Use of the Triquetrum-Hamate Portal in Four-Corner Wrist Fusion: A Useful Technical Trick

Abstract

Arthroscopy-assisted partial wrist-fusion techniques are becoming more popular nowadays. It became clearer that avoiding the violation of important ligament and tendinous structures - which is impossible when using the classic open techniques - enables a more biological approach, which is essential for faster healing and improvement in function. We describe the use of the triquetrum-hamate (TH) portal, which is seldomly applied in routine arthroscopic techniques for hand and wrist surgery, as an accessory portal to better perform anterior midcarpal debridement in four-corner fusion. This trick enables an almost complete anterior resection of the capitate and hamate chondral surfaces, increasing the subchondral osseous contact in the midcarpal joint after fixation, thus leading to higher consolidation rates.

Keywords: arthroscopy; osteoarthritis; wrist injuries; wrist joint.

Fig. 1

( A ) Dorsal view of the wrist after the creation of the triquetrum-hamate (TH) portal distal to the 6U portal. ( B ) Ulnar view of the wrist after the creation of the TH portal distal to the 6U portal.

Fig. 2

( A ) Schematics for visualization through the midcarpal ulnar (MCU) portal, which is usually applied in the standard four-corner fusion technique. ( B ) Schematics for visualization through the TH portal. This portal provides much better visualization of the dorsal chondral surface of the capitate. ( C ) Schematicsfor the visualizartion and instrumentation through standard dorsal portals, as in the standard technique, in a lateral wrist perspective (as would have been seen through the TH portal). ( D ) Schematics for instrumentation through the TH portal: the shaver reaches much better the anterior aspect of the chondral surface of the capitate, as seen in our modification of the standard technique.

Fig. 1

( A ) Vista dorsal do punho após a criação do portal piramidal-hamato (PH), que é criado distalmente ao portal 6U. ( B ) Vista ulnar do punho após a colocação do portal PH, criado distalmente ao portal 6U.

Fig. 2

( A ) Esquema de visualização através do portal carpal medial ulnar (CMU), geralmente aplicado na técnica padrão de fusão de quatro cantos. ( B ) Esquema de visualização através do portal PH. Este portal melhora muito a visualização da superfície condral dorsal do capitato. ( C ) Esquema de visualização e instrumentação através de portais dorsais comuns, como na técnica padrão, em uma perspectiva lateral do punho (como seria visto através do portal PH). ( D ) Esquema da instrumentação através do portal PH: o shaver atinge muito melhor a face anterior da superfície condral do capitato, como em nossa modificação da técnica padrão.