Wrist Ligament Surgery

Transcript:

Let’s talk about wrist ligament surgery. The wrist ligaments are small ligaments that hold the eight bones in the wrist together, and they provide important tethering of these bones during wrist movement. When just one ligament becomes disrupted, this alters the mechanics of the wrist, which can cause significant pain and significant limitation of function, leading to premature arthritis over the long term. This occurs most commonly from a fall and an outstretched wrist. Look at this snowboarder going down, all his body weight under the hard surface with that extended wrist. Frequently, you go into the emergency room; these patients get normal x-rays, which is usually the case, and this does not rule out a soft tissue or significant ligament disruption in many cases, so it’s frequently missed. The diagnosis is missed, and after several months, the patient may just present to our office when frequently it’s too late. Now let’s look at the anatomy of the wrist. This shows the carpal bones right here, the forearm bone, the radius, the ulna, over to the left-hand side. You can see the scaphoid bone here, the scapholunate ligament, which is a blue ligament between the scaphoid and the lunate, and over between the lunate and the triquetrum is a lunotriquetral ligament. These are one millimeter-thick ligaments that tether these three bones together, very important structures. But the most frequently torn tears of ligaments in the wrist, let’s look at an MRI now. This is called an MR arthrogram, and it’s the gold standard for diagnosing ligament tears in the wrist before performing invasive arthroscopic surgery. This shows the fluid, this white fluid that’s injected into the radiocarpal joint, which is the arthrogram component of the test. This fluid, this fluid should stay right along this joint; it should not enter between these bones as you see it doing here. And you can see this arrow is pointing to a disruption of this black line, which is the scapholunate ligament. Now, initially with a ligament tear on the wrist, conservative treatment would be about four to six weeks in a cast or brace, and sometimes that will heal. But after that period, there’s about a three-month golden period where we aggressively treat these with minimally invasive arthroscopic surgery to go in and try to get these ligaments to heal. Let’s look at an actual normal scapholunate ligament. This is a lunate here, this bone is covered by normal cartilage, and then over on the scaphoid, the same, and then there’s this fluffy ligament where the arrow is pointing, called the scapholunate ligament, that can be disrupted. So let’s look at an actual disruption here. This is through again, looking at the monitor, we’re seeing in surgery through a two-millimeter cut. We’re putting in this tube that broadcasts through a camera to this monitor, we’re seeing right here, this image. Through a second two millimeter cut on the back of the wrist, we’re putting in this small probe that looks magnified, looks large here, but it’s really a very fine probe that is actually coming in and hooking behind the scaphoid of the scapholunate ligament, pulling it away from the scaphoid. It’s a pretty substantial tear. Now, usually these ligaments are torn down the middle, in which case they don’t have the ability to be repaired. Sometimes, though, they’re pulled off the edge of the scaphoid or the lunate, where you can actually go put an anchor in place and tie these down. But in this case, minimally invasive surgery ligament is, as we said, is frequently torn down the middle. So what we do is we go in and put three stainless steel pins between the carpal bones where the ligaments torn, the scaphoid, the lunate. Three stainless steel pins are placed in. These are cut off right underneath the skin. But this shows again normal alignment of the scaphoid and the lunate. Now, the next most common ligament to be torn is the lunotriquetral ligament. You can see the lunotriquetral ligament is in this depression here between the triquetrum and the lunate down in the bottom left-hand corner, but it’s in this area, as you can see, this can be torn. Well, let’s look at a tear. This is a little grainy, but you can see here the triquetrum and the lunate where the L is, and you can see this gap right here. And so what we want to do is we want to put these pins in that will be in for a period of time that will allow these ligaments and the bones to adhere together to restore stability to these hypermobile bones. So let’s look at actually the, again, pins coming in from the opposite side of the wrist with this less commonly torn lunotriquetral ligament. We put three pins here that rigidly hold these bones together. Now these pins will stay in for about eight weeks, and then through another little five-minute outpatient procedure, we take the pins out, and we start rehab. It’s a very carefully orchestrated rehab protocol that we follow for about three months before return to normal function. The success rate is 80% when it’s in that three-month golden period. Each month that goes beyond from that becomes less successful. But overall, the success rate is much greater than the much larger, more invasive reconstructive procedures that are done for more chronic injuries. For more on this condition and many conditions, please visit the Hand and Wrist Institute website.