wrist Αrthroscopy review: from clinical Εxam to complex repair ioannina 2014
DESCRIPTION
Review of the clinical exam, radiologic findings and operative treatment of common wrist conditions treated with wrist arthroscopy Ομιλία στο Σεμινάριο Χειρουργικής του Χεριού, Ιωάννινα 30 Οκτ- 1 Νοε, 2014. "Ανασκόπηση της Αρθροσκόπησης στο Χέρι".TRANSCRIPT
Wrist ArthroscopyClinical applications
Nickolaos A. Darlis, MD, PhD
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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