Volar Central Portal in Wrist Arthroscopy
14 September 2015
01 December 2015
15 January 2016 (online)
Background Nowadays, the wrist is not limited to a dorsal visualization; the joint can be thought of as a “box,” which can be visualized from almost every perspective. The purpose of this study was to describe a new volar central portal for the wrist, following three principles: a single incision that allows access to both the radiocarpal and midcarpal joints, centered on the lunate, with the volar structures at risk protected not only by retractors, but also by tendons.
Description of Technique The incision begins in the distal wrist crease and extended 1.5 cm proximally up to the proximal wrist crease, following the axis of the third intermetacarpal space. The flexor superficialis tendons are identified and retracted toward the radial side. Next, the fourth and fifth flexor digitorum profundus tendons are retracted toward the ulnar side, while the third and second tendons are retracted toward the radial side. The volar central midcarpal portal is performed under direct vision just over the anterior horn of the lunate through the Poirier space. The volar central radiocarpal portal is created under the lunate through the interval between the ulnocarpal ligaments and the short radioulnar ligament.
Methods An anatomical study was performed on 14 cadaver specimens. Two data were recorded: iatrogenic injuries of the structures at risk and the distances to the structures at risk.
Results The median (interquartile range [IQR]) distances from the volar central radiocarpal portal to the median nerve, palmar cutaneous branch of the median nerve, and ulnar neurovascular bundle were 10.5 (7.8–15.0), 18.5 (15.8–20.3), and 7.0 (5.0–10.5) mm, respectively. The median (IQR) distances from the volar central midcarpal portal to the median nerve, palmar cutaneous branch of the median nerve, and ulnar neurovascular bundle were 7.0 (4.8–10.3), 16.0 (14.8–19.0), and 4.5 (3.8–9.0) mm, respectively. No iatrogenic injuries were observed.
Conclusion The volar central portal is reproducible and safe. The risk of iatrogenic injury is low. The capsule is pierced through one of its thinner portions, and both the radiocarpal and midcarpal joints can be inspected through one single incision.
- 1 Bain GI, Munt J, Turner PC. New advances in wrist arthroscopy. Arthroscopy 2008; 24 (3) 355-367
- 2 Slutsky DJ. Wrist arthroscopy through a volar radial portal. Arthroscopy 2002; 18 (6) 624-630
- 3 Slutsky DJ. The use of a volar ulnar portal in wrist arthroscopy. Arthroscopy 2004; 20 (2) 158-163
- 4 Jantea CL, McCarthy DM, Herndon JH, Horikoshi M. Palmar approaches/portals for arthroscopy of the wrist. Arthroskopie 1994; 7: 225-231
- 5 Tham S, Coleman S, Gilpin D. An anterior portal for wrist arthroscopy. Anatomical study and case reports. J Hand Surg [Br] 1999; 24 (4) 445-447
- 6 Chang W, Peduto AJ, Aguiar RO, Trudell DJ, Resnick DL. Arcuate ligament of the wrist: normal MR appearance and its relationship to palmar midcarpal instability: a cadaveric study. Skeletal Radiol 2007; 36 (7) 641-645
- 7 Lichtman DM, Wroten ES. Understanding midcarpal instability. J Hand Surg Am 2006; 31 (3) 491-498
- 8 McAdams TR, Srivastava S. Arthroscopic evaluation of scaphoid waist fracture stability and the role of the radioscaphocapitate ligament. Arthroscopy 2004; 20 (2) 152-157
- 9 Ritt MJ, Stuart PR, Berglund LJ, Linscheid RL, Cooney III WP, An KN. Rotational stability of the carpus relative to the forearm. J Hand Surg Am 1995; 20 (2) 305-311
- 10 Moritomo H, Murase T, Arimitsu S, Oka K, Yoshikawa H, Sugamoto K. Change in the length of the ulnocarpal ligaments during radiocarpal motion: possible impact on triangular fibrocartilage complex foveal tears. J Hand Surg Am 2008; 33 (8) 1278-1286
- 11 Wolfe SW, Crisco JJ, Orr CM, Marzke MW. The dart-throwing motion of the wrist: is it unique to humans?. J Hand Surg Am 2006; 31 (9) 1429-1437
- 12 Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989; 14 (4) 594-606
- 13 Corella F, Del Cerro M, Ocampos M, Larrainzar-Garijo R. Arthroscopic ligamentoplasty of the dorsal and volar portions of the scapholunate ligament. J Hand Surg Am 2013; 38 (12) 2466-2477
- 14 Ho PC. Arthroscopic partial wrist fusion. Tech Hand Up Extrem Surg 2008; 12 (4) 242-265
- 15 del Piñal F, Klausmeyer M, Thams C, Moraleda E, Galindo C. Early experience with (dry) arthroscopic 4-corner arthrodesis: from a 4-hour operation to a tourniquet time. J Hand Surg Am 2012; 37 (11) 2389-2399
- 16 Weiss ND, Molina RA, Gwin S. Arthroscopic proximal row carpectomy. J Hand Surg Am 2011; 36 (4) 577-582
- 17 Abe Y, Doi K, Hattori Y, Ikeda K, Dhawan V. Arthroscopic assessment of the volar region of the scapholunate interosseous ligament through a volar portal. J Hand Surg Am 2003; 28 (1) 69-73