Toen ik bij deze ingreep stond, ging de Brunelli plastiek na openen en identificeren van het ligament niet door, de slijtage was namelijk bij deze patiënt op de lunatum geconcentreerd, niet op het scaphoïd, het vastzetten met de pees zou voor versnelde slijtage hebben gezorgd. Er werd besloten om te sluiten en met de patiënt te bespreken wat de alternatieve opties zijn.
Het operatieverslag kreeg ik van de assistent van een eerdere situatie.
Ind
Scaphoidlunatum ligament dislocatie, zie verder onderaan
Dat
Aug 2015
Netten
Handen net
Evt. Mitek Boor doos (voor Mini Mitek Anchor)
PCH Boor/zaag net (niet voor Mitek boor, die gaat op de hand, zelfs zonder jacobsklauw
boorrekje (nu nog MKA klein boorrekje, ooit rekje op PCH boor/zaag net)
Gecannuleerde boor doos
Zwachtel vlgs. Martin
App
Diathermie (alleen bipolair: 10 watt)
Bloedleegte
accu voor boor
Pos
Rugligging,
armtafel (röntgendoorlaatbare armtafel, doorlichting voor controle K-draden-positie)
krukken voor artsen en instr., de turquise PCH-stoelen hoeven niet meer
Thema
Dagbak
Gebruikersmand met K-draden
gipskar
Afd
Handentray
Disp
Deppers
10x10
Bonney's Blue
spuitje voor Bonney's Blue (omloop trekt dit op en spuit een beetje in kommetje voor instr.)
kommetjes
mesjes 15 (
PDS loop (splijten FCR pees), cave: Dr O. Gebruikt evt. cardio kinder sternumdraad
Vicryl 2-0 FS (peeshechting),
monocryl 5-0 (huid)
suture retriever
K-draden
lomatüll
synth. watten
crepe zwachtel
gips
Evt mini mitec ankor
Operatieverloop
Evt. vooraf een arthroscopie van de pols om wel of niet arthrose aan te tonen. Bij arthrose wordt afgezien van de plastiek.
Incisie voor het oogsten van de Flexor carpi radialis (opvoeren suture retriever vanuit distaal, PDS loop door 1/3 dikte van pees halen met de naald, dan lus maken van draad, deze middels de suture retriever geleiden, dan met de PDS draad de pees op de hele lengte splijten, uiteindelijk heb je de peesstrip uit de distale incisie hangen, hiermee wordt de plastiek gemaakt)
Incisie onderarm, ook daar flexorpees opzoeken, hechting op dit deel van de pees zetten., proximaal hiervan pees doornemen en distale deel middels de opgevoerde suture retriever naar distaal (van onderarm naar pols dus) doortrekken.
Op distale pool een opening frezen
Dorsaal op pols 3de incisie, opzoeken scaphoid en lunatum. Bevestigen dat het om een totale ruptuur van het ligament gaat.
Gat frezen op distale dorso-ulnaire scapoid.
Boorgaten verbinden (K-draad)
Tunnel over boorgaten creëren (gecanulleerde boor 2.7 mm)
Opnieuw suture retriever opvoeren van FCR slip vanuit distale pool scaphoid naar dorsale SL-regio.
4de incisie ulnair van ECU, prepareren tot triquetrum.
Vanaf triquetrum K-draad richting dorsale lunatum boren
Doorlichting om K-draad positie te controleren (hoeft niet bij Dr S.)
Hier overheen tunnel boren (gecanuleerde boor)
Doorvoeren slip van FCR (suture retriever) vanaf SL-regio naar triquetrum.
Over dorsale polskapsel en onder extensoren doortunnelen naar ulnair, hierdoor oppervlakkig terughalen van FCR-slip naar SL-regio.
FCR slip fixeren op zichzelf en op RT-ligament (Vicryl 2-0 FS)
Doorlichting voor controle of scaphoid in extensie staat en SL-gap gesloten is, lunatum moet neutraal staan.
Evt. Bij totale dislocatie van SL ligament is ook een Mini Mitek Anchor nodig, hiercoor ook een Mitek boordoos
Sluiten incisies (monocryl 5-0)
Onderarmgips
van medscape.com
Scapholunate instability
There is no consensus on the appropriate treatment of scapholunate instability. The treatment is usually specific to the different stages or degree of injury. Partial tears of the SLIL are thought to represent occult or predynamic instability.[18, 39]For these injuries, most recommend an initial trial of splinting and/or casting.[39, 40] Arthroscopic debridement with or without pinning can be an option in these patients in whom initial conservative treatment is unsuccessful.[41, 42]
A complete tear of the SLIL may not by itself lead to an acute scapholunate gap or diastasis. Biomechanical studies support the concept that additional supporting ligaments must also be injured for this gap to be apparent. In addition, attenuation of these ligaments may lead to a diastasis that is observed late with respect to the initial injury date. In either case, a complete tear of the SLIL is suggested in the presence of the significant scapholunate diastasis on static or dynamic radiography.
With complete SLIL tears, cast immobilization does not reduce or prevent scapholunate diastasis.[39] Significant force occurs at the scapholunate interval on wrist loading. Options for acute management of these tears include direct repair with or without dorsal capsulodesis or arthroscopic debridement, reduction, and pinning. Some recommend the latter treatment for acute (< 3 mo) tears that have evidence of instability on static radiography (gap < 3 mm or DISI).[41, 42]
A retrospective study by Weiss et al showed that 33% of patients who underwent arthroscopic debridement, reduction, and pinning of complete SLIL tears had persistent pain and required further surgery.[43] Most reconstructive wrist surgeons recommend direct repair for acute (< 6 wk) tears if a sufficient SLIL remnant is present.[39, 44] Lavernia et al reported on dorsal capsulodesis to augment a direct repair and demonstrated good results in 81% of their patients.[45] Satisfactory results were seen in patients, even as long as 3 years after injury.
In patients with unrepairable SLIL but with a reducible scapholunate interval and without degenerative changes, an indirect or direct ligament reconstruction has been advocated. Typically, the presentation is chronic, and the SLIL is usually not repairable. Indirect ligament reconstruction is based on stabilizing the scaphoid to prevent the rotatory subluxation that often occurs in scapholunate instability.
Some indirect ligament reconstructions also attempt to close the scapholunate gap. The most widely used indirect ligament reconstruction is the Blatt dorsal capsulodesis.[46] This technique uses a flap of dorsal capsule to tether the scaphoid tuberosity to retard scaphoid flexion. Because the flap is attached to the distal radius, wrist flexion is significantly reduced by 20% on average.
More recent techniques attempt to avoid limitation of flexion by not tethering the scaphoid to the radius.[47, 48] Several techniques have been described. As Berger et al initially proposed{Ref3} a strip of dorsal intercarpal ligament detached from the triquetrum can be used to tether the distal scaphoid pole to the lunate or radius (see image below). Slater et al described the use of a portion of the dorsal intercarpal ligament that attaches to the distal scaphoid and trapezoid and reinserts it to the distal pole of scaphoid tuberosity.[48] These authors believe that this technique not only serves to limit scaphoid flexion but also reduces the scapholunate gap more effectively than the Blatt capsulodesis.
Mayo dorsal intercarpal (DIC) capsulodesis. Copyright Mayo Clinic, used with permission of Mayo Foundation.
Direct ligament reconstruction is indicated when the SLIL is not directly repairable, when the scapholunate dissociation is reducible, and when no evidence of degenerative arthritis is observed. Some also believe that evidence of carpal instability (DISI) should be absent.[39] Techniques for this approach involve either a tendon to reconstruct the SLIL or a bone-ligament-bone construct.[39, 49, 50, 51, 52] All of these techniques have had some degree of success, but they are not universally durable. They require a long period of wrist immobilization and result in some loss of final wrist motion.
Brunelli and Brunelli described one such technique that shows promise.[50] Their technique uses a strip of the flexor carpi radialis (FCR) and weaves it through the scaphoid. The tendon is also sutured across the scapholunate interval. Limited intercarpal fusions are indicated when carpal instability (DISI) is present without gross evidence of degenerative changes at the radiocarpal joint.[39]
Fusions that have been described involve the scaphocapitolunate,[53] the scaphotrapezial trapezoid,[21, 54, 55, 56, 57] the scaphocapitate,[58] and the scapholunate.[59] Viegas et al found that the scaphocapitolunate and scapholunate fusions distributed the load more uniformly across both the scaphoid and lunate fossae than the scaphotrapezial trapezoid or scaphocapitate fusions.[60]
For studies of new techniques, see Garcia-Elias[61] , Ogunro[62] , Short[63] , and Danoff.[64]
When arthritic change (advanced scapholunate collapse) or a wide, irreducible scapholunate gap is present, options include a proximal row carpectomy or scaphoid excision and fusion of the lunate, triquetrum, capitate, and hamate (4-corner fusion). Significant degenerative changes at the proximal hamate or of the lunate fossa are a contraindication to proximal row carpectomy. Once pancarpal arthritis involves the lunate fossa, the best surgical option may be total wrist fusion.