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Your Own Free Home PageKienbock Operative Report
Date of Surgery: October 27,1997
Preoperative Diagnosis: Kienbock’s disease, left wrist.
Postoperative Diagnosis: Kienbock’s disease, left wrist.
Operation:
1. Radial Shortening
2. Application of external fixture
3. Vascularization of left lunate
4. Bone grafting of lunate
Anesthesia: General anesthesia
Findings: See procedure
Procedure: The patient was brought to the operating room, placed in supine position on the operating table and given general anesthesia with intubation techniques. After sufficient anesthesia was obtained, the left upper extremity was prepped and draped in the usual sterile fashion. Examination of superficial anatomy was unremarkable. The arm was elevated, exsanguinated with use of Esmarch bandage. Tourniquet was inflated to 250 mmHg. Beginning first on the dorsal aspect of the midshaft of the right radius, a longitudinal incision was made over the radius, carried down to subcutaneous tissue. The dissection was carried out between the extensor pollicis longus and the wrist extensors and extended in the midportion of the forearm. Dissection was taken down to the periosteum and a seven hole 2.7 DCP plate was chosen, because the 3.5 seemed to be too large and actually hung over the edge of her bone. An oblique osteotomy was made, 2 mm, with the feeling that with the shortening, it would actually come out to 3 mm. The plate was coapted to the bone and fixed with AO principles of loading it at sites 1,2, and 3 and then an interfragmentary screw and then the rest of the screw holes, by drilling, measuring, tapping, and filling the holes appropriately. Satisfactory alignment was confirmed on XI scan. Attention was then directed to the distal aspect of the radius on the radial side of it, where longitudinal incision was made on the mid-axial line, carried down to the subcutaneous tissue. The interval between the brachial radialis and wrist extensor was entered. The superficial radial nerve was protected from harm’s way, and the two proximal pins for the external fixator were placed distal to the osteotomy. I did not want to risk distracting across the osteotomy by placing it more proximal, so I elected to go distal. Initially, the Agee external fixator was chosen; however, the Agee proved to be too long, and had to be converted to an AO fixator with a standard frame. Thus, the pins for the index metacarpal were placed in position and drilled at oblique angles into the index metacarpal. All wounds were closed with 5-0 Prolene and the fixator was placed under just general distraction. At this point we were two hours on the tourniquet. The tourniquet was let down for 20 minutes and then placed back up to 250 mmHg. Next, a longitudinal incision was made over the dorsum of the wrist, carried down to subcutaneous tissue. The extensor retinaculum was opened in a Z fashion and the finger extensors were taken to the ulnar side. The dorsal intermetacarpal artery between the second and third metacarpals was isolated and dissected all the way out to the level of the intermetacarpal ligament, where is was ligated. It was dissected back proximally and freed up around the carpal metacarpal joint to allow it to rotate to the lunate. The capsule of the wrist joint was then opened along the DIC ligament and along the radial triquetral ligament. This was folded over radially and applied to allow access to the lunate. A Kirschner wire was then drilled dorsally into the lunate and using the OEC mini scan to confirm alignment, this was widened with the use of curets and a small bur to hollow out the anterior of the lunate. Again, using the EOC quite liberally to make sure that we did not puncture through the cartilaginous surface, and also, using Freer in and around the lunate to make sure that we were not getting close to the cartilaginous surface, the anterior was reamed out. There was a small crack in the lunate, but it appeared to be stable and moved as one unit, with movement of the lunate itself. Bone graft was then harvested from the distal radius and packed down very firmly, trying to pump up the lunate back to its original shape. A 0.062 Kirschner wire was then drilled down through the lunate. A small incision was made over the volar aspect of the distal forearm and the dissection was taken around the flexor tendon to expose where the pin was coming through the lunate, through the volar carpal ligaments. A suture was then placed around the distal metacarpal ligament, which was then placed down through the lunate and drawn out and set onto the volar capsular ligaments to hold that in place. At this point in time, the tourniquet was let down and after 15 to 20 minutes, the pulsations for the intermetacarpal artery were not there. Thus, warm water and Priscoline were used and then finally pulsations were obtained after about 45 minutes. The capsule was then closed around the artery, making a little window to insure that there was no compression on the artery. The capsular ligaments were then closed with a 4-0 Tycron. The extensor tendons were allowed to fall back in place and the retinaculum was closed with 4-0 Tycron and then the skin was closed with 4-0 Monocryl and 5-0 Monocryl. The skin edges were injected with 0.5% plain Marcaine. The wound was dressed with Betadine soaked Adaptic 4 x 4 and a soft sterile bandage, reinforced with Coban. Sponge and needle count was correct. Blood loss was less than 100 cc. The patient appeared to tolerate the procedure well and was returned to the recovery room in satisfactory condition, with good pink fingers.
This page was last-updated February 10, 1998
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