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VID1-00663-en-US | B | Intraosseous Scapholunate Reconstruction: Cadaveric Demonstration

Steven J. Lee

Human

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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Intraosseous Scapholunate Reconstruction: Cadaveric Demonstration

I'm Stephen Jay Lee from New York City. I practice at Lenox Hill Hospital. Today is a technique designed for a complete tear of the scapholunate. So all three components of the scapholunate interosseous ligament are torn. So first we're going to start with a dorsal incision. Incision is usually somewhere between seven eight centimeters or so. It's based off the maybe between the third and fourth compartments. I tend to do at least a pin ectomy on most of my scapholunate procedures. So go ahead and open up the fourth compartment. I'll go ahead and take out the pin nerve, which is usually on the radial border of the radial floor of the fourth compartment. At this point, we'll feel the edge of the distal radius. We'll make a longitudinal capsulotomy, but it is important to be able to see the entire dorsal aspect of the proximal pole of the scaphoid, the distal pole of the scaphoid, and the entire dorsal surface of the lunate part of Part of this procedure is going to involve open booking, the scaphoid and the lunate. And if there are little connections that are still holding you from open booking, then we'll go ahead and transect the rest of them. The rest of those connections at this point going to go ahead and put joysticks in for two reasons. Joysticks is going to help us to open book the two bones so we can get at the insides of the scaphoid and lunate. And also we're going to use them later on to clamp them together so that the the bones can be nice and tight on each other as we're doing the reconstruction. So these joysticks have to be placed with a little forethought. So we're going to put them in a area away from where our future drill tunnels are going to be. So the first one can go into the scaphoid waist. Second one is. So I tend to put it on the ulnar side and maybe a little bit distal. We're going to open up the from inside out with the two joysticks. And we're going to use it put a guidewire into it. So this is where I think the central portion of the of the scaphoid looks like. So this is the dorsal aspect. Here's the palmar aspect and the volar aspect. And this is what I believe is about central. So we're going to go ahead and drill that and drill it just past the laser line. And we're going to use a 3.5mm drill Cannulated drill. This Cannulated drill does have the depth stop as a drill guide that stops you at at one centimeter. So you can drill this all the way to its depth. Stop. So next the drilling of the lunate is a little bit more technical. I'm going to look on the ulnar side just to kind of make sure I'm drilling central all the way through. And again this is going to be drilled to about one centimeter depth. So same thing. We're going to use a 3.5mm drill. This point it's important to go ahead and clear off any soft tissue that you might have around your holes that the soft tissue can kind of get in the way of your tendon graphs. So I'm just going to go look in here. Take my knife. Clear out. That hole looks pretty good. We'll go ahead and irrigate and suck out any debris here. The drill hole that we just made was from inside out on the lunate. Now we're going to make an outside in hole that's going to connect with the drill hole that we made. I usually put some sort of wire into the hole that I just made. It just gives me something to aim at. And then we're going to take another wire and drill from outside in. This outside hole is going to be targeted towards the inside out hole I just made on the lunate. It's going to be on the dorsal ulnar corner. You can see where the articular surface more or less ends on the lunate. And it's going to be just distal to that on the ulnar side. So I'm going to pick a spot. And we're going to angle that in maybe at about a 45 degree and aim towards my other K-wires, which is in the inside out hole. You can usually feel it hit your other K-wires. So I felt that the K-wires move when I drilled that. So I know it should be in that connecting with my other tunnel. Once again, you could use these joysticks to your advantage to try to give to give yourself some room away from your soft tissues. I'm going to take just the end of this needle. It's got a little nitinol wire on the end of it, and one I'm just going to confirm that it connects with my other hole. So I'm going to put it in here and look to see if it shows up on my other hole. So we're going to use a suture passing technique just to put the connect the two holes. I have a suture on the end of this needle. I'm just going to pull that out. So our last hole is going to be in the distal pole of the scaphoid. Be worthwhile to get an x ray or fluoro on this just to confirm that you like the position of that distal pole. So we're going to use a 3.5mm drill for the distal pull the scaphoid same thing down to the one centimeter depth. Stop. Now we've made a drill hole that goes from inside out in the central axis of the scaphoid. And we made a drill hole that started out as an inside hole, inside out hole from the lunate that's connected with an outsider on the dorsal ulnar corner of the lunate, and the last drill hole is in the distal pole of the scaphoid. So we're going to take a tendon graft with an internal brace and stick it into the scaphoid. Shuttle it through the lunate and fix it into the lunate. And then shuttle it into the distal pole of the scaphoid. The overall size of the graph should be about two millimeters in width and about at least ten centimeters in length. This is called FiberLoop. And this is two of FiberLoop that comes in your set. The tendon is on a clamp and we've taken the loop and put it around the tendon. We're going to go ahead and spear this three times. Spear the tendon. Once we've done that, we're going to separate the sutures and let the clamp drop through. And we're going to just repeat that two more times. So I'm going to get this telegraph I'm taking. I'm trying to find a raphe between in the tendon so we can get a nice little intra Graft. And again, I can't stress enough how thin this needs to be. Everyone wants to the one of the big mistakes and you'll see it will cause a problem later on if you get a graph that's too thick. So I'm going to go ahead and take a tendon stripper. Just a standard old tendon stripper. It could be closed or open and put a fair amount of tension on my stitch. And I'm just going to use this just like you would any other tendon stripper. When it's all alone by itself over here, it looks like such a small, thin graft. But that's what I want this. So this measures out to about appears to be about two millimeters in width. And so that looks pretty good for us. Once I have the graph I'm going to go ahead and stretch the graft out. Try to get any creep out of this graft. Put two FiberLoop on both ends of the graft. I recommend you doing it on both ends. For tendon management purposes. The tendon graph is going to shuttle or slide in that pitchfork. And so one of the reasons why I was saying how thin this graph needs to be is that if the graph is too thick, it will not shuttle through that pitchfork eyelet very well. So go ahead. I've put it on the pitchfork, and I'm going to take the limbs of the FiberLoop and hook it on to the tab on the SwiveLock on both sides. And once I do that, I can let go and everything is sitting nicely for me. And then I'm going to add a LabralTape. Great. So if you look at our construct here, we have a tendon graft and LabralTape that's around the pitchfork of the SwiveLock. And you could also see we have the FiberLoop in there as well for suture management purposes. So here's our construct. We're ready to go. We're going to use our joysticks and open book the scapholunate. We're going to put this the tendon graft with the SwiveLock into the central hole of the scaphoid. So you can see that the anchor body is right up Right up against the bone. So once it's like that. So at this point I'm going to hold the square and turn the pair. So we're going to hold the tab steady. And then we're going to go ahead and screw in the anchor body. Until the laser line is flush with the bone. I'm going to go ahead and get rid of undo all these off of your tabs. Now you'll see we have a bunch of limbs here of sutures. So all I really want is the tendon graft and one limb of the LabralTape. So at this point, we're going to pass the sutures that I have on the end of the tendon graft. I'm going to pass it through my. Suture passing stitch as well as one limb of my LabralTape. And we're going to go ahead and just feed this through that inside out hole. Put some firm steady pressure. And this should hopefully come out over onto the outside in hole. And then at this point we would we'd go ahead and clamp down our joysticks to close our inner space together. So if I take the pitchfork off Basically all you have left is a Bio-Tenodesis screw. So we can use this now to secure this graft. And then we can stick this in the hole in the same position that we drilled it. And same thing. Hold the square, turn the pear and send that down into the hole until the laser line is down below. Okay. So at this point we have the it is secure into the scaphoid and now secured into the lunate. This extra limb of the what we use for the LabralTape and for the suture passing for the tendon. Since it's now secured into the scaphoid and lunate, we don't need any more. So I'm going to go ahead and cut this out. If you can see the graph. I've taken the LabralTape and I've twirled it a little bit just to get the tendon graph in the. Labraltape together and to sit sit seed into the SwiveLock a little easier. So I've twirled it and we're going to take the Pitchfork of the SwiveLock, and we're going to go ahead and spear the tendon with the LabralTape near the area of the hole that we made. We're going to let this thing dive into the hole first. So for some firm but steady pressure, slow and firm steady pressure until the anchor body has seated into the scaphoid. So same thing. I'm going to hold the square, turn the pear and let the SwiveLock. Now screw into the drill hole. That's our final reconstruction. I'm going to cut off any ends here that we have. So we have end of tendon graft here and our LabralTape. We'll just cut the end of that off. You'll notice that these two bones are not one coming apart. And two, I'm going to go ahead and move this. And you're going to see because this is a central reconstruction. You can see a little bit of movement here. But you will notice we'll see it on an x ray in a minute. But there won't be any gapping between those two bones and the last limb of this. I just wanted to kind of pull on this with a with a pickup. But you can see how strong this is. And this limb is meant to do mostly to keep that scaphoid from flexing and lunate from extending. But it also gives also some support to GAP resistance between the scaphoid and lunate. I am still putting in a scaffold capitate pin to hold everything together for about 6 or 8 weeks, and hopefully some of those other secondary and tertiary stabilizers will also heal at the same time. The scaphoid capitate pin comes out at about, on average 6 or 7 weeks or so. During that period of time, the patient's been fitted with a thumb spike of forearm based orthopedic splint. And we'll start therapy somewhere in about the 7 or 8 week period of time. And the therapy usually goes on for about six weeks at about three months or so. I will allow them to return back to normal and full activity.

Intraosseous Scapholunate Reconstruction: Cadaveric Demonstration

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