Wrist Αrthroscopy review: From Clinical Εxam to Complex Repair Ioannina 2014
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Transcript of Wrist Αrthroscopy review: From Clinical Εxam to Complex Repair Ioannina 2014
Wrist ArthroscopyClinical applications
Nickolaos A. Darlis, MD, PhD
To access this presentation on the web:
MRI 1,5T
• Fairly accurate in interosseous lig. & TFCC tears
• SL lig.:
– 70% sensitivity
– 90% specificity
– 85% accuracy
• TFCC: worse
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
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
SL lig. lesions
• Staging
• Management •Δυναμική Αστάθεια
•Στατική Αστάθεια
•Αρθρίτιδα (SLAC)
3mo
ACUTEGood Healing Potential
CHRONICPoor Healing Potential
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 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
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
DRUJ instability: clinical exam unreliable
Radioulnar ballottement test
(Neutral- pronation- supination) DRUJ compression test
Piano- Key sign
ECU subluxiation in supination-
ulnar deviation
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
Open Ulna Recession Procedures
Another approach: Keep it simple…
• Step-Cut Ulnar Shortening Osteotomy
Darlis& Sotereanos JHS(A), 2005
Timing of the repair
ACUTEGood Healing Potential
SUBACUTEUnpredictable
CHRONICPoor Healing Potential
0 6 months 1 year
3mo 6mo
• Clinical DRUJ instability
• Fracture through the fovea
• MRI findings
• Arthroscopic findings
– Positive Hook Test
– Direct Foveal Portal Arthroscopy
Foveal attachment involvement
1. Mini open: Sotereanos
Chou, Sarris, Sotereanos, JHS(B), 2003
U
EDM ECU
Incision
Chou, Sarris, Sotereanos JHS(B), 2003
REATTACH TO FOVEA
• 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
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