Christian Dumontier Institut de la Main & hôpital saint ... - ClubOrtho.fr

Débridementarthroscopique du poignetChristian DumontierInstitut de la Main & SOS Main saint Antoine,ParisMerci au GEAP/EWAS

Débridement ?LibérationRaideur capsulo-ligamentaire (arthrolyse)AblationCorps étrangers (PSA scaphoïde, Kienböck,...)Arthrose (styloïde radiale, wafer, hamatum, STT, TM,...)Déchirure ligamentaire (TFCC)Synovite (PR)Kystes synoviaux

Lésions ligamentairesDébridement TFCCDébridement ligament scapholunaire

Débridement TFCCSeuls les 25% périphériques sont vascularisésToutes les lésions “centrales”, traumatiques oudégénératives ne peuvent cicatriserAblation arthroscopique

Débridement TFCCScope dans voie 3/4Instrumentation 4/5 (ou 6R)Apprécier l’étendue de la rupture

Techniques de débridementdébridement mécaniqueLambeau instabledébridement électrique (VAPR)

Débridement TFCCDifficultés:La partie postérieure du TFCC(trop proche de l’instrument)Garder suffisamment de bergepour ne pas déstabiliser laRUD

Débridement TFCC- gestesassociésUlna long avec conflit ulnocarpienRésection arthroscopique del’ulna (Wafer) 2/3 mm

Wafer: difficultésEnlever (assez) et de façon régulièreUtiliser la pronosupination (difficultésen arrière)Ampli de brillance

Wafer: difficultésEnlever assez en dehorsSans abîmer le cartilage radial

Débridement TFCC- gestesassociésLésions cartilagineuses en miroir(excision des fragmentscartilagineux libres)

Débridement TFCC:résultatsOsterman (52 cas)85% de bons et très bons résultatsFontes (248 cas)84% de bons résultats (traumatique)63% de bons résultats (dégénératif)

Débridement ligamentinterosseuxRéinsertionDébridementLuno-triquetral (peu accessible)Scapholunaire: seule la portion proximale estavasculaire et peut être débridée85-100% indolence dans séries anciennes

Lésions cartilagineusesChondrite hamatumArthrose stylo-scaphodïenneArthrose STTArthrose TM

Chondrite hamatumPlus fréquente dans les lunatumde type 2Non visible à l’arthroscannerDouleurs ulnairesCHL

Styloïdectomie

Ablation du fragment proximal d’unepseudarthrose du scaphoïde

Prothèse partielle associée

Résection fragments arthrosiques

ArthroseSTT : Résection pôle distal duscaphoïdeDifficultés: Etre régulier, letrapézoïdeTM : (peu d’expérience)

Divers

DiversRésection d’une cicatricefibreuse post-fracture duradius

SynovectomieDans la PRIsolée si atteinte intra-articulaireexclusiveAssociée à un geste tendineux àciel ouvert (même temps ou 2temps opératoire)

ArthrolyseSection capsulo-ligamentaire dansles raideurs post-traumatiques oupost-algodystrophieGeste difficile en arrière

ConclusionEn dehors des lésions du TFCC dont les indications etles résultats sont “validés”Les autres indications sont possibles, probablementutiles mais on manque de séries cliniques pourapprécier leur place réelle et leurs résultats

Wrist ganglia: naturalhistory, results of surgicaland arthroscopic treatmentChristian Dumontier, MD, PhDInstitut de la Main & hôpital saint Antoine, Paris

Wrist ganglia: how frequent are they ?Lowden (JHS 2005): MRIstudy58% in females, 48% inmales70% anterior, 14% dorsalVariable localization

Wrist ganglia (clinical)Dorsal scapholunate : 2/3 of thegangliaVolar : 1/3Other localization: rarer (joint effusion)

What is a dorsal wristganglion ?Mucoid degeneration of thescapholunate ligament (Kuhlman 2003)due to differential tearing during wristmotionMore frequent in lax people (females)

Dorsal wrist gangliaLocalization may vary according tothe way the ganglion exits the wristcapsule and they look eitherradiocarpal or midcarpalMethylen blue injectionof an ulnar-sidedganglion

Volar wrist gangliaOriginate from the anterior part of the scapholunateligament between radio-scapho-capitate andradiolunate ligaments

ExampleVolar ganglion arising between radiolunate andradioscaphocapitate ligamentNeedling (arthroscopy with air)

However !According to Angelides, 50% of volarwrist ganglia originate from the STTArgentin authors reported variableradiocarpal origin1/3 of volar ganglia did not originatefrom the radiocarpal joint (Rocchi)A precise radiological examination is needed toknow where does the ganglion originate

Imaging modalitiesPlain X-rays are needed toeliminate another pathology

Imaging modalitiesMRI or sonography may be useful to make thediagnosis in atypical localizationI use sonography to know where does the ganglioncome from

Natural History ??40% of 101 ganglia disappeared by 6 years (Zachariae, 1973)9/19 disappeared by 10 years (McEvedy, 1955)

Natural History ?28/39 (72%) volar gangliadisappeared by 5 years(Dias 2003)45% of volar ganglia willdisappear within 6 years(Trent audit - Burke 2003)63% of volar gangliadisappeared at 10 years(Derby audit - Burke 2003)23/55 (42%) dorsal gangliadisappeared by 6 years(Dias 2007)33% of dorsal ganglia willdisappear within 6 years(Trent audit - Burke 2003)51% of dorsal gangliadisappeared at 10 years(Derby audit - Burke 2003)VolarDorsal

Non-surgical treatment ?No !Press the ganglion with the corner of a Holy book / acoin,..Fluid aspiration +/- steroid injectionsPlace suture into the ganglion and leave it in place for 3weeks....

Why can we treat a ganglionunder arthroscopy ?Surgical treatment should debride the base, not removethe pocket1971, Fowler:Propose to only ressect the capsule in dorsal ganglia.1987, Osterman:Cure incidently a patient of her dorsal wrist ganglionduring a wrist arthroscopyStarts a prospective study of 18 cases published in1995

How do we do ?Wrist arthroscopyScope 2,7 mm / Shaver +/- RF probeArthroscopic approachesDébridement of the pathological capsuleWhere is it ?Enough, not too much resection !

Dorsal gangliaFig 1. Dorsal anatomic landmarksof dorsal carpal ganglioncysts.As the ganglion is dorsal, like thewas attempted. This procedure has been performed since theportalsmid to late 1980s and is currently an accepted and valuableprocedure for the wrist arthroscopist. Only individuals with aworking knowledge of basic wrist arthroscopy should performthis procedure.An understanding of the external and deep anatomic landmarksof the dorsum of the wrist and hand is essential. Thearthroscopic portals to be used during this procedure are the3-4 portal, 4-5 or 6R portal and the midcarpal radial and ulnarportals (Fig 2). Preoperatively the cyst is circumferentiallymarked. Standard wrist arthroscopy equipment is necessary tocomplete this procedure. A 1.9 mm or 2.7 mm 30 degree angledarthroscope is used for visualization. Also needed are the ap-Very tangent, work “a retro”propriate TV monitor, VCR, Video camera, power for theScope 6R portalShaver in the 3/4 (1/2) portalEXCISION OF DORSAL CARPAL GANGLION CYSTS 119Start arthroscopy with air to find itsbase of implantationarises from the distal dorsal scapholunate joint, arthroscopicexcision of these cysts makes some sense.The hypothesis that dorsal carpal ganglion cysts are a manifestationof stage I scapholunate instability makes arthroscopicexcision of the dorsal carpal ganglion cyst attractive as it allowsfor further evaluation of the scapholunate ligament. Dorsalwrist pain is commonly caused by occult dorsal carpal ganglioncysts. Having a dorsal carpal ganglion cyst does not rule out thepossibility of other intraarticular wrist pathology. For all thesereasons, arthroscopic excision of dorsal carpal ganglion cystsshaver, wall suction, an illuminator, and a source for continuousirrigation. Two or four fingertraps can be used dependingon the surgeons preference. A hand table is used to support thearm and a traction device is needed for distraction. Also needed,are a 2.9 mm full radius shaver, probe, basket and graspingforceps. A radio frequency probe can also be used if the surgeonis comfortable with its use in small joints.Anesthesia of the arm is typically done as a regional block butgeneral anesthesia is acceptable. Tourniquet control is usuallynecessary for visualization and the tourniquet should be inflatedto 250 mm mercury pressure before beginning the procedure.The patient’s arm is prepped and draped with antisepticsolution. Before beginning the procedure the wrist can be examinedfor any instability. The ganglion, if not previously outlinedcircumferentially, should be marked at this time. The armis then placed in the wrist traction tower with 10 pounds ofweight placed on the device. To accomplish this, the arm mustbe secured to the table so to give reasonable counter traction.The radiocarpal joint may insufflated with a saline solutionwith a 25-gauge needle and a 10 mL syringe. If this is done, itshould be done through either the 4-5 or 6R interval. Doing thisalso allows one to accurately find the radiocarpal joint. No morethan 5 to 6 mL of fluid can be placed into the radiocarpal joint.If more fluid can be placed, it often indicates that there is aperforation in either the triangular fibrocartilage complex orthat there is a communication between the radiocarpal andmidcarpal joints. A small incision is then made directly over the4-5 or 6R portal. Blunt dissection with a small hemostat isperformed through the incision down to the wrist capsule andthe wrist capsule is entered bluntly. Some moderate force istypically necessary to perforate the wrist capsule, so care mustbe taken not injure carpal structures, or to penetrate the volarwrist capsule. Once the 4-5 or 6R portal is established, thetrocar canula apparatus is then placed atraumatically throughthe established portal. This portal will now be used as theprimary visualization portal for the resection of the ganglion.The ulnar radiocarpal joint is now inspected for any intraarticularpathology. Any significant pathology is noted at this time.On completion and inspection of the ulnar radiocarpal joint,the arthroscope is pointed dorsally and radially to the area ofthe ganglion (Fig 3). The ganglion is easily transilluminated atthis time and its full extent can be determined. Most of the timea stalk can be visualized coming from the dorsal aspect of thescapholunate ligament (Fig 4). Osterman has described fourarthroscopic findings in patients with the dorsal carpal ganglioncysts. 10 Twenty-six percent of patients will have a largeganglion stalk visible, 37% will have an intraligamentous stalk,(Fig 5), and 37% will have no stalk identifiable (Fig 6). Synovitiswill be present dorsally in 89% of patients (Fig 7). Oncethis assessment is complete an 18-gauge needle is placedthrough the ganglion cyst, rupturing it. The needle is thenadvanced into the radiocarpal joint through the 3-4 portal. A

Find thescapholunatespaceRemove synovial2fringes1Follow the SL ligamentdown to the capsule3

Look for a ganglion in theSL ligament(visible in 30-60% ofcases)Excise it(with moderation)54Then resect the6capsule

A trick6bisI use methylene blue (few droplets) injected in theganglion before starting to better find itsimplantation base

Excise the capsule to8empty the ganglia7Up to the tendons8

DifficultiesDuring capsular excision, fluid flows in thesubcutaneous tissuesLoss of pressure = loss of visibilitySometimes difficult to differentiate between the capsuleand the tendons ! Beware

Associated lesions ?Not in my experience50% in Osterman’s series100% in Polvsen’s seriesNo patient had an associated surgery,none had instabilityNo relation ganglion and instability

Volar gangliaArthroscopic treatment is much moreeasierScope in 3/4 portalShaver in 1/2 portalFind its origin with air

1See the spacebetweenligamentsExcise, with the2shaver up, thecapsularinsertion on theSL ligament

3Size of needed excisionis unknown

What are the results ?No scar surgery

Results: wrist mobilityNo stiffness1% to 25% of patientshad some stiffness afteropen surgeryMobility: 96% ofcontrolateral side after A°

Results: grip strengthNo loss of strength2% - 45% of pts lost 10-20% of their grip strengthafter open treatmentSymetrical grip strength in 96% of endoscopicallytreated patients

Results: return to workEarlier return to work15 - 42 D after surgical treatment8 - 21 D after endoscopic treatment

Results: pain reliefMost patients experienced some persisting pain for 2-3months after endoscopic treatment. 85% were painfreeat follow-up (11% in Osterman’s series)After open treatment15% scar tenderness or sensitivity (Dias)28% pain, dysesthesiae (Jacobs)

Recurrence rate ?0% Guiboux0% Shih (32 cases, 26 months FU)1/150 (Osterman), 1/14 (Pederzini, 1995), 1/21 (Viegas,2003), 1/32 (Fontes, 1997), Nishikawa, 20012/34 (Luchetti, 2000);

Recurrence rate ?10,7 % at 1 year (Kang,2004)25% (Ho, 2001)30% (personal series), 50%occuring after 2 years of FU

Results of surgical treatment ?1% recurrence rate (Angelides,1976)3% (Clay, 1988) - 4% Barnes (1964)14% (Faithful, 2000)15% Le Viet (1991), Amadio (1993)27% (out of 370 dorsal ganglia) and 40% (out of 230volar ganglia) - Dias 2003, 200728% (262 dorsal); 25% (166 volar) - Derby audit28% volar (Jacobs)

Prospective study ?1 year follow-up, prospective randomized study(Kang 2004) on dorsal wrist gangliaNo difference between groups10-15% still complain of symptoms10,7% recurrence (A°) vs 8,7% (open)

Prospective study ?Rocchi (2008): compared 30 open vs 30 A° volargangliaRecovery (15 days vs 6), RTW (23 days vs 10)2/3 excellent results in both groupsMore complications in the open group

Does arthroscopic treatment4improve the results ?OpenArthroscopicPain = =Scar - +Mobility - +Strength - +Return to W - +

RememberA benign lesion whose natural history is to disappear inabout 40% of casesSurgical treatment carries a (low) risk of complicationswhile arthroscopic treatment had little complicationsPatients are more satisfied after surgical removal oftheir ganglion even if they had recurrence

Temporary conclusionNatural history is still poorly knownFunctionally disabling ganglia should besurgically treatedPatients treated arthroscopically and whom ganglionhad not reccured are very satisfied !Those whose their ganglion had reccured still havesome persisting symptomsComplications of arthroscopic treatment are very rare