Robert J. Strauch
32. Arthroscopic Tr eatment of Wrist Ganglion Cysts 257
Scott R. Hadley and Ranjan Gupta
33. Basal Joint Arthritis-Arthroscopy/Debridement 263
Jay T. Bridgeman and Sanjiv H. Naidu
34. Arthroscopy of the Basal Joint: Tr eatment of Arthritis with Soft-Tissue
Interposition 267
Julie E. Adams and Scott P. Steinmann
PART VII: NERVE COMPRESSION
35. Endoscopic Carpal Tu nnel Release: The Single-Portal Mirza Te chnique 275
Tamara D. Rozental, Charles S. Day,and Orrin I. Franko
36. Endoscopic Carpal Tu nnel Release: Chow Te chnique 281
James C.Y.Chow and Athanasios A. Papachristos
37. Limited Incision Carpal Tu nnel Release with the Indiana Tome 293
Kenneth R. Means, Jr., James P. Higgins, and Thomas J. Graham
38. Minimally Invasive Carpal Tu nnel Release Using the Security Clipe 299
James W. Strickland and Lance A. Rettig
39. Endoscopic Carpal Tu nnel Release: Agee Te chnique 305
Emran Sheikh, Ednan Sheikh, and Virak Ta n
PART VIII: TENDONS AND SOFT TISSUES
40. Percutaneous Tr igger Finger Release 311
Min Jong Park
41. Endoscopic DeQuervain’sRelease 317
Joseph F. Slade III and GregMerrell
42. Treatment of Pyogenic Flexor Te nosynovitis Using Closed Catheter Irrigation 321
Karol A. Gutowski
43. Dupuytren’sContracture 327
Lawrence C. Hurst and Marie A. Badalamente
Index 333
Contents&ix
Contributors
Julie E. Adams Department of Orthopedic Surgery, Mayo Clinic, Rochester,Minnesota, U.S.A.
Vikrant Azad Department of Orthopedics, The New Jersey Medical School, University of
Medicine and Dentistry of New Jersey,Newark, New Jersey,U.S.A.
Marie A. Badalamente Department of Orthopedics, State University of New York, Stony Brook,
New Yo rk, U.S.A.
Rocco A. Barbieri, Jr. Southern Bone &Joint Specialists, Hattiesburg, Mississippi, U.S.A.
PedroK.Beredjiklian DepartmentofOrthopedic Surgery, Hospitalofthe University of
Pennsylvania, Presbyterian Medical Center,Philadelphia, Pennsylvania, U.S.A.
David J. Bozentka Department of Orthopedic Surgery,University of Pennsylvania Medical
Center,Philadelphia, Pennsylvania, U.S.A.
Jay T. Bridgeman Department of Orthopedics and Rehabilitation, Penn State University College
of Medicine, Hershey,Pennsylvania, U.S.A.
John T. Capo Department of Orthopedics, The New Jersey Medical School, University of
Medicine and Dentistry of New Jersey,Newark, New Jersey,U.S.A.
James C.Y.Chow Orthopaedic Center of Southern Illinois, Mount Ve rnon, Illinois, U.S.A.
Aaron Daluiski Department of Orthopedic Surgery,Hospital for Special Surgeryand We ill
Medical College of Cornell University,New York, New York, U.S.A.
Charles S. Day Department of Orthopedic Surgery,Beth Israel Deaconess Medical Center,
HarvardMedical School, Boston, Massachusetts, U.S.A.
Gregory K. Deirmengian Department of Orthopedic Surgery, Hospital of the University of
Pennsylvania, Presbyterian Medical Center,Philadelphia, Pennsylvania, U.S.A.
Drew Engles Summit Hand Center,Crystal Clinic, Inc., Akron, Ohio, U.S.A.
Orrin I. Franko Department of Orthopedic Surgery,Beth Israel Deaconess Medical Center,
HarvardMedical School, Boston, Massachusetts, U.S.A.
Alan E. Freeland Department of Orthopedic Surgeryand Rehabilitation, University of
Mississippi Medical Center,Jackson, Mississippi, U.S.A.
David A. Fuller Cooper University Hospital, University of Medicine and Dentistry of New
Jersey,Camden, New Jersey,U.S.A.
Ankur Gandhi Department of Orthopedics, The New Jersey Medical School, University of
Medicine and Dentistry of New Jersey,Newark, New Jersey,U.S.A.
WilliamB.Geissler Department of Orthopedic Surgery and Rehabilitation, University of
Mississippi Medical Center,Jackson, Mississippi, U.S.A.
Thomas J. Gillon Department of Orthopedics and Rehabilitation, Yale University School of
Medicine, New Haven, Connecticut, U.S.A.
Steven H. Goldberg Department of Orthopedic Surgery,Columbia University Medical Center,
New Yo rk, New Yo rk, U.S.A.
Thomas J. Graham The Curtis National Hand Center,Union Memorial Hospital, Baltimore,
Maryland, U.S.A.
Ranjan Gupta Peripheral Nerve Research Laboratory,Department of Orthopedic Surgery,
Anatomy &Neurobiology,and Biomedical Engineering, University of California, Irvine,
Irvine, California, U.S.A.
Karol A. Gutowski Division of Plastic and Reconstructive Surgery, University of Wisconsin,
Madison, Wisconsin, U.S.A.
Scott R. Hadley Peripheral Nerve Research Laboratory,Department of Orthopedic Surgery,
University of California, Irvine, Irvine, California, U.S.A.
Douglas P. Hanel Section of Hand and Microvascular Surgery,Department of Orthopedics and
Sports Medicine, University of Wa shington, Seattle, Washington, U.S.A.
James P. Higgins The Curtis National Hand Center,Union Memorial Hospital, Baltimore,
Maryland, U.S.A.
Lawrence C. Hurst Department of Orthopedics, State University of New York, Stony Brook,
New Yo rk, U.S.A.
Igon Indriago Miami Hand Center,Miami, Florida, U.S.A.
Charles M. Jobin Department of Orthopedic Surgery, Columbia University Medical Center,
New Yo rk, New York, U.S.A.
Min Jong Park Department of Orthopedic Surgery,Samsung Medical Center,Sungkyunkwan
University School of Medicine, Seoul, Korea
Jesse B. Jupiter Orthopedic Hand Service, Massachusetts General Hospital, Harvard Medical
School, Boston, Massachusetts, U.S.A.
Mark L. Kavanagh Department of Orthopedics, The New Jersey Medical School, University of
Medicine and Dentistry of New Jersey,Newark, New Jersey,U.S.A.
Tosca Kinchelow Department of Orthopedics, The New Jersey Medical School, University of
Medicine and Dentistry of New Jersey,Newark, New Jersey,U.S.A.
AnthonyJ.Lauder DepartmentofOrthopedic Surgeryand Rehabilitation,University of
Nebraska Medical Center,Omaha, Nebraska, U.S.A.
SheldonLin Department of Orthopedics, TheNew JerseyMedical School,University of
Medicine and Dentistry of New Jersey,Newark, New Jersey,U.S.A.
Frank Liporace Department of Orthopedics, The New Jersey Medical School, University of
Medicine and Dentistry of New Jersey,Newark, New Jersey,U.S.A.
Christophe L. Mathoulin Institut de la Main, Clinique Jouvenet, Paris, France
Margaret M. McQueen Royal Infirmary of Edinburgh, Edinburgh, Scotland, U.K.
Roy A. Meals Department of Orthopedic Surgery,David Geffen School of Medicine at UCLA,
Los Angeles, California, U.S.A.
Kenneth R. Means, Jr. The Curtis National Hand Center,Union Memorial Hospital, Baltimore,
Maryland, U.S.A.
Greg Merrell Department of Orthopedics, Brown University School of Medicine, Providence,
Rhode Island, U.S.A.
Bruce A. Monaghan Orthopedics at Wo odbury,Woodbury,New Jersey,U.S.A.
Sanjiv H. Naidu Department of Orthopedics and Rehabilitation, Penn State University College
of Medicine, Hershey,Pennsylvania, U.S.A.
DamonNg Department of Orthopedics, TheNew Jersey MedicalSchool, University of
Medicine and Dentistry of New Jersey,Newark, New Jersey,U.S.A.
xii&Contributors
Jose´M. Nolla Department of Hand and Upper Extremity Surgery,Massachusetts General
Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.
Jorge L. Orbay Miami Hand Center,Miami, Florida, U.S.A.
Athanasios A. Papachristos Orthopaedic Research Foundation of Southern Illinois, Mount
Vernon, Illinois, U.S.A.
Regis L. Renard Department of Orthopedics, The New Jersey Medical School, University of
Medicine and Dentistry of New Jersey,Newark, New Jersey,U.S.A.
Lance A. Rettig Department of Orthopedic Surgery,Indiana University School of Medicine,
Indianapolis, Indiana, U.S.A.
Melvin P. Rosenwasser Department of Orthopedic Surgery,Columbia University Medical
Center,New Yo rk, New York, U.S.A.
Tamara D. Rozental Department of Orthopedic Surgery,Beth Israel Deaconess Medical Center,
HarvardMedical School, Boston, Massachusetts, U.S.A.
David S. Ruch Department of Orthopedics, Duke University Medical Center,Durham, North
Carolina, U.S.A.
Vincent Ruggiero Staten Island University Hospital, Staten Island, New York, U.S.A.
Ednan Sheikh Department of General Surgery, New York Presbyterian Hospital/Weill Cornell
Medical Center,New York, New Yo rk, U.S.A.
Emran Sheikh Department of Orthopedics and Plastic Surgery, Rothman Institute, Thomas
Jefferson University,Philadelphia, Pennsylvania, U.S.A.
Joseph F. SladeIII Hand and Upper Extremity Service, Department of Orthopedicsand
Rehabilitation, Ya le University School of Medicine, New Haven, Connecticut, U.S.A.
Scott P. Steinmann Department of Orthopedic Surgery, Mayo Clinic, Rochester,Minnesota,
U.S.A.
Robert J. Strauch Department of Orthopedic Surgery,Columbia University Medical Center,
New Yo rk, New Yo rk, U.S.A.
JamesW.Stric kland Depar tmentofOrthopedicSurgery,IndianaUniversity School of
Medicine, Indianapolis, Indiana, U.S.A.
Kenneth G. Swan, Jr. Department of Orthopedics, The New Jersey Medical School, University
of Medicine and Dentistry of New Jersey,Newark, New Jersey,U.S.A.
Virak Ta n Department of Orthopedics, The New Jersey Medical School, University of Medicine
and Dentistry of New Jersey,Newark, New Jersey,U.S.A.
Amel To uhami Miami Hand Center,Miami, Florida, U.S.A.
Yi-Meng Yen Steadman-Hawkins Clinic Va il, Vail, Colorado, U.S.A.
Contributors&xiii
Part I: Introduction
1
Technical Considerations and Anatomical Basis for
Minimally Invasive Hand Surgery
VirakTan and John T. Capo
Department of Orthopedics, The New Jersey Medical School, University of Medicine and Dentistry of New Jersey,
Newark, New Jersey, U.S.A.
&
INTRODUCTION
Anatomic structures in the hand and wrist lie in close proximity
to each other and are critical for precise functioning of the upper
extremity.Therefore, minimally invasive surgery (MIS) in this
region of the body is of particular interest because of the desire
to restore hand function as quickly as possible after asurgical
procedure. Oftentimes,the pain,discomfort, andother
morbidity associated with surgeryare duetothe surgical
dissection to access the area of interestrather than from the
procedure itself. As such, decreased surgical trauma and tissue
disruptionwillleadtodecreased postoperative pain and
swelling, shorter recovery period, and afaster return to activities of daily living. These advantages not only benefit patients,
but also the health care system because most procedures can be
done on an outpatient basis; and when required, hospital stays
are usually shorter than those for traditional open procedures.
Disadvantages to MIS are the steep learning curve for the
surgeon and staff, and higher costs (1). In the early part of the
learning curve, MIS is considered moretechnically demanding
than traditional open surgical methods. Surgeons are working
in smaller areas through smaller incisions, and need to employ a
three-dimensional mental picture of the anatomy.Using instruments like trocars,endoscopes, andcameras requires some
degreeof“hand–eye” coordination and technological knowhow by the surgeon and his or her assistants. Arthroscopic
instruments can be moredifficult to maneuver and manipulate
because the working end is further away from the surgeon’s
hands. Often, the surgeon is not looking directly at the threedimensional operative field but at atwo-dimensional video
screen,which mayadd to thedifficultyofthe procedure.
Becauseofthis, thereisapossibilityofcausingiatrogenic
trauma to surrounding tissue that is not in view of the camera
or fluoroscopic image. However,these problems can usually be
mastered with training, experience, and precise knowledge of
the anatomy.
&
ADVANCES IN HAND AND WRIST MIS
There have been several factors that have led to advances in
wrist and hand MIS. First, improvements in fiber-optic technology (and its use in the arthroscope and endoscope) have
enhanced visualization of intra- and periarticular anatomy that
previously could not be seen on standard open exposures. At
the time of this writing, arthroscopy is generally agreed to be
the gold standard for diagnosis of intra-articular wrist pathology (2). In conjunction with improved visualization of the
joint, dedicated and appropriately sized arthroscopicinstruments have been developed for the surgeon to treat pathologies
in the hand and wrist (3). For example, triangular fibrocartilage
complex tears can be debrided or repaired through the scope
(4). Similar to the larger joints, small joint arthroscopic surgery
has gained aplace in the upper extremity and continues to push
the field of MIS forward.
The mini C-arm image intensifier has also been amajor
contribution to MIS of the upper extremity,combining superior
image quality,ease of use, and relatively low doses of emitted
radiation (5–7). Atypical mini C-arm has afocus X-ray tube that
uses 0.02 to 0.10 mA of current with atube potential of 40 to
75 kV and anarrowfield, resultinginless ionizing radiation
than the bigger C-arms. The patient’s arm can be placed close to
the image intensifier to generate high-quality digital images, yet
there is enough room to performthe surgery (Fig. 1). This
capacity to perform an operationunder dynamic,real-time
fluoroscopy allows for percutaneous reduction and fixation of
afracture, thereby lessening the invasiveness of the procedure.
Another area of MIS advancement in the hand and wrist is
the development of implants and surgical devices specific to
minimally invasive techniques. For example, the MICRONAIL
(Wright Medical Te chnology,Arlington, Te nnessee, U.S.A.) was
designed to be inserted by percutaneous means through the
“barespot” between the first and second dorsal compartment
tendons; it is arigid fixation device for distal radius fractures
and malunions (8,9). For metacarpal and proximal phalangeal
shaft fractures, flexible prebent intramedullarynails canbe
inserted through asmall incision at the base of the bone with
the aid of aprefabricated awl (Small Bone Fixation System,
Hand Innovations, LLC, Miami, Florida, U.S.A.) (10). Minimally
invasive carpal tunnel release can be performed with one of
severalsystems (11) thatwere designed specifically for the
purpose of dividing the transverse carpal ligament without
violatingthe overlyingskinand subcutaneous tissue, as is
done with the traditional open method. Another example of a
specially designed instrument is the HAKI knife (BK Meditech
Inc., Seoul, South Korea), which was developed for percutaneous trigger finger release (12). In addition, there are other
devices that are not described in this book and more that are
being developed, which will also contribute to the MIS field.
&
ANATOMIC BASIS FOR HAND AND WRIST MIS
The wrists and hands are particularly suitable for minimally
invasive procedures because for the most part the anatomic
structures are subcutaneous. Additionally,tendon excursion is
of major importance to the function of the hand, and procedures
that limit postoperative swelling and tendon adhesions, such as
MIS, are of great value. The major neurovascular structures in
the wrist and hand are located volarly; therefore, the majority of
arthroscopic portals, limited incision surgical approaches and
locationsofpercutaneous Kirschner (K)-wire placementfor
minimally invasive techniques are situated dorsally (Fig. 2).
As such, the extensor tendons are most at risk for injury,but
most of these injuries are relatively minor.
Arthroscopicportals arebased with respecttothe
extensor tendons (Fig. 2). The 3/4 portal lies between the
thirdand fourth extensor compartments, and the 4/5 portal is
between the fourth and fifth compartments, wherethere is
minimal risk to neurovascular structures.The dorsal ulnar
sensory nerve is in close proximity to the 6U and 6R portals,
which are located just ulnar and radial to the extensor carpi
ulnaris tendon,respectively. Theintervalbetween the
abductor pollicis longus and extensor carpi radialis longus
tendons (at the base of the anatomic snuffbox) is the location
for the 1/2 portal, entry point of the MICRONAIL, and radialsided percutaneous K-wires. Care must be taken in this area of
the wrist due to the proximity of the radial sensory nerve and
deep branchofthe radial artery (Fig.3). With surgical
approaches to the thumbcarpometacarpal joint, the radial
sensory nerve is still at risk. In most instances, the described
approaches for minimally invasive procedures of the metacarpals and metacarpophalangeal joints require only avoidance of
theextensor tendons.AminiC-arm maybehelpful for
localization of the joint or bone.
There are only several minimally invasive procedures that
utilize the volar side of the hand. Endoscopic carpal tunnel
release is performed with small volar skin incision(s) that is in
the corridor between the hook of the hamate and the palmaris
longus tendon (Fig.4). Instrumentsthatare placed toofar
ulnarly will potentially injure the ulnar neurovascular bundle
in Guyon’s canal, and those too radial may injure the median
nerve. Kaplan’s cardinal line serves as alandmark for the distal
edge of the transverse carpal ligament and is proximal to the
superficial palmar arch(13). For percutaneous trigger release
and palmar incisionsfor drainage of suppurativeflexor
tenosynovitis, knowledgeofthe flexorsheathand pulley
anatomy is essential (Fig. 5). Studies have demonstrated that
thepro ximaledgeofthe first annular pulleycoincides
with the proximal palmar crease in the index finger,halfway
between the proximal and distal palmar creases in the middle
finger,and at the distal palmar crease in the ring and little
fingers (14,15). In the thumb, the metacarpophalangeal crease
overliesthe middleportion of theA1pulley, butspecific
attention must be given to the radial digital nerve because it
traverses from ulnar to radial across the metacarpal in close
proximity to the pulley (16).
FIGURE 1 UseofaminiC-arm duringpercutaneous
scaphoid fixation. The C-arm is draped out sterilely and used
in the horizontal fashion with the wrist closetothe image
intensifierside. Source:Courtesy of Virak Tan, MD.
DUSN
RSN
1
2
3
4
5
6
FIGURE 2 Surgical anatomy of the wrist and hand. Injuries to the
extensor tendons can be minimized with blunt dissection to mobilize
them from the surgical approach. The RSN and DUSN are most at risk of
injury at the wrist during radial and ulnar sided approaches, respectively.
Portalsfor wrist arthroscopy arenamed accordingtothe dorsal
extensor compartments: green (1/2), red (3/4), blue (4/5), white (6R)
and pink (6U). Abbreviations :DUSN, dorsal ulnar sensory nerve; RSN,
radial sensory nerve. Source:Courtesy of Virak Tan, MD.
2
&
Tan and Capo
In the fingers, the mid-axial approach is preferred because
it is dorsal to the digital neurovascular bundle. This line is
established by connecting the dorsal most points of the interphalangeal flexion creases and extending it over the proximal
and distal phalanges (Fig. 6). Staying dorsal to the mid-axial line
minimizes therisk of injury to the digitalneurovascular
structures (Fig.7).
&
SUMMARY
The various anatomicstructuresinthehand are inclose
proximity to each other and are critical for precise functioning
of the upper extremity. Thehand and wrist act together as a
specialized unit that has multiple functional requirements: fine
sensation, prehensile power grip, motion in several planes, and
fine dexterity.Theserequirements rely on the appropriate
alignment and integrityof several tissue types, including
bone, tendon, nerve, and blood vessels. Operative procedures
that can repair and/or reconstruct these structures by minimally invasive techniques with decreased trauma to the tissue
and gliding planeswillimprove and accelerate outcomes.
Novel surgicaltechniquesand improvedtechnologies,as
described in this book, have enhanced the field of hand surgery.
Factors that have lead to advances in the hand and wrist
MIS included: endoscopic/arthroscopic technology, high image
ER
3
2
1
RSN
Radial artery
CMC
FIGURE 3 Surgical anatomy of the radial side of the
wrist, showing the relative positionoftheRSN in
relationship to the extensortendonsand underlying
joints. Abbreviations:RSN,radial sensory nerve; CMC,
thumb basal (carpometacarpal) joint; RA, radial artery;
ER, extensor retinaculum. Source:Courtesyof Virak
Tan, MD.
Superficial
palmar arch
Kaplan,s
line
Motor branch
Radial a.
Median n.
PL
FCR
Pisiform
Ulnar n. & a.
Hook of hamate
FIGURE 4 Surgical anatomy for endos copic/minimal incision carpal
tunnel release. The “safe zone” is in the corridor (white rectangular area)
between thepalmaris longus tendon and hook of the hamate. Source:
Courtesy of Virak Tan, MD.
FIGURE 5 Positions of the A1 pulleys relative to the flexion creases in
the palm. The proximal edge of the A1 coincides with the proximal palmar
crease (blackdottedline)in the indexfinger, halfway betweenthe
proximal and distal palmar creases in the middle finger, and the distal
palmar crease (white dotted line) in the ring and little fingers. In the
thumb, metacarpophalangeal crease (black dashed line) indicates the
middle of the A1 pulley. Source:CourtesyofVirak Tan, MD.
Technical Considerations and Anatomical Basis&3