Radiographic Landmarks for Ideal Port Placement in Wrist Arthroscopy

Background The placement of wrist arthroscopy portals is traditionally performed using distances from anatomic landmarks. We sought to evaluate the safety of traditional portal placement and determine if radiographic landmarks could provide an additional method of identifying tendon intervals. Methods Six cadaveric specimens were used to evaluate the accuracy of portal placement based on anatomic and radiographic landmarks. Fluoroscopic images were used to document the location of previously described surface landmarks. Soft tissue was dissected away to identify the relationship between the transcutaneously placed portals and the extensor tendons. With soft tissue removed, tendon intervals were identified in relationship to anatomic carpal bone landmarks, and interval distances measured. Portals were then placed under radiographic imaging on the final three specimens and accuracy was examined by the removal of overlying soft tissue to confirm accurate interval placement Results The 3,4 portal was safely placed using only surface anatomic landmarks, however the 4,5 and midcarpal ulnar (MCU) portal sites were not consistently placed in the intended tendon interval, especially in larger wrists. Radiographic interval targets for the 3,4 portal were identified at the ulnar aspect of the scaphoid and the 4,5 portal at the ulnar one-third of the lunate. The radiographic site for the MCR was located at the inferior radial one-third of the capitate and the MCU portal was located at the radial aspect of the hamate. The 6R portal radiographic landmark is at the radial aspect of the triquetrum and 6U at the ulnar aspect of the triquetrum. Conclusion Portal placement in wrist arthroscopy based on anatomic landmarks alone can be unreliable in larger wrists. Radiographic imaging based on carpal bone landmarks provides an additional tool for consistent placement of portals in wrist arthroscopy and may limit unintended injury to extensor tendons. Level of Evidence This is a Level VI study.

Hip arthroscopy via a peripheral compartment first capsular-preserving technique: a step-by-step description

Hip arthroscopy is a well-recognized procedure for the treatment of several hip pathologies. Different methods of arthroscopic access to the hip have been published. The most popular approach is the central compartment first technique, where the first portal to the central compartment is placed under traction and fluoroscopic control. This technique, however, carries the risk of iatrogenic damage to the cartilage and labrum, especially when adequate distraction cannot be obtained. In addition, secondary exposure of the peripheral compartment frequently requires larger capsulotomies. The current article is to describe an alternative arthroscopic approach to the hip with the peripheral compartment being first accessed. The peripheral compartment first technique offers the advantages of a limited capsular release for peripheral compartment exposure and a reduced risk of iatrogenic cartilage and labrum damage during subsequent central compartment portal placement.

Prevalence of Ganglion Cyst Formation After Wrist Arthroscopy: A Retrospective Longitudinal Analysis of 2420 Patients

Background Dorsal wrist ganglion cysts arise from the leakage of synovial fluid through tears in the scapholunate ligament and/or dorsal wrist capsule. An analogous disruption of the dorsal capsule is created with routine portal placement during wrist arthroscopy. We hypothesized that wrist arthroscopy would predispose to wrist ganglions. Methods Using the Truven MarketScan Outpatient Services Database from 2015 to 2016, patients who underwent wrist arthroscopy and developed an ipsilateral wrist ganglion were identified. Exclusion criteria included ganglion diagnosis preceding arthroscopy and bilateral pathology. Postoperative ganglion diagnosis was modeled with logistic regression. Predictor variables included age, gender, comorbidities, and arthroscopic procedure. Results In all, 2420 patients underwent wrist arthroscopy. Thirty (1.24%) were diagnosed with an ipsilateral wrist ganglion at a mean time of 4.0 months (standard deviation: 2.4, range: 0.2-9.0). Significant predictors of ganglion diagnosis included female gender (odds ratio [OR]: 4.0, P < .01) and triangular fibrocartilage complex and/or joint debridement (OR: 0.13, P < .01). By comparison, among all 24,718,751 outpatients who had not undergone wrist arthroscopy, 39,832 patients had a diagnosis of a wrist ganglion cyst (0.16%). Conclusions Wrist arthroscopy is associated with a postoperative rate of ganglion cyst formation that is nearly 8 times the rate in the general population. Additional studies are needed to investigate techniques that minimize the risk of this complication.

Do Patient Positioning and Portal Placement for Arthroscopic Subtalar Arthrodesis Matter?

Background: Arthroscopic subtalar arthrodesis was first described over 2 decades ago and originally performed in the lateral decubitus or supine position using anterolateral and posterolateral portals situated about the fibula. More recently, several authors have advocated for prone positioning utilizing posteromedial and posterolateral portals with an optional accessory lateral portal. To date, a comparison of these techniques has been limited. Purpose: To determine the effect of patient positioning and portal placement on complication rates after arthroscopic subtalar arthrodesis. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Patients were placed into 1 of 3 groups: the lateral group if they were positioned lateral or supine with lateral-based portals; the 2-portal prone group if they were positioned prone with posteromedial and posterolateral portals; or the 3-portal prone group if posteromedial, posterolateral, and accessory lateral portals were utilized in the prone position. Inverse variance–weighted fixed-effects models were used to evaluate pooled estimates. Results: A total of 20 studies examining 484 feet in 468 patients with a mean follow-up of 36.1 months were included for analysis. Overall, 8 studies examined patients in the prone position with 2 posterior portals (n = 111; 22.9%), 7 articles evaluated lateral portals (n = 182; 37.6%), and 5 studies examined patients in the prone position with 3 portals (n = 191; 39.5%). The total complication rate was similar ( P = .620) between the 2-portal prone (18.9%), 3-portal prone (17.8%), and lateral (17.6%) groups. There was no difference observed in the rate of complications secondary to portal placement ( P ≥ .334), rate of painful hardware ( P ≥ .497), and rate of repeat surgery ( P ≥ .304). The 2-portal prone group had a significantly higher rate of nonunion than the lateral group (8.1% vs 1.1%, respectively; P = .020) but not the 3-portal prone group (5.8%; P = .198). Conclusion: The current study demonstrated a higher rate of nonunion following arthroscopic subtalar arthrodesis with prone patient positioning using posteromedial and posterolateral portals without an accessory lateral portal.

Portal placement for endoscopic surgery in the deep gluteal area: a cadaveric study

Partial or complete avulsion of the insertion of the proximal hamstrings at the level of the ischial tuberosity is most often treated by open exploration and reinsertion. However, endoscopic reinsertion could be considered to minimize the soft tissue damage. In this study, we aimed to determine the most optimal location of four endoscopic portals that allow for a safe exploration of the proximal hamstring insertion site. The reference points for the portals run vertically through the center of the sciatic tuberosity and through a horizontal line which lies on the inferior edge of the tuberosity. The distance and relationship between the sciatic, the inferior gluteal and posterior femoral cutaneous nerves and the four proposed endoscopic portals was documented. Our results showed that it was best to start with the inferior portal followed by the medial and lateral portal. The inferior portal allowed for a clear visualization of the sciatic nerve and was along with the medial portal at a distance of &gt;5 cm from any of the surrounding nerves. Care must be taken with the lateral portal, as the distance to the surrounding nerves varied between specimens. A fourth portal could be used as a viewing portal when necessary. Our study showed that the sequence and position of the proposed endoscopic portals provide a safe approach to the proximal part of the hamstrings and the ischial tuberosity. These findings can be helpful for endoscopic procedures to the ischium and the sciatic nerve in the gluteal region.