Before surgery can be started, the patient has to be positioned in such a way that the<unk>  is stabilized. In order to do this, the patient has to be placed on the operating table with his or her face upward. The<unk>  of the arm on which will be operated on, has to be placed on a separate operating table on the side of the other operating table. To properly stabilize the<unk> , the patient's elbow is flexed and the forearm is immobilized by using a traction apparatus. By using a traction apparatus, it will also become easier to insert the instruments. Traction Tower In general, 4.5-6.8 kilograms of traction is implemented with the aid of finger traps. The surgeon can either opt for nylon finger traps or for wire traps. In most cases, nylon finger traps will be preferred to wire traps, as nylon is a more resilient material and thus distributes the traction force to the skin more evenly. Usually, traction is applied to two fingers, namely the index finger and middle finger. Sometimes it may be necessary to more evenly distribute the traction force on the skin, as the patient's skin may be too fragile or atrophic. The traction brought about by the traction apparatus is then applied to three or even four fingers. The surgeon can either opt for dry<unk>  or for wet<unk> . When performing a dry procedure the<unk>  can still, if necessary, be approached using open surgery. This may, for example, be required when a TFCC lesion is diagnosed. The latter is not possible when a wet procedure is performed, because the fluid that is used causes expansion of the tissue. To improve visualization within the<unk> , an inflow irrigation system is used during surgery. Currently, several systems are available, such as gravity flow, a hand pump, large syringes, or a mechanical infusion pump. For irrigation, lactated Ringer’s solution is generally used. The characteristics of lactated Ringer’s solution are that it is physiological and rapidly absorbed. Moreover, the right equipment must be available to finish a complete diagnostic<unk> , as well as to perform various operative procedures. Complications of using an irrigation system is that fluid extravasation into the soft tissues of the forearm can result in a compartment syndrome. Materials To perform a<unk> , the surgeon can use a standard<unk>  set. This set contains a variety of tools for both a diagnostic and therapeutic<unk> c intervention. The sets currently available contain: scopes; probes; punches; graspers; joint shavers and electrocautery. To get a clear view of the<unk>  a high quality camera with a small diameter between 2 and 3 mm is needed. This camera is attached to a fiberoptic light source and shows the image of the inside of the joint. Probes are used for examination of internal structures by palpating, pulling of moving tissue. They are essential for diagnostic investigation of the joint. All probes bear markings at 5 mm intervals to indicate the scale, since the cameras used in<unk>  have different magnifications. Punches or basket forceps have sharp edges to cut away redundant and damaged tissue. Suction punches are punches which can be connected to a suction pump to immediately remove cut tissue from the joint. Graspers or grasping forceps are useful to grab tissue floating loosely through the joint. A surgeon might want to remove this particular piece of tissue for tactile feedback. Every different<unk> c intervention has its own set of tools, depending on difficulty, type of tissue and available working space. Techniques In recent years,<unk>  is becoming a more familiar technique for the diagnosis and treatment of various<unk>  abnormalities. Every surgeon has his or her own preference, concerning the variety of available techniques. In this subsection, not all techniques will be described. A description of the most commonly used techniques will be given. Before surgery To prevent postoperative infections, the amount of pathogens in the operating-room has to be minimized. In order to achieve this, the surgeon, assistants, equipment and the operation area have to be sterile during the operation. Furthermore, the doors in the operating-room should not be opened, or this should at least be limited. Before the patient can undergo<unk> , he or she has to be positioned in a specific way. This operation procedure has already been thoroughly described earlier in subsection ‘’Procedure’’. The patient will only be operated on when every requirement for surgery is implemented. Entrance To perform<unk> , the instruments will have to be inserted in the<unk> . The surgeon will start by making a small incision for creating a so-called portal. The different portals will be further discussed in the next section. After the incision has been made, the portal is used to insert a scope. This scope will provide the visualization. In that way, the surgeon will be able to orient within the joint of the<unk> . Once a clear view of the<unk>  is obtained, a possible problem can be identified. This problem, for example a TFCC lesion, may then immediately be solved by operative treatment. Portals A patient may suffer from various illnesses regarding the<unk> . Examples include TFCC lesion, scapholunate and lunotriquetral instability, ganglions, and synovitis. These illnesses concern many different tissues and structures. By using just one portal, one will never be able to visualize all these structures and tissues. For that reason, several portals exist, each having its own function (Table 1). The traditional portals are at the back of the hand (dorsal side), because many neurovascular structures are at risk at the palmar side of the hand. Table 1. Different portals that can be used during<unk>  Dorsal Radial portals The portals lay between the dorsal extensor compartments. 1-2 portal: * Between the 1st and 2nd extensor compartments * Located in the Anatomical snuff box * not often utilized 3-4 portal: * between the 3rd and 4th extensor compartments * Located distal to Lister's tubercle * primary viewing portal 4-5 portal: * Between the 4th and 5th extensor compartments * mainly for instrumentation and visualization of TFCC 6R portal: * at the Radial side of the extensor carpi ulnaris (ECU) * For TFCC repair 6U portal: * Located at the Ulnar side of the extensor carpi ulnaris (ECU) * For TFCC repair Volar radiocarpal(VR) portal * This portal is used for evaluation the dorsal radiocarpal ligament(DRCL) and the scapholunate interosseus ligament (SLIL) Midcarpal portals: Midcarpal Radial portal (MCR) * Allows visualization of the scapholunate(SL), scaphocapitate(SC) and scaphotrapezoid(ST) joints. Location of the Portals used for<unk>  Midcarpal Ulnar portal (MCU) * Allows visualization of the lunocapitate(LC), lunotriquetral(LT) and triquetrohamate (TH)joints. Dorsal Distal Radioulnar joint portal (DDRUJ) * Both the proximal and distal DRUJ can be used. * It’s the best way to get a clear view of the DRUJ Volar Distal Radioulnar joint portal (VDRUJ) * Used for assessing the TFCC attachment
Wrist arthroscopy
Hip arthroscopy
Arthrogram
Back brace
Auricular splint
Spica splint
Arthroscopy
Shin splints