3 common clinical scenarios leading to wrist arthroscopy. alexandropolis 2014
DESCRIPTION
Overview of the 3 most common clinical scenarios leading to wrist arthroscopy. Invited lecture at the 20th Congress of the Hellenic Hand Surgery Society Meeting, Sep 4-6 2014. Ανασκόπηση των 3 κυριοτέρων κλινικών Σεναρίων που οδηγούν σε αρθροσκόπηση του καρπού. Προσκεκλημένη Ομιλία στο 20ο Συνέδριο της Ελληνικής Εταιρείας Χειρουργικής του Χεριού, 4-6 Σεπ, Αλεξανδρούπολη,TRANSCRIPT
3 Common Clinical Scenariosleading to
Wrist ArthroscopyNickolaos A. Darlis, MD, PhD
To access this presentation on the web:
To access this presentation on the web:
I am here to convince you that
Clinical Exam + Plain X-rays=80% of the indications for wrist arthroscopy
#1. Radial-sided wrist pain
Radial-sided pain DD
Scaphoid fractureSL lig. tearKienbock’sAVN Scaphoid/ Preiser’sCMC arthritisOccult ganglion cystMetacarpal bossRadiocarpal 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 diastasis2. Ulnocarpal Impingement3. 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 pinning
Darlis & 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 tearLT lig. tearDRUJ arthritisFracture/ Non-union Ulnar styloidUlnocarpal Impaction SyndromeECU tendinitis/ instabilityFracture hamatePisiform arthritisUnlar artery thrombosisUlnar n. compression Guyon’sSuperficial 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.radiusulna
N.D
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
TFCC6R
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
European Wrist Arthroscopy Society
www.geap.org
Thank you
To access this presentation on the web: