3 common clinical scenarios leading to wrist arthroscopy. alexandropolis 2014

3 Common Clinical Scenariosleading to

Wrist ArthroscopyNickolaos A. Darlis, MD, PhD

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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

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