The Volar Distal Radioulnar Portal in Wrist Arthroscopy: An Anatomical Study.

Background Advances in wrist arthroscopy and the emergence of novel surgical techniques have created a need for new portals to the wrist. The aim of this study was to define and verify the safety of the volar distal radioulnar (VDRU) portal. Description of the Technique The VDRU portal is located ∼5 to 10 mm proximal to the proximal wrist crease, just on the ulnar edge of flexor carpi ulnaris tendon and radial to the dorsal cutaneous branch of the ulnar nerve. The ulnar styloid marks the distal point of the portal. Methods An anatomical study was performed on 12 upper extremity specimens of 6 human cadavers. Iatrogenic injuries of neurovascular structures potentially at risk were assessed, and the distance from the portal to these structures was measured. Results No iatrogenic injuries of the structures at risk occurred. Mean distances from the VDRU portal to the ulnar neurovascular bundle, the radial branch of the dorsal sensory branches of the ulnar nerve (DSBUN), and the ulnar branch of the DSBUN were 9.29 ± 0.26 mm, 8.08 ± 0.25 mm, and 10.58 ± 0.23 mm, respectively. There were no differences between left and right wrists. The distances from the VDRU portal to the ulnar neurovascular bundle and the ulnar branch of the DSBUN were significantly shorter in women; this distance was not less than 7 mm in any case. Conclusions The VDRU portal is safe, reproducible, and facilitates the implementation of various techniques related to triangular fibrocartilage complex pathology.

Arthroscopic Pisiform Excision in Pisotriquetral Osteoarthritis Technique Using a Direct Pisotriquetral Portal.

Pisotriquetral (PT) joint arthritis is a common cause of ulnar-sided wrist pain. Open pisiform excision is a well-established procedure and is indicated when the conservative treatment fails. Although arthroscopic visualization of the PT joint is part of the routine examination in a patient with ulnar-sided wrist pain, therapeutic arthroscopy of the PT joint is limited to one case in the literature through the standard dorsal portals. Arthroscopic pisiform excision is a novel technique described by the authors. The first aim of this procedure is pain relief maintaining wrist stability and strength. With this minimally invasive approach we believe that preserving the flexor carpi ulnaris and the PT ligament complex we maintain their biomechanical function, while at the same time, reducing scar tenderness and postoperative discomfort with better esthetic results and less recovery time. In addition to standard dorsal portals, a direct PT portal was used to have access to the PT space and as a working portal to complete the pisiform excision.

All-Arthroscopic Triangular Fibrocartilage Complex Ligamentoplasty for Chronic DRUJ Instability.

Peripheral injuries of the triangular fibrocartilage complex can produce pain and instability of the distal radioulnar joint (DRUJ). There are several techniques for the repair or reconstruction of these injuries, which vary depending on the location, healing capacity, and viability of the tissues, as described by the classification proposed by Atzei. In irreparable chronic injuries of the triangular fibrocartilage complex in which there are no associated chondral injuries of the DRUJ or in failures in previous repair techniques, ligament reconstruction plasty with tendon grafts, either by open surgery or assisted by arthroscopy, are the treatments of choice. We present a completely arthroscopic reconstruction technique of the triangular fibrocartilage complex by means of tendon graft to provide stability to the DRUJ. This reconstruction technique provides a more stable reconstruction after the integration of the tendon plasty in the bone tunnels, based on the anatomic insertions of the triangular fibrocartilage in the fovea and in the corners of the dorsal and volar sigmoid notch, along with the advantages offered by arthroscopy in terms of recovery time, esthetic result, less mobility loss, and pain.