Wrist ArthroscopyClinical applications

Nickolaos A. Darlis, MD, PhD

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1.Diagnostic

MRI 1,5T

• Fairly accurate in interosseous lig. & TFCC tears

• SL lig.:

– 70% sensitivity

– 90% specificity

– 85% accuracy

• TFCC: worse

MRI 3,0Τ

• Accuracy improved but far from excellent

1.Diagnostic

2.TFCC Lesions –DRUJ instability

3. Wrist Instability-SL LT lesions

4. Bony ProceduresWafer- Styloidectomy- PCR

5.Dorsal Ganglion Resection

6.Synovectomy-Washout - Arthrolysis

7. FracturesDistal Radius- Scaphoid

#1. Radial-sided wrist pain

Radial-sided pain DD

Scaphoid fracture

SL lig. tear

Kienbock’s

AVN Scaphoid/ Preiser’s

CMC arthritis

Occult ganglion cyst

Metacarpal boss

Radiocarpal impingement

ScaphoLunate instability

Scapholunate ballottment test

Watson’s test Wrist flexion- finger extension maneuver

Anatomic snuffbox synovial irritation

Anatomic snuffbox= synovial irritation

Dorsal SL- lunate pain

Watson’s test

X-rays 1: True PA view

900 -900 position

X-rays 1: True PA view

• SL gap> 2-3mm (static instability)

• “Shortened” scaphoid

• Cortical ring sing

X-rays 2: Pronated grip view

1. Dynamic SL diastasis

2. Ulnocarpal Impingement

3. Ulnar Variance measurements

X-rays 2: Pronated grip view

NEUTRAL GRIP

Dynamic SL instability

X-rays 3: Comparative

Dynamic SL instability

Radiocarpal Arthroscopy• Always Probe the SL lig.

Geissler classification

Type I

L S

Geissler classification

Type II

L S

Geissler classification

Type III

L S

Geissler classification

Type IV

SL

C

Geissler classificationType IV

Mid-carpal Arthroscopy• Essential for accurate staging

Mid-carpal Arthroscopy• Essential for accurate staging

SL lig. lesions

• Staging

• Management •Δυναμική Αστάθεια

•Στατική Αστάθεια

•Αρθρίτιδα (SLAC)

3mo

ACUTEGood Healing Potential

CHRONICPoor Healing Potential

Acute, Geissler II, III

• Arthroscopic reduction, K-wire stabilization

L S L S

Acute, Geissler III, IV

• Open reduction, Repair

L S SL

C

E V O L V I N G C O N C E P T S

Acute, Geissler III, IV

• Attempts at arthroscopically-assisted direct repairDel Piñal, JHS(A) 2011

L S SL

C

Chronic, Geissler I, II

• Arthroscopic debridement & pinning

L SL S

Chronic, Geissler I, II

• Thermal shrinkage & pinningDarlis & Sotereanos, JHS(A), 2005

L SL S

Chronic, Geissler III, IVDynamic Instability

• Open treatment: Capsulodesis, partial wrist arthrodesis, tendodesis, ligament reconstruction

L S SL

C

Chronic, Geissler III, IVDynamic Instability

• Aggressive arthroscopic debridement,

percutaneous pinningDarlis & Sotereanos, JHS(A), 2006

L S SL

C

Chronic, Geissler III, IVStatic Instability/Arthritis

• Open treatment: Capsulodesis, partial wrist arthrodesis, tendodesis, wrist arthrodesis

L S SL

C

Chronic, Geissler III, IVStatic Instability

• Arthroscopic Reduction and Association of the Scaphoid and Lunate (RASL) Aviles et al, Arthroscopy, 2007

L S SL

C

#2. Ulnar-sided wrist pain

Ulnar-sided pain DD

TFCC tear

LT lig. tear

DRUJ arthritis

Fracture/ Non-union Ulnar styloid

Ulnocarpal Impaction Syndrome

ECU tendinitis/ instability

Fracture hamate

Pisiform arthritis

Unlar artery thrombosis

Ulnar n. compression Guyon’s

Superficial Ulnar n. neuritis

Fovea sign

TFCC lesion

TFCC impaction

test

Nakamura/ ulnocarpal stress test

TFCC lesion

Volar & Dorsal RU lig.- Foveal attachment

DRUJ instability: clinical exam unreliable

Radioulnar ballottement test

(Neutral- pronation- supination) DRUJ compression test

Piano- Key sign

ECU subluxiation in supination-

ulnar deviation

LT instability

LT ballottement/ Reagan’s test Kleinman’s shear test (LT)

X-rays : Pronated grip view

•Unlocarpal impaction syndrome

•Ulnar variance measurements

X-rays : Pronated grip view

Central tear

Peripheral tear)

Radial tear

Tear location

Deep bundle of TFCC

Volar radioulnar lig.radius

ulna

1. Central TFCC lesions

• Poorly vascularized- healing potential minimal

• Arthroscopic debridement up to 2/3 of articular disc

Arthroscopic TFCC debridement using radiofrequency probes Darlis NA & Sotereanos DG, JHS(B)2005

1. Central TFCC lesions

1. Central TFCC lesions

• Often degenerative and associated with ulnocarpal impaction syndrome

• Ulnar recession procedure to prevent symptom recurrence

Ulnocarpal Impaction Syndrome

Clinical features:

• Ulnar sided wrist pain

• Associated degenerative changes:

– Ulnar side of the lunate

– Radial side of the ulnar dome

– TFCC central tear

– Triquetrum- LunoTriquetrum lig.

• Usually positive or neutral ulnar variance

MRI

Arthroscopic Wafer procedure

• Preferred when modest shortening needed

Open Ulna Recession Procedures• Several options…

Open Ulna Recession Procedures

Another approach: Keep it simple…

• Step-Cut Ulnar Shortening Osteotomy

Darlis& Sotereanos JHS(A), 2005

2. Peripheral (ulnar) TFCC tears

• Well vascularized

• Repairable

Timing of the repair

ACUTEGood Healing Potential

SUBACUTEUnpredictable

CHRONICPoor Healing Potential

0 6 months 1 year

3mo 6mo

Usual location of peripheral tears

Dorsal

Usual location of peripheral tears

The Iceberg Concept Atzei &Lucetti 2011

REPAIR TO CAPSULE REATTACH TO FOVEAOR

TFCC TFCC

3. Peripheral (ulnar) TFCC tears

• Clinical DRUJ instability

• Fracture through the fovea

• MRI findings

• Arthroscopic findings

– Positive Hook Test

– Direct Foveal Portal Arthroscopy

Foveal attachment involvement

Hook test

REPAIR TO CAPSULE

REATTACH TO FOVEA

3. Peripheral (ulnar) TFCC tears

REPAIR TO CAPSULE

REPAIR TO CAPSULE

1. Mini open: Sotereanos

Chou, Sarris, Sotereanos, JHS(B), 2003

U

EDM ECU

Incision

Chou, Sarris, Sotereanos JHS(B), 2003

REATTACH TO FOVEA

2. All Arthroscopic, Knotless: Geissler

REATTACH TO FOVEA

TFCC

6R

ACC 6R

TFCC

6R

ACC 6R

TFCC

6R

ACC 6R

TFCC

6R

ACC 6R

TFCC

6R

ACC 6R

3. Distal Radius Fracture

• Consider in young, high demand patients

• Currently indicated in selected injuries:

– Radial styloid Fx

– Die Punch Fx

– Three & Four part Fx

– DRUJ instability or interosseous lig tear

• No metaphyseal comminution

Arthroscopically assisted reduction

1. Radial styloid

1. Radial styloid

1. Radial styloid

1. Radial styloid

1. Radial styloid

1. Radial styloid

2. die punch2. Die punch

3. Three & Four part fractures

3. Three & Four part fractures3. Three & Four part fractures

3. Three & Four part fractures3. Three & Four part fractures

3. Three & Four part fractures3. Three & Four part fractures

3. Three & Four part fractures3. Three & Four part fractures

3. Three & Four part fractures3. Three & Four part fractures

3. Three & Four part fractures3. Three & Four part fractures

3. Three & Four part fractures3. Three & Four part fractures

2008, Caroline Leclercq, MD & the European Wrist Arthroscopy Society

Wrist Arthroscopy complications

Inability to complete procedure(ganglion excision, TFCC repair)

20%

Nerve Lesions(Radial and Ulnar n. sensory branches)

10%

Chondral lesions 9%

CRPS 8.5%

Traction- Potitioning(oedema, neurapraxia, stiffness)

8.5%

Loose bodies 5%

6% in 9185 procedures

European Wrist Arthroscopy Society

www.geap.org

Thank You

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